Routine Opt-out Testing Research Articles

Associations Between Clinic-Based HIV Testing Guidelines and Population-Level HIV Testing Rates in the United States.

Between 2005 and 2006, the United States Preventive Services Task Force and the Centers for Disease Control and Prevention revised their risk-based HIV testing guidelines to include universal HIV testing in routine health care. We examined trends in HIV testing and associations with changing policy recommendations using the 2000-2017 National Health Interview Surveys. Multivariable logistic regression and difference-in-difference approach were used to assess rates and correlates of HIV testing before and after the policy changes. Changes in recommendations had minimal effects on overall HIV testing rates but had significant effects on selected subpopulations. The odds of HIV testing increased disproportionately among African Americans, Hispanics, individuals with some college education, low perceived HIV risks, and those who were never married but decreased among those with no regular source of care. A strategy combining risk-based and routine opt-out testing holds promise to rapidly link recently infected individuals to care while reaching individuals who have never been tested.

Reducing barriers to the hepatitis C care cascade in prison via point-of-care RNA testing: a qualitative exploration of men in prison using an integrated framework.

Hepatitis C virus (HCV) is highly prevalent within the prison setting. Although HCV testing and treatment are available within prisons, system barriers can impede progress along the HCV care cascade for those who are incarcerated. The PIVOT intervention used a 'one-stop-shop' model (i.e. point-of-care HCV RNA testing, Fibroscan-based liver disease assessment and treatment) at a reception prison in New South Wales, Australia. This analysis sought to understand the role of point-of-care HCV RNA testing at intake in reducing barriers to the HCV care cascade within the male prison setting. Qualitative analysis using semi-structured interviews in a reception prison in Australia. Twenty-four men enrolled in the PIVOT study; all participants had undergone HCV point-of-care testing in the intervention arm. Høj's Integrated Framework informed this analysis. Participants widely expressed the view that point-of-care HCV RNA testing on entry was beneficial for care engagement. Point-of-care testing was perceived as timely (compared with standard pathology) and reduced opportunities for adjudication by correctional officers due to fewer clinic visits for testing and results. Adoption of routine opt-out testing at prison intake was regarded as an important strategy for normalising HCV testing (and likely to increase pathways to treatment uptake) and fostered patient candidacy (i.e. self-perceived eligibility to access care). Twenty-four men in prison in New South Wales, Australia, who underwent opt-out point-of-care HCV RNA testing on entry into prison, widely supported the programme as a means of overcoming barriers to HCV testing and treatment in the prison setting, as well as providing public health benefits through early detection of HCV infection among people entering into custody.

964. Opt-Out HIV- Hepatitis C (HCV) Testing at a Primary Care Resident Clinic in Columbia, SC: Who Gets Tested and Who Opts Out of Testing?

