Opt-out Human Immunodeficiency Virus Testing Research Articles

HIV Testing Strategies for Health Departments to End the Epidemic in the U.S.

An important goal of the Ending the HIV Epidemic in the U.S. initiative is the timely diagnosis of all people with HIV as early as possible after infection. To end the HIV epidemic, health departments were encouraged to propose new and innovative HIV testing strategies and improve the reach of existing programs. These activities were divided into 3 core strategies: expansion of routine screening in healthcare settings, locally tailored HIV testing initiatives in nonhealthcare settings, and specific efforts to increase the frequency of testing for individuals with increased potential for acquiring HIV. Because HIV testing is such a crucial part of the core activities of the Centers for Disease Control and Prevention's HIV prevention programs, there are many examples of evidence-based programs and best practices for HIV testing in both clinical and nonclinical settings. This article reviews the evidence base for these strategies and some of the activities proposed under the Diagnose pillar to achieve the goal of diagnosing all HIV infections as early as possible. All other Ending the HIV Epidemic in the U.S. activities start with an awareness of HIV status, which is actually the indicator for which most health departments are closest to the proposed targets. There are both proven and emerging approaches to increasing HIV screening and increasing the frequency of HIV screening available. The Ending the HIV Epidemic in the U.S. initiative provides the motivation, the resources, and a coordinated plan to bring them to scale.

An Assessment of Emergency Nurses’ Perspectives on Nurse-Driven Human Immunodeficiency Virus Testing in the Emergency Department

IntroductionEngaging emergency clinicians in universal human immunodeficiency virus screening is paramount to achieving goals of reengaging human immunodeficiency virus–positive persons into care, identifying new human immunodeficiency virus cases, and linking them to care. The study aim was to identify beliefs and barriers towards opt-out human immunodeficiency virus testing among emergency nurses. MethodsA cross-sectional study used Qualtrics software to deliver a survey on a tablet device to emergency nurses in a private Level 1 trauma hospital in Houston, Texas during downtimes of their clinical shifts. The survey evaluated perspectives on human immunodeficiency virus screening and knowledge relative to rapid screening and human immunodeficiency virus prevalence rates locally and nationally. ResultsFifty emergency nurses were enrolled. Few nurses accurately identified human immunodeficiency virus prevalence rates at the local hospital and city level (10% and 42%, respectively). Most (54%) of nurses correctly estimated human immunodeficiency virus prevalence rates nationally. Nearly half of the nurses (42.0%) correctly predicted the cost of a rapid human immunodeficiency virus test with accuracy and most were willing to offer rapid human immunodeficiency virus testing all the time (60.0%). Eighty-eight percent of nurses were supportive of facilitating universal human immunodeficiency virus screening. However, 92.0% strongly supported human immunodeficiency virus testing for high risk patients only when compared to 80.0% support of testing for all eligible patients. Qualitative data revealed time constraints and follow-up concerns as barriers. DiscussionEmergency nurses reported barriers that sometimes prevented application of Centers for Disease Control and Prevention recommendations to human immunodeficiency virus screening. Strategies to overcome these barriers are instrumental to programmatic success. Solutions can corroborate the importance of emergency nurses to the nation’s Ending the HIV Epidemic plan.

The Potential Epidemiological Impact of Coronavirus Disease 2019 (COVID-19) on the Human Immunodeficiency Virus (HIV) Epidemic and the Cost-effectiveness of Linked, Opt-out HIV Testing: A Modeling Study in 6 US Cities

