Perceptions of Human Immunodeficiency Virus Testing Services Among HIV-Positive Persons Not in Medical Care

Abstract

To the Editor: We read with interest the article by Rudy et al, “Perceptions of Human Immunodeficiency Virus Testing Services Among HIV-Positive Persons Not in Medical Care” in the April 2005 issue of your journal.1 Although we strongly agree with the authors’ assertions that a proper HIV testing experience requires adequate counseling, education, and time for the newly diagnosed HIV-positive patient to fully understand his or her test results and referral needs, we take serious exception to their suggestion that patients testing positive for HIV in a health maintenance organization (HMO) or private care setting are the most likely to go without proper follow up. The authors report on data from an apparent convenience sample that was not collected specifically for the analysis described. To assess HIV testing services more convincingly, a study design that is more likely to reflect the patient populations of interest should have been used. The small sample size (n = 13 and wide confidence margins) cannot represent all HMO/private care patients. Furthermore, the patients studied were highly selected, generally disadvantaged, and all represent failures of follow up. Although lessons can be learned from such a group, it is important to view their experience in the context of all new positives, particularly if the authors want to draw such general conclusions. If the sample reported on was in fact representative, the relatively low frequency of HMO/private care HIV-positive patients out of care suggests that those care delivery settings are the most successful at providing follow up and keeping patients in care. Although many private physicians’ offices do not have care coordinators or HIV test counselors, many HMOs do. Even if the sample were representative, the rationale for grouping patients from HMOs and private offices together is not intuitive. Kaiser Permanente’s experience with HIV testing contradicts the results of this study. Although we do not have exact figures, it is policy in most of our clinical facilities to have HIV test results given by specially trained HIV test counselors (usually certified health educators). In all of our regions, HIV is now a medical subspecialty and patients are immediately referred to the HIV care team (often with a care coordinator) on diagnosis. In Kaiser Permanente’s Northern and Southern California regions combined, 94% (699 of 744) of patients newly diagnosed with HIV in 2004 were in care a year later and had at least 2 CD4 cell counts and 2 HIV viral loads in the first year of follow up—a marker for patients receiving proper follow up. This measure is in line with, if not superior to, the outcome of the intensive case management intervention arm of the main ARTAS study (the context of the Rudy article). We hope that your readers do not draw erroneous conclusions from the work of Rudy et al. Many HMOs, including Kaiser Permanente, provide excellent HIV care, from initial testing through comprehensive care management.