BackgroundSouth Carolina (SC) remains one of the most heavily affected states for both HIV and HCV infections. Males account for the majority of cases. Implementation of universal opt-out testing has improved screening rates but not much has been published describing the characteristics of those who opt out of testing. This becomes important as 10-50% of patients have opted out in previous studies.MethodsBetween February and August 2019, we conducted a quality improvement (QI) project which implemented opt- out HIV-HCV testing at a single primary care resident clinic in SC with the primary aim of increasing screening rates for HIV-HCV by 50%. Secondary aims included describing the demographic characteristics of the opt-out population. Persons were considered eligible for testing if they were between the ages of 18-65 years for HIV and 18-74 years for HCV. This was prior to the USPSTF 2020 guidelines which recommend HCV screening for adults aged 18-79 years. A retrospective chart review was used to obtain screening rates, opt status and demographic data. Logistic regression and the firth model were used to determine linkages between categorical variables. We present 3-month data.Results1253 patients were seen between May 1, 2019- July 31, 2019 (See Table 1). 985 (78%) were eligible for HIV testing. 482 (49%) were tested for HIV as a result of our QI project and all tests were negative. 212 (22%) of eligible patients opted out of HIV testing. Males were 1.59 times more likely to opt out (p=0.008). (see Table 2,3)Regarding HCV, 1136 (90.7%) were deemed eligible for testing. 503 (44%) were tested for HCV as a result of our QI project. 12 (2.4%) were HCV antibody positive with viremia. 11 (90%) of antibody positive with viremia cases were in the 1945-1965 birth cohort (see Table 4). 244 (21%) opted out of HCV testing. Males and persons without a genitourinary chief complaint were more likely to opt out (p=0.02).Table 1: Demographic characteristics of the population seen at the internal medicine resident clinic between May- July 2019 Table 2: Relationship between demographic variables and the odds of being tested for HIV or HCV within the last 12 months. Logistic Model. Table 3: Relationship between demographic variables and the odds of opting out of testing for HIV or HCV. Firth Model. ConclusionAlthough implementation of routine HIV-HCV opt-out testing led to increased screening rates for both HIV and HCV, roughly 1 in 5 eligible patients chose to opt out of testing. Males were more likely to opt out despite accounting for the majority of newly diagnosed HCV cases. Future studies investigating drivers for opting-out in the male population could improve testing and assist with early diagnosis.Table 4: Characteristics of patients newly diagnosed with HCV positive with viremia. Disclosures All Authors: No reported disclosures

Routine Versus Risk-Based HIV Testing and Mortality of Patients With HIV Under National Health Insurance: A Population-Based Cohort Study

Background: Expanding routine opt-out HIV testing to control HIV epidemic is beneficial for vulnerable persons and for the society. However, data are lacking on long-term survival and safety outcomes of those tested HIV-positive by routine opt-out versus non-routine (risk-based) HIV testing under the same treatment and health care. Methods: We analyzed the population-based HIV/AIDS registry and follow-up data under Taiwan National Health Insurance, comparing the clinical outcomes of those diagnosed by routine opt-out testing or risk-based testing. The main outcomes were HIV/AIDS-related mortality, non-HIV-related mortality, and 1-year suicidal/accidental mortality. We matched subjects by year of diagnosis, and adjusted for effects of age, sex, transmission routes, and socioeconomic status using regression models. Findings: This study included all 28,674 Taiwan citizens diagnosed with HIV infection during 1986-2014 (8,431 [29%] by routine opt-out testing, and 18,305 [64%] by risk-based testing), with verified follow-up data. Compared with risk-based testing, routine opt-out HIV testing was associated with a significantly lower likelihood of late diagnosis (adjusted odds ratio 0·20, 95% CI 0·18-0·23; p<0·001), and a significantly lower HIV/AIDS-related mortality (adjusted hazard ratio [aHR] 0·63, 95% CI 0·53-0·75; p<0·001). In addition, routine opt-out HIV testing was not associated with increased non-HIV-related death (aHR, 0·94, 95% CI 0·91-0·98; p=0·001) or suicidal/accidental mortality (aHR 0·80, 95% CI 0·43 -1·49; p=0·48) compared with risk-based HIV testing. Interpretation: Compared with risk-based HIV testing, routine opt-out HIV testing is safe, and associated with favorable clinical relevant outcomes, including early HIV diagnosis and lower HIV/AIDS-related mortality, among individuals who were tested HIV-positive under National Health Insurance. Funding Statement: This work was supported by Taiwan Ministry of Science and Technology (grants no. MOST-102-2628-B-002-037-MY2, MOST-104-2314-B-002-035-MY2, and MOST-106-2314-B-002-115-MY3) and Taiwan Centers for Disease Control (grants no. MOHW-106-CDC-JH-105030, MOHW107-CDC-CB-106040, and MOHW-108-CDC-YH-107030). Declaration of Interests: All authors have no competing interest to disclose. Ethics Approval Statement: The study procedure was approved by the Research Ethics Committee (REC) of National Taiwan University Hospital (Taipei, Taiwan) (#201711046RIND). The REC approved the exemption of informed consent since all personal information had been anonymized.