BackgroundWidespread viral and serological testing for SARS-CoV-2 may present a unique opportunity to also test for HIV infection. We estimated the potential impact of adding linked, opt-out HIV testing alongside SARS-CoV-2 testing on HIV incidence and the cost-effectiveness of this strategy in six US cities.MethodsUsing a previously-calibrated dynamic HIV transmission model, we constructed three sets of scenarios for each city: (1) sustained current levels of HIV-related treatment and prevention services (status quo); (2) temporary disruptions in health services and changes in sexual and injection risk behaviours at discrete levels between 0%-50%; and (3) linked HIV and SARS-CoV-2 testing offered to 10%-90% of the adult population in addition to scenario (2). We estimated cumulative HIV infections between 2020-2025 and incremental cost-effectiveness ratios of linked HIV testing over 20 years.ResultsIn the absence of linked, opt-out HIV testing, we estimated a total of 16.5% decrease in HIV infections between 2020-2025 in the best-case scenario (50% reduction in risk behaviours and no service disruptions), and 9.0% increase in the worst-case scenario (no behavioural change and 50% reduction in service access). We estimated that HIV testing (offered at 10%-90% levels) could avert a total of 576-7,225 (1.6%-17.2%) new infections. The intervention would require an initial investment of $20.6M-$220.7M across cities; however, the intervention would ultimately result in savings in health care costs in each city.ConclusionsA campaign in which HIV testing is linked with SARS-CoV-2 testing could substantially reduce HIV incidence and reduce direct and indirect health care costs attributable to HIV.

Viral Hepatitis and Human Immunodeficiency Virus Testing and Linkage to Care for Individuals Enrolled in an Opioid Treatment Program.

In the United States, many opioid treatment programs (OTPs) do not offer viral hepatitis (VH) or human immunodeficiency virus (HIV) testing despite high prevalence among OTP clients. We initiated an opt-out VH and HIV testing and linkage-to-care program within our OTP. All OTP intakes are screened for VH and HIV and evaluated for rescreening annually. A patient navigator reviews laboratory results and provides counseling in the OTP clinic. The medical record is queried to identify individuals with previously diagnosed, untreated VH or HIV. Navigation support is provided for linkage or relinkage to VH or HIV care. Between March 2018 and Februrary 2019, 532 individuals were screened for hepatitis C virus (HCV), 180 tested HCV antibody positive (34%), and 108 were HCV-ribonucleic acid (RNA) positive (20%). Sixty individuals were identified with previously diagnosed, untreated HCV. Of all HCV RNA+, 49% reported current injection drug use (82 of 168). Ninety-five individuals were seen by an HCV specialist (57% of HCV RNA+), 72 started treatment (43%), and 69 (41%) completed treatment. Individuals with primary care providers were most likely to start treatment. Four individuals were diagnosed with hepatitis B; 0 were diagnosed with HIV. The implementation of an OTP-based screening and navigation protocol has enabled significant gains in the identification and treatment of VH in this high prevalence setting.

Physician-initiated HIV testing leads to missed opportunities in an East London Hospital Acute Admissions Unit

Background The United Kingdom National Guidelines for Human Immunodeficiency Virus (HIV) Testing 2008 suggest that an HIV test should be considered in all general medical admissions, when diagnosed HIV prevalence exceeds 2 in 1000 in the local population. We evaluated physician-initiated HIV testing rates in the Acute Assessment Unit of an East London hospital. Methods All acute presentations over one month were reviewed retrospectively, using electronic records. Patients with confirmed HIV were identified and the requested diagnostic HIV tests were measured. The number of patients with clinical indicator conditions for adult HIV infection, as defined in the United Kingdom National Guidelines for HIV Testing 2008, who did not receive appropriate testing, was calculated. Results In the cohort of 1023 patients, two patients had known HIV. 58 diagnostic HIV tests were performed, including 40 tests in patients with no clinical indicator diseases. There were five admissions with ‘AIDS-defining conditions’, all of which were pulmonary tuberculosis and four out of five (80.0%) were tested. There were 118 admissions with ‘conditions where HIV testing should be offered’, 14 of which (11.9%) were tested. All HIV tests were negative. Conclusion Physician-initiated HIV testing was inadequate for such a high prevalence area, even in clinical indicator diseases. Physician-initiated HIV testing should be replaced with routine opt-out HIV testing in acute medical admissions units in areas of high HIV prevalence, as suggested by BHIVA (British HIV Association) guidelines, as we progress towards ending the HIV epidemic in the United Kingdom.