HIV Testing Trends at Visits to Physician Offices, Community Health Centers, and Emergency Departments - United States, 2009-2017.

In 2019, the U.S. Department of Health and Human Services launched the Ending the HIV Epidemic: A Plan for America (EHE) initiative to end the U.S. human immunodeficiency virus (HIV) epidemic by 2030. A critical component of the EHE initiative involves early diagnosis of HIV infection, along with prevention of new transmissions, treatment of infections, and response to HIV outbreaks (1). HIV testing is the first step in identifying persons with HIV infection who need to be engaged in treatment and care as well as persons with a negative HIV test result and who are at high risk for infection and can benefit from HIV preexposure prophylaxis (PrEP) and other prevention services. These opportunities are often missed for persons receiving clinical services in ambulatory care settings (2). Data from the 2009-2016 National Ambulatory Medical Care Survey (NAMCS) and 2009-2017 National Hospital Ambulatory Medical Care Survey (NHAMCS) were analyzed to estimate trends in HIV testing at visits by males and nonpregnant females to physician offices, community health centers (CHCs), and emergency departments (EDs) in the United States. HIV tests were performed at 0.63% of 516 million visits to physician offices, 2.65% of 37 million visits to CHCs, and 0.55% of 87 million visits to EDs. The percentage of visits with an HIV test did not increase at visits to physician offices during 2009-2016, increased at visits to CHC physicians during 2009-2014, and increased slightly at visits to EDs during 2009-2017. All adolescents and adults should have at least one HIV test in their lifetime (3). Strategies that reduce clinical barriers to HIV testing (e.g., clinical decision supports that use information in electronic health records [EHRs] to order an HIV test for persons who require one or standing orders for routine opt-out testing) are needed to increase HIV testing at ambulatory care visits.

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.

1292. Integrating HIV and Hepatitis C Screening in a High-Risk Emergency Department Population

BackgroundWith the acceleration of the hepatitis C (HCV) epidemic in the United States and the ongoing public health impact of undetected human immunodeficiency virus (HIV) co-infection, there is a critical need for enhanced secondary prevention efforts where patients accessing care are not routinely screened. The purpose of this program was to implement routine opt-out HIV and HCV screenings in a high-volume urban emergency department (ED) through the use of an EMR enhancement to increase a provider’s likelihood of testing eligible patients, and to provide linkage to care for patients identified to have positive tests.MethodsFrom November 27, 2018 to March 31, 2019, EMR-based HIV and HCV screening was implemented in a quaternary care ED in Northern California. EMR best practice alerts were developed based on a combination of local and CDC guidelines and populated on registered patients receiving blood laboratories or receiving STI testing. Laboratory HIV/HCV screening utilized a unique two-specimen collection scheme to enable molecular testing without requiring patient return visits. Patients were excluded if they chose to opt out from testing or the provider deemed opt out was not possible. Upon notification of a positive test result through the EMR, a patient navigator was responsible for providing disease education and linking patients to care.ResultsThe prevalence of HCV antibody positivity was 9.6% (637/6,627) and 0.97% (55/5,628) for HIV. Of the 255 HCV-RNA positives, 110 were known and 145 newly diagnosed. Of the 90 HIV patients, 31 were known and 8 newly diagnosed. Although current CDC hepatitis C screening guidelines recommend screening all adults born during 1945–1965, we conducted universal screening of adults 18 years or older. Of those screened antibody-positive for HCV 64% fell within the 1945–1965 birth cohort.ConclusionIntroducing routine opt-out testing using an automated EMR-based screening program is an effective method to identify and screen eligible patients for HIV and HCV in episodic care safety net settings where universal screenings are not routinely implemented. The unexpectedly high rate of HIV seroprevalence suggests the ED environment continues to be an important setting to access populations not receiving routine care despite longstanding CDC recommendations for universal screening. Disclosures All authors: No reported disclosures.