612. Increase in Perinatal HIV Infection in North Florida: Missed Opportunities to Prevent Maternal-to-Child Transmission in Rural Areas

BackgroundThe rate of mother-to-child transmission of human immunodeficiency virus (HIV) in the United States has significantly declined due to routine opt-out HIV testing of pregnant women and implementation of effective prenatal, intrapartum and postnatal interventions. This includes first trimester HIV testing and retesting in the third trimester in areas with high HIV prevalence or in high-risk social situations. The University of Florida Pediatric Infectious Disease division serves a 31 county area for pediatric HIV care that includes Gainesville, Tallahassee and the entire Florida panhandle encompassing mostly rural counties. There are two HIV perinatal coordinators for pregnant women serving 19 of the counties.MethodsHIV-positive mother–infant pair chart review 2008–2018.ResultsBetween 2008 and 2012 there was one HIV-infected infant in the entire catchment area. From 2013 to 2017, there were 10 HIV-infected infants and two thus far in 2018. Statewide from 2013 to 2017 there were 41 HIV-infected infants. In the past 2 years, the North Florida region had 31% of the total number of HIV-infected infants. Eight of 12 mothers transmitting infection were known to be HIV infected and were prescribed antiretroviral (ARV) therapy with noncompliance documented in all 8. Two were teenagers; four received no prenatal care and insurance problems were reported in 3 as reasons for ARV noncompliance. Mental illness and/or substance abuse was documented in 6. Three were presumed infected during the third trimester—two tested negative in the first trimester, one was retested early in the third trimester and one was tested only at delivery due to lack of prenatal care.ConclusionImproved access to prenatal case management and access to mental health and substance abuse services are seriously needed in rural areas. Improving pregnancy compliance with ARV therapy is crucial in preventing vertical transmission. The number of perinatal coordinators needs to be significantly increased to support compliance and provides services. HIV testing in the first and third trimesters should become routine and testing of all (but especially high-risk women such as teenagers and those with mental illness or substance abuse) should be strongly considered at the time of delivery.Disclosures All authors: No reported disclosures.

Patients' Misconceptions Regarding HIV Testing: A Communication Gap in the Ambulatory Care Setting

Undiagnosed human immunodeficiency virus (HIV) infection is associated with increased morbidity, mortality, and healthcare costs. Despite recommendations for standardized, non-targeted, opt-out HIV testing, a substantial subset of HIV-infected individuals remain undiagnosed. We performed an anonymous, voluntary, cross-sectional survey among adult patients visiting an internal medicine clinic at the University of Florida to assess whether potential misconceptions of patients regarding routine blood work could contribute to underdiagnosis of HIV. We developed one question to assess participants’ beliefs regarding consistent HIV screening via routine laboratory tests: “I think my doctor checks me for HIV/AIDS every time he/she checks my blood.” The question had five answer options arranged in a 5-point Likert-type scale: “strongly agree”, “agree”, “neither agree nor disagree”, “disagree”, or “strongly disagree.” Of the 78 patients who participated in the study, 39 (50%) either “disagreed” or “strongly disagreed” that routine laboratory tests detect HIV. The “neither agree nor disagree” option was selected by 26 (33%). Ten participants (13%) “Agreed” or “strongly agreed” that routine laboratory testing detects HIV. Our study highlights the need for improved communication between healthcare providers and patients about the nature of the laboratory tests and their implications as they relate to HIV screening.

Predictors of Linkage to Care for Newly Diagnosed HIV-Positive Adults.

IntroductionLinkage to care following a human immunodeficiency virus (HIV) diagnosis is critical. In the U.S. only 69% of patients are successfully linked to care, which results in delayed receipt of antiretroviral therapy leading to immune system dysfunction and risk of transmission to others.MethodsWe evaluated predictors of failure to link to care at a large urban healthcare center in Philadelphia in order to identify potential intervention targets. We conducted a cohort study between May 2007 and November 2011 at hospital-affiliated outpatient clinics, emergency departments (EDs), and inpatient units.ResultsOf 87 patients with a new HIV diagnosis, 63 (72%) were linked to care: 23 (96%) from the outpatient setting and 40 (63%) from the hospital setting (ED or inpatient) (p<0.01). Those who were tested in the hospital-based settings were more likely to be black (p=0.01), homeless (p=0.03), and use alcohol or drugs (p=0.03) than those tested in the outpatient clinics. Patients tested in the ED or inpatient units had a 10.9 fold (p=0.03) higher odds of failure to link compared to those diagnosed in an outpatient clinic. When testing site was controlled, unemployment (OR 12.2;p<0.01) and substance use (OR 6.4;p<0.01) were associated with failure to link.ConclusionOur findings demonstrate the comparative success of linkage to care in outpatient medical clinics versus hospital-based settings. This study both reinforces the importance of routine opt-out HIV testing in outpatient practices, and demonstrates the need to better understand barriers to linkage.

Changes in Testing for Human Immunodeficiency Virus, Sexually Transmitted Infections, and Hepatitis C Virus in Opioid Treatment Programs

To the Editor Opioid dependence is a risk factor for human immunodeficiency virus (HIV), sexually transmitted infections (STIs), and hepatitis C virus (HCV) infection.1 Opioid treatment programs, which provide medication-assisted treatment to over 300 000 opioid-dependent Americans,2 are well-positioned to offer testing for these infectious diseases to a high-risk population. They were among the first venues to offer HIV testing and are more likely to offer HIV, STI, and HCV testing than other drug treatment programs.1 Private for-profit opioid treatment programs are increasingly widespread and such programs offer on-site HIV testing less often than nonprofit and public programs.3 However, with the 2006 national recommendations for routine opt-out HIV testing,4 we hypothesized that the percent of programs offering on-site testing for HIV, STIs, and HCV would increase.

The High Burden of Tuberculosis (TB) and Human Immunodeficiency Virus (HIV) in a Large Zambian Prison: A Public Health Alert

BackgroundTuberculosis (TB) and human immunodeficiency virus (HIV) represent two of the greatest health threats in African prisons. In 2010, collaboration between the Centre for Infectious Disease Research in Zambia, the Zambia Prisons Service, and the National TB Program established a TB and HIV screening program in six Zambian prisons. We report data on the prevalence of TB and HIV in one of the largest facilities: Lusaka Central Prison.MethodsBetween November 2010 and April 2011, we assessed the prevalence of TB and HIV amongst inmates entering, residing, and exiting the prison, as well as in the surrounding community. The screening protocol included complete history and physical exam, digital radiography, opt-out HIV counseling and testing, sputum smear and culture. A TB case was defined as either bacteriologically confirmed or clinically diagnosed.ResultsA total of 2323 participants completed screening. A majority (88%) were male, median age 31 years and body mass index 21.9. TB symptoms were found in 1430 (62%). TB was diagnosed in 176 (7.6%) individuals and 52 people were already on TB treatment at time of screening. TB was bacteriologically confirmed in 88 cases (3.8%) and clinically diagnosed in 88 cases (3.8%). Confirmed TB at entry and exit interventions were 4.6% and 5.3% respectively. Smear was positive in only 25% (n = 22) of bacteriologically confirmed cases. HIV prevalence among inmates currently residing in prison was 27.4%.ConclusionIneffective TB and HIV screening programs deter successful disease control strategies in prison facilities and their surrounding communities. We found rates of TB and HIV in Lusaka Central Prison that are substantially higher than the Zambian average, with a trend towards concentration and potential transmission of both diseases within the facility and to the general population. Investment in institutional and criminal justice reform as well as prison-specific health systems is urgently required.

Time to Linkage to Care and Viro-Immunologic Parameters of Individuals Diagnosed Before and After the 2006 HIV Testing Recommendations

To assess the time from linkage to care and viro-immunologic parameters before and after implementation of the Centers for Disease Control and Prevention's 2006 revised human immunodeficiency virus (HIV) testing strategy. Case reports from South Carolina's enhanced HIV/AIDS (acquired immunodeficiency syndrome) Reporting System were used to compare time to linkage to care and viro-immunologic indicators at diagnosis and 1 year after diagnosis of HIV in individuals diagnosed between 2004 and 2006 (n = 2456) with those diagnosed between 2008 and 2010 (n = 2118). CD4 T-cell count/percent and viral load tests were used as a proxy for a clinical visit and to determine disease stage. Individuals diagnosed between 2008 and 2010 were less likely than those diagnosed between 2004 and 2006 to be in care after 12 months than within 3 months of HIV diagnosis (adjusted odds ratio [AOR] 0.42, 95% confidence interval [CI] 0.34-0.51). Individuals diagnosed between 2008 and 2010 were more likely than those diagnosed between 2004 and 2006 to have high CD4 T-cell counts (>500 cells per cubic millimeter than ≤200 cells per cubic millimeter; AOR 1.24, 95% CI 1.01-1.51) and have undetectable viral loads 1 year post-HIV diagnosis (AOR 8.42, 95% CI 6.96-10.18). Although period of diagnosis did not predict disease stage 1 year post-HIV diagnosis (AOR 0.99, 95% CI 0.87-1.13), there was a decrease from 13% between 2004 and 2006 to 10% between 2008 and 2010 in the percentage of HIV-only patients at diagnosis who progressed to AIDS 1 year post-HIV diagnosis. Implementation of routine, opt-out HIV testing resulted in more timely linkage to care and improved viro-immunologic parameters 1 year postdiagnosis when compared with the previous testing recommendations.