Behavior intention to use routine opt-out HIV testing in primary care settings among men who have sex with men in China

ABSTRACTThe opt-out option has the advantages of potentially normalizing HIV testing and hence remove stigma involved in HIV testing among men who have sex with men (MSM). The present study investigated behavioral intention to use free routine opt-out HIV testing in primary care settings and associated factors among MSM in Hong Kong, China. A cross-sectional survey was conducted among 336 MSM recruited from multiple sources during October 2015 and September 2016. Of the participants, 37.2% intended to use free routine opt-out HIV testing in primary care settings in the next 12 months if it was made available. Adjusted for significant background variables, variables on positive attitudes, perceived subjective norm (i.e., perceived support from male partners for taking up routine opt-out testing) and perceived descriptive norm (i.e., perceived >60% of peers would use this option) were significantly associated with behavioral intention use such testing option. In addition, had ever tested for HIV, and perceived level of trust of health professionals in primary care settings were also significant. Routine opt-out HIV testing is a potential useful means to increase HIV testing coverage among MSM in Hong Kong. Policy makers should consider allocating resources to pilot and implement this testing option.

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.

1273. Routine Opt-out HIV Screening and Detection of HIV Infection Among Emergency Department Patients

BackgroundThe Southeastern United States bears a disproportionate burden of HIV infection, accounting for nearly half of all new cases. The Centers for Disease Control and Prevention released routine opt-out testing recommendations in 2006. Our emergency department collaborated with our infectious diseases clinic (ECU-ID) to implement suggested guidelines among adults since March 2017.MethodsOur primary aim was to implement routine, opt-out HIV testing in the Vidant Medical Center Emergency Department (ED) for patients between 18 and 65 years of age who have blood work completed, and have not had a test documented in the electronic medical record (EMR) in the last year. A secondary aim was to successfully link HIV-positive patients to care at ECU-ID or preferred clinic. Methods defining programmatic success included developing nurse directed opt-out ordering protocol, integrating testing into normal ED workflow, utilizing the existing EMR to prompt testing, and hiring a linkage coordinator to initiate post-test counseling and linkage-to-care.ResultsSince March 2, 2017, a total of 7,109 HIV tests were performed; an average of 592 monthly tests conducted compared with a previous average of 10 stat tests. Testing increased 5,820% compared with 2015. Of the 21 HIV-positive patients found, 16 were newly diagnosed. Among those newly diagnosed, 14 (87.5%) were linked to care; and among the five known positives, two (40%) were linked to care. Reasons why patients could not be linked included incarceration, refusal to link to care, and re-location.ConclusionJoined with the implementation of a routinized ED HIV testing program, a seamless process was developed to link persons found to be positive in the ED to HIV care services; therefore, establishing a systems-level prevention model. Future plans include expanding testing to adolescents and utilizing similar methods to integrate Hepatitis C testing.Disclosures All Authors. Gilead Sciences, Inc.: Grant Investigator, Grant recipient and Salary.

HIV Testing at Visits to Physicians’ Offices in the U.S., 2009–2012

HIV testing serves as an entry point for HIV care services for those who test HIV positive, and prevention services for those who test HIV negative. The Centers for Disease Control and Prevention recommends routine testing of adults and adolescents in healthcare settings. To identify missed opportunities for HIV testing at U.S. physicians' offices, data from the National Ambulatory Care Surveys from 2009 to 2012 were analyzed. The mean annual number and percentage of visits with an HIV test among HIV-uninfected nonpregnant females and males aged 15-65 years was estimated using weighted survey data. Factors associated with HIV testing at visits to physicians' offices were identified. The mean annual number of U.S. physicians' office visits with an HIV test conducted was 1,396,736 (0.4% of all visits) among nonpregnant females and 986,891 (0.5% of all visits) among males. For both nonpregnant females and males, HIV testing prevalence was highest among those aged 20-29 years (1.3% of all visits by nonpregnant females; 1.7% of all visits by males) and non-Hispanic blacks (1.1% of all visits by nonpregnant females; 1.0% of all visits by males). An HIV test was not conducted at 98.5% of visits at which venipuncture was performed for both nonpregnant females and males. Important opportunities exist to increase HIV testing coverage at U.S. physicians' offices. Structural interventions, such as routine opt-out testing policies, electronic medical record notifications, and use of non-clinical staff for testing could be implemented to increase HIV testing in these settings.

Routinization of HIV &amp; HCV Testing in the Inpatient Setting: Involvement of Residents and Nurses

BackgroundApproximately 1 in 5 and 1 in 2 of people infected with HIV and HCV respectively in the US are unaware of their infection. Risk based opt-in testing strategies result in missed or delayed diagnoses and may further stigmatize these illnesses. The use of routine opt-out testing increases test uptake and can identify patients with HIV or HCV early, resulting in improved outcomes and decreased transmission. This strategy has not yet been fully accepted or operationalized in many health care settings.MethodsWe implemented routine opt-out HIV and HCV testing for all inpatients using internal medicine resident and nurse driven screening models. Patients were eligible for each test if they had not been tested within 1 year and were not known to be infected. Residents were educated on rationale and protocols for routine opt out testing via one grand rounds lecture (January 2016) and one residency orientation lecture (August 2016). Between March and November 2016, residents were incentivized with gift cards awarded for most tests ordered. Nurses were educated through targeted forums. Instructions were distributed and placed in high traffic areas and HIV 1/2 fourth-generation Ag-Ab and HCV Ab orders were added to admission order sets. Patients were given a chance to decline after routine opt-out testing was offered and educational brochure provided, in accordance with Maryland law. Positive tests were confirmed using Western Blot initially, later changed to HIV 1/2 differentiation assay; HCV was confirmed with HCV RNA. Those with confirmed infection were linked to care.Results71% of 3814 and 83% of 2219 eligible patients were tested for HIV and HCV; 54 (2%) and 390 (21%) were diagnosed with HIV and HCV respectively (Figure 1). Testing activity averaged 32 HIV and 28 HCV tests per month from January to March 2016 and increased after the noted interventions to an average of 300 HIV and 247 HCV tests per month from January to March 2017.ConclusionA high disease burden was found within the studied population, highlighting the benefit of routine opt out testing for HIV and HCV. Empowering residents and nurses to offer screening at time of admission is a viable strategy to scale up testing in the inpatient setting.Disclosures All authors: No reported disclosures.

Hepatitis C Testing Strategies in a Correctional Setting

Background There is no widely accepted testing approach for Hepatitis C Virus (HCV) infection in correctional settings, and the majority of U.S. prisons do not provide routine testing. Given the high prevalence of HCV in this setting, effective strategies for testing in corrections are needed.Methods We used data from the Washington State Department of Corrections (WADOC), which has implemented opt-out HCV testing for all inmates at intake, to assess the difference in yield between routine testing vs.. current recommendations for risk-based and birth cohort testing for individuals born between 1945 and 1965. We analyzed data from a retrospective cohort of individuals who entered WADOC from January 1, 2012 to July 7, 2016. We also calculated the liver fibrosis stage of individuals with chronic HCV, defined as having a detectable HCV viral load, using Aspartate aminotransferase to Platelet Ratio Index (APRI).Results24,731 individuals (83%) had opt-out HCV antibody testing upon prison entry, and 4,951 (20%) had a reactive test. Of those, 3,797 (77%) were white, 4,023 (81%) were male, and 51% of individuals with a reactive test had a history of any drug use, defined by self-report or a drug-related offense. 2407 (47%) had an HCV RNA performed, and of those 1730 (72%) had chronic HCV infection. The prevalence of HCV antibody positivity was higher in individuals born between 1945 and 1965 when compared with those outside of the birth cohort (44% vs. 16%); however, the majority of cases (72%) were diagnosed outside of the birth cohort. Up to 35% of those with a reactive test would have been missed with combined risk-based and birth cohort testing compared with routine opt-out testing of all inmates at intake. Among individuals with chronic HCV infection and available liver fibrosis staging, 369 (21%) had at least moderate fibrosis including 209 (12%) with severe fibrosis. In addition, 262 (21%) of individuals outside of the birth cohort without a history of drug use, had at least moderate liver fibrosis.Conclusion Targeted testing practices in prisons likely miss a substantial proportion of persons living with HCV, and associated liver fibrosis. Routine testing at prison entry should be considered for inclusion in the national HCV elimination strategy.Disclosures All authors: No reported disclosures.