Routine Inpatient Human Immunodeficiency Virus Testing System Increases Access to Pediatric Human Immunodeficiency Virus Care in Sub-Saharan Africa

Routine Human Immunodeficiency Virus (HIV) testing, called provider-initiated opt-out HIV testing and counseling (PITC), is recommended in African countries with high HIV prevalence. However, it is unknown whether PITC increases access to pediatric HIV care. In 2008, the Baylor International Pediatric AIDS Initiative implemented PITC (BIPAI-PITC) at a Malawian hospital. We sought to evaluate the influence of BIPAI-PITC, compared with nonroutine HIV testing (NRT), on pediatric HIV care access. Retrospective data from 7077 pediatric inpatients were collected during sequential 4-month periods of NRT and BIPAI-PITC. In-hospital and 1-year outcomes for 337 HIV-infected and HIV-exposed uninfected inpatients not previously enrolled in HIV care were analyzed to assess the clinical influence of each testing strategy. During BIPAI-PITC, a greater proportion of all hospitalized children received HIV testing (81.0% vs. 33.3%, P < 0.001), accessed inpatient HIV-trained care (7.5% vs. 2.4%, P < 0.001), enrolled into an outpatient HIV clinic after discharge (3.2% vs. 1.3%, P < 0.001), and initiated antiretroviral therapy (ART) after hospitalization (1.1% vs. 0.6%, P = 0.010) compared with NRT. Additionally, BIPAI-PITC increased the proportion of hospitalized HIV-infected and HIV-exposed uninfected children receiving DNA polymerase chain reaction testing (73.5% vs. 35.2%, P < 0.001), but did not improve outpatient enrollment or ART initiation of identified HIV-infected patients. BIPAI-PITC increases access to inpatient and outpatient pediatric HIV care for hospitalized children, including DNA polymerase chain reaction testing and ART. Broader implementation of BIPAI-PITC or similar approaches, along with more pediatric HIV-trained clinicians and improved defaulter-tracking methods, would improve pediatric HIV service utilization globally.

Time for Oncologists to Opt In for Routine Opt-Out HIV Testing?

Human immunodeficiency virus (HIV)-infected individuals are at high risk of malignancies. However, it is not currently the standard of care to routinely test cancer patients for HIV. In 2006, the Centers for Disease Control and Prevention recommended HIV testing in all health care settings, calling for standard nontargeted "opt-out" HIV screening. For a variety of reasons, routine opt-out HIV testing is still not widely used in the United States. Although many barriers to routine opt-out HIV testing have been addressed, such opt-out HIV testing continues to be conducted primarily in venues that target specific patient populations such as pregnant women. Although opt-out testing has been piloted in emergency departments, less emphasis has been placed on opt-out HIV testing in other clinical settings. In this article, the background, rationale, and evidence for supporting opt-out HIV testing as routine care for cancer patients are presented. In addition, evidence is discussed for the potential of opt-out HIV testing to improve clinical outcomes by facilitating appropriate HIV management during cancer treatment for individuals who are found to be HIV positive.