Adopting Routine Opt-Out Testing in a Children's Hospital to Reach Traditionally Difficult Adolescent Population

Adopting Routine Opt-Out Testing in a Children's Hospital to Reach Traditionally Difficult Adolescent Population

Clinical outcomes of routine opt-out antenatal human immunodeficiency virus screening: a systematic review.

To evaluate the clinical outcome of routine screening of human immunodeficiency virus in antenatal clinic settings. Despite the growing advances in human immunodeficiency virus management, nearly 30% of the estimated 1·5 million seropositive pregnant women are undiagnosed. Routine opt-out testing is a strategy endorsed by the World Health Organization in to increase testing rates in clinical settings. A systematic review of relevant published literature. A comprehensive electronic search for relevant studies in Science Direct, MEDLINE, SCOPUS, CINAHL and PubMed was conducted with search terms (Box2). Hand searches were also conducted for additional resources. There were no geographical restrictions. Searches were restricted to English language and studies conducted between 1998-2015; totaling 1097 were retrieved and carefully appraised for review. Eighteen studies were eligible for review: eight from Africa, five from the United States, three from Europe, one from Australia and one from Asia. Fourteen studies reported increases in human immunodeficiency virus testing rate. Following the introduction of routine testing, human immunodeficiency virus testing rates increased from values ranging from 68-99·9% with median value of 88%. The comparison studies reported testing uptake of 22-93·5% with median value of 59%. Maternal human immunodeficiency virus case detection rates nearly doubled following adoption of routine testing at values of 99 and 45% during opt-in. Linkage to treatment and care for prevention of vertical transmission was reported on six studies, and results ranged between 12·9-77·2%. The findings show that irrespective of human immunodeficiency virus epidemiological scenarios, routine testing gave more women opportunity to learn their human immunodeficiency virus status and take measures for prevention of mother-to-child transmission of human immunodeficiency virus. Future studies should focus on identifying strategies to improving linkages to treatment and care for prevention of vertical transmission. Understanding the contributions of Routine opt-out testing in antenatal clinic would help practitioners adopt the novel testing model for more mothers to learn their human immunodeficiency virus status for prevention of mother-to-child transmission.

Integrating Routine HCV Testing in Primary Care: Lessons Learned from Five Federally Qualified Health Centers in Philadelphia, Pennsylvania, 2012-2014.