A Cluster-Randomized Trial of Provider-Initiated (Opt-Out) HIV Counseling and Testing of Tuberculosis Patients in South Africa

To determine whether implementation of provider-initiated human immunodeficiency virus (HIV) counseling would increase the proportion of tuberculosis (TB) patients who received HIV counseling and testing. Cluster-randomized trial with clinic as the unit of randomization. Twenty, medium-sized primary care TB clinics in the Nelson Mandela Metropolitan Municipality, Port Elizabeth, Eastern Cape Province, South Africa. A total of 754 adults (18 years and older) newly registered as TB patients in the 20 study clinics. Implementation of provider-initiated HIV counseling and testing. Percentage of TB patients HIV counseled and tested. SECONDARY: Percentage of patients with HIV test positive, and percentage of those who received cotrimoxazole and who were referred for HIV care. : A total of 754 adults newly registered as TB patients were enrolled. In clinics randomly assigned to implement provider-initiated HIV counseling and testing, 20.7% (73/352) patients were counseled versus 7.7% (31/402) in the control clinics (P = 0.011), and 20.2% (n = 71) versus 6.5% (n = 26) underwent HIV testing (P = 0.009). Of those patients counseled, 97% in the intervention clinics accepted testing versus 79% in control clinics (P = 0.12). The proportion of patients identified as HIV infected in intervention clinics was 8.5% versus 2.5% in control clinics (P = 0.044). Fewer than 40% of patients with a positive HIV test were prescribed cotrimoxazole or referred for HIV care in either study arm. Provider-initiated HIV counseling significantly increased the proportion of adult TB patients who received HIV counseling and testing, but the magnitude of the effect was small. Additional interventions to optimize HIV testing for TB patients urgently need to be evaluated.

Routine Opt-Out HIV Testing: Rationale for the Consensus Conference and This Supplement

This supplement was developed from a national meeting entitled "Opportunities for Improving HIV Diagnosis, Prevention & Access to Care in the U.S.," held 29-30 November 2006 in Washington, D.C. Leaders in the fight against human immunodeficiency virus (HIV) infection were recruited from areas of government, academia, clinical medicine, patient advocacy, and private industry to discuss the following ambitious topics: (1) strategies to significantly reduce overall HIV transmission rates in the United States, (2) methods to identify the estimated 250,000 individuals in the United States who remain unaware of their positive HIV serostatus, so they can be offered treatment earlier in the course of their disease, and (3) obstacles associated with opt-out HIV testing, including limits on resources for treatment of HIV infection. We served as cochairs for the meeting and, in conjunction with a scientific planning committee we appointed, oversaw the selection of the articles published in this supplement. Cumulatively, the articles address the stated topics by identifying methods to ensure the success of more-aggressive HIV testing measures, such as those described in the September 2006 recommendations of the Centers for Disease Control and Prevention; examining the success of current measures to prevent HIV infection such that future strategies can be improved; identifying the methods that will foster earlier diagnosis and access to treatment for individuals with HIV infection; and determining the limitations in human and financial resources to adequately care for a surge in the number of individuals with newly diagnosed HIV infection.

Legal and Ethical Implications of Opt-Out HIV Testing

New guidelines from the Centers for Disease Control and Prevention recommend that opt-out screening for human immunodeficiency virus (HIV) without written patient consent be part of routine clinical care and imply that state HIV-associated laws in conflict with this approach should be amended. However, HIV testing and treatment issues are governed by a range of federal and state laws, common law principles, constitutional provisions, and various codes of ethics. Patient testing protocols should satisfy the legal definition of informed consent, to reduce risk of liability for providers (i.e., health care professionals and facilities). Rigid application of the new guidelines may trigger legal claims, especially if there is no link to care for persons with a positive test result, no proof of informed consent, or inadequate counseling. Ensuring confidentiality, better test training for providers, and provider collaboration with HIV service organizations can reduce the risk of patient claims, but state and federal laws, codes of ethics, and concerns about provider liability should temper reflexive wholesale adoption of guidelines that recommend opt-out screening.

Evidence-Based Efforts to Prevent HIV Infection: An Overview of Current Status and Future Challenges

Since the early 1990s, the incidence of human immunodeficiency virus (HIV) infection in the United States has been approximately 40,000 cases per year. Because this rate has not decreased substantially in >15 years, the efficacy and cost-effectiveness of programs to prevent HIV infection have come under intensifying examination. In this article, several issues are addressed, including the efficacy of HIV prevention strategies at the national level in the United States, the status of the goals from the current (albeit expired) national HIV prevention plan, the role of opt-out HIV testing in a new comprehensive national HIV prevention plan, and a review of evidence-based prevention strategies that should be emphasized in a new plan.