An estimated 2.7-3.9 million Americans are infected with hepatitis C virus (HCV). Despite being the most common blood-borne virus in the United States, routine HCV testing is not commonly practiced. To address this gap, we measured the impact of integrated routine HCV testing on patient care. As part of CDC's Hepatitis Testing and Linkage to Care initiative, which promoted viral hepatitis B and hepatitis C screening, posttest counseling, and linkage to care at 34 U.S. sites, National Nursing Centers Consortium integrated a routine opt-out HCV testing and linkage-to-care model at five federally qualified health centers in Philadelphia, Pennsylvania, from October 1, 2012, to June 30, 2014. The model included medical assistant-initiated testing, reflex laboratory-based HCV tests, and electronic health record modifications to prompt, track, and facilitate reimbursement for tests performed on uninsured patients. During the study period, 4,207 unique patients received HCV antibody (anti-HCV) testing, of whom 488 (11.6%) tested anti-HCV positive. Of those testing positive, 433 (88.7%) received a confirmatory HCV RNA test; of these 433 recipients, 313 (72.3%) were diagnosed with current infection (overall prevalence = 7.4%), of which 243 (77.6%) received their HCV RNA-positive results, 184 (58.8%) were referred to an HCV care provider, and 121 (38.7%) were linked to care. The highest rates of current infection were among non-Hispanic white patients (18.1%, 90/496); patients from the Public Health Management Corporation Care Clinic, which treats HIV and HCV patients on-site (14.3%, 200/1,394); and patients aged 50-69 years (10.7%, 189/1,767). Our model successfully integrated HCV testing and linkage to care into routine primary care. This study also identified potential successes and barriers that may be experienced by other primary care health centers that are integrating HCV testing.

Opt-out testing for blood-borne viruses in primary care: a multicentre, prospective study.

Hepatitis B (HBV), hepatitis C (HCV), and HIV blood-borne viruses (BBV) are associated with chronic ill health and mortality. Early diagnosis reduces disease transmission, delays progression, and improves outcomes. Routine opt-out testing for BBV in primary care may be viable in identifying unknown disease. To assess the viability and yield of routine opt-out testing for BBV. A multicentre, prospective, routine opt-out testing study of BBV in primary care between September 2014 and February 2015 across four sites in Dublin, Ireland. All adult patients attending for routine blood tests were offered an additional BBV test during a 6-month period. All individuals were given an information leaflet before phlebotomy and were given the choice to opt out of BBV testing. In total, 1188 patients were invited to participate in the study and 1063 (89.5%) opted to be tested (95% confidence interval [CI] = 87.7% to 91.2%). A total of 125 patients (10.5%) opted out. There were 10 positive results, four new diagnoses, and six previously known. There were two new HBV and two new HCV diagnoses, a yield of four per 1000 (95% CI = 0.9 to 7.5 cases per 1000). No new HIV cases were diagnosed. This study indicates that testing for BBV in patients presenting for routine blood tests in primary care is viable. The yield of HBV and HCV suggests that opt-out testing should be considered in primary care to increase detection rates of BBV.

HIV Testing in Patients With Cancer at the Initiation of Therapy at a Large US Comprehensive Cancer Center.

To determine the rates of HIV testing and infection among patients with cancer at initiation of systemic cancer therapy. We conducted a retrospective cohort study of adults with cancer who registered at a comprehensive cancer center from January 2004 through April 2011 and received systemic cancer therapy. We determined rates of HIV-1/2 and/or Western blot testing and HIV positivity at initiation of systemic cancer therapy. Multivariable logistic regression was used to determine predictors of HIV testing. Of 18,874 patients with cancer who received systemic cancer therapy during the study period, 3,514 (18.6%) were tested for HIV at initiation of cancer therapy. The prevalence of positive HIV test results was 1.2% (41 of 3,514), and the prevalence of newly diagnosed HIV was 0.3% (12 of 3,514). The HIV testing rate was lower in black than in white patients (13.7% v 19.2%), but the prevalence of positive test results was higher in black patients (4.5%) than in any other racial/ethnic group. Among patients with AIDS-defining cancers (eg, non-Hodgkin lymphoma and cervical cancer), predictors of HIV testing were history of non-Hodgkin lymphoma, younger age, and registration after 2006. Among patients with non-AIDS-defining cancers, predictors of HIV testing were younger age, registration after 2006, male sex, history of illicit drug use or sexually transmitted disease, having a hematologic malignancy, and black race. The prevalence of HIV infection among patients with cancer was 1.2%, higher than the 0.1% prevalence threshold above which national guidelines recommend routine opt-out testing; however, the overall HIV testing rate was low.

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.