HIV TESTING, INFORMED CONSENT AND COUNSELING
quarter (252,000 to 312,000) of HIV-positive people in the United States
is unaware of their HIV status.
An estimated 49% of people living with HIV/AIDS in the US are African
American and 20% are Latino.
It is likely that the majority of people unaware of their positive HIV
status are people of color.
The Centers for
Disease Control and Prevention (CDC) predict that this 25% of
HIV-positive people may be responsible for 54-70% of sexually
transmitted HIV infections. The transmission rate among people
unaware of their positive status is approximately 3.5 times greater than
those aware of their positive status.
In an effort to reduce
the number of people unaware of their positive status, and in hope of
preventing future transmissions by this population, the CDC has
developed a number of new recommendations to encourage and increase HIV
testing around the country.
SHAPE \* MERGEFORMAT
departments (ED) are ideal locations to implement routine HIV testing.
High rates of undiagnosed HIV infections in patient populations are
common to many inner-city EDs, which may provide the only access to the
health care system for many people at high-risk.
The largest implementation challenges in EDs are time and personnel
constraints. These could be reduced by using streamlined testing and
counseling methods, examples of which are outlined later in this report.
screening is cost-effective, even in areas with low HIV/AIDS prevalence.
The cost of implementation is often perceived to be a challenge to
routine HIV testing, but two 2005 studies show that in the long run, HIV
testing and prevention will reduce future healthcare expenses involving
HIV/AIDS. The cost-effectiveness is similar to that of commonly accepted
interventions, such as routine diabetes testing.4
Early diagnosis of
HIV is shown to be more cost-effective than late diagnosis. People
who are diagnosed and receive treatment and care for HIV early remain
healthier longer and need less extensive healthcare services than those
with a late diagnosis.
People who are diagnosed early live approximately 13.3 years longer than
those who are not treated.
STRATEGIES TO INCREASE HIV TESTING IN
HEALTHCARE SETTINGS: WHAT WORKS
As routine procedure, clinicians will inform a patient that an HIV test
will be performed unless they decline. This tests everyone, regardless
of their risk status, and therefore does not miss people who are outside
the targeted high-risk behavior. Opt-out testing could also reduce
stigma associated with HIV testing by making it just as common as other
health screenings. Opt-out testing during pregnancy has already shown to
be highly effective, with acceptance rates of over 85%.
Example: Denver, CO. Opt-out testing is used at main HIV testing site
in the city. Written informed consent is still required, and written
refusal of HIV test is required on a consent form. Pre/post-test
counseling is provided for every patient. Opt-out consenting did
increase the number of people accepting HIV testing.
Example: Dallas, TX. Opt-out testing with written informed consent is
used in the STD clinic, but not in the HIV Testing and Counseling Center
(the HIV testing center still maintains complete written informed
consent and pre/post-test counseling).
In the STD clinics, the proportion of patients tested has increased by
Videos as pre-test
counseling tool: Using a video as a pre-counseling tool is another
option in reducing the time and personnel constraints to routine HIV
testing. Videos have shown to be a cost-effective strategy in pre-test
and can reduce problems involving literacy.20
Example: In a recent study in New York, the use of a pretest counseling
video, which relayed the necessary information to make an informed
decision to consent to an HIV test, was shown to be at least as
effective as an in-person counselor in an urgent care emergency
Graphic flip charts: Flip charts that graphically relay
information about HIV/AIDS, the HIV test and transmission modes are
another quick and consistent way to reduce pre-test counseling time.
Example: Perinatal rapid testing in Illinois has successfully used flip
charts in over 130 birthing hospitals throughout the state to offer HIV
testing to pregnant women, who are unaware of their HIV status. Copies
are available in both English and Spanish.
pamphlets: These can easily outline the HIV antibody test, state the
fact that the test is voluntary, and describe the consequences of a
positive or negative result. Patients could receive this information
while waiting, and a counselor may only be needed to answer questions
and make sure the patient understood the information.
risk-assessment: This technique makes full pre/post-test counseling
available to high-risk people, while low-risk people receive information
in pamphlet form.
Example: In Edinburgh, a study tested the efficacy of a risk-assessment
table that identified people as high or low risk for HIV infection.
Those who were high-risk received full HIV pre/post-test counseling,
while those at low-risk received pamphlets relaying the necessary
information. The risk assessment table correctly identified HIV-positive
people 93% of the time.
Using efficient techniques to train clinicians, nurses and
counselors can make the transition to rapid testing more smooth and make
time constraints more manageable.
Example: ACTS: A Rapid System for HIV Counseling and Testing:
The Adolescent AIDS Program has created techniques to help healthcare
centers adapt to the new CDC recommendations, while maintaining
counseling and written informed consent requirements. The program is
called ACTS (Assess Consent Test Support). The ACTS manual provides
healthcare centers with checklists, talking points, chart stickers, and
health questionnaires that help ease the transition to routine testing.
They also have HIV/AIDS brochures available on their website. All of
their toolkits are free. The program aims to decrease counseling time
from 30-40 minutes to 5-10. More information about the program can be
Rapid Testing with streamlined counseling:
Rapid testing techniques in combination with streamlined counseling have
shown to be more successful in conveying HIV results. A patient must not
return to the clinic days after the HIV test, but finds out his/her
result in as little as 20 minutes.
Example: Los Angeles, CA. In a study conducted in the primary and
urgent care clinics of the Los Angeles Department of Veteran Affairs,
90.2% of patients tested by rapid testing received their results,
compared to 52.1% of patients tested under traditional counseling and
testing techniques. Results from the study show that implementing rapid
testing “will likely result in higher screening rates than traditional
HIV testing models in primary care.”
 CDC. Revised Recommendations for HIV
Testing of Adults, Adolescents and Pregnant Women in Health Care
Settings, Draft 3/7/06.
 HIV/AIDS Policy Fact Sheet: The HIV/AIDS
Epidemic in the United States. The Henry J. Kaiser Family
Foundation, September 2005.
 Gary Marks, et al. Estimating sexual
transmission of HIV from persons aware and unaware that they are
infected with the virus in the USA. AIDS 2006; 20: 1447-1450.
 Gabor D. Kelen, et al. Feasibility of an
Emergency Department-Based, Risk-Targeted Voluntary HIV
Screening Program. Annals of Emergency Medicine 1996; 27:
 Gillian D. Sanders, et al.
Cost-Effectiveness of Screening for HIV in the Era of Highly
Active Antiretroviral Therapy. The New England Journal of
Medicine 2005; 352: 570-585.
 A. David Paltiel, et al. Expanded
Screening for HIV in the United States – An Analysis of
Cost-Effectiveness. The New England Journal of Medicine 2005;
 Ray Y. Chen, et al. Distribution of Health
Care Expenditures for HIV-Infected Patients. Clinical Infectious
Diseases 2006; 42: 000-000.
 Rochelle P. Walensky, et al. The Survival
Benefits of AIDS Treatment in the United States. The Journal of
Infectious Diseases 2006; 194: 11-19.
 HIV/AIDS in Illinois. Statistics on
HIV/AIDS. AIDS Foundation of Chicago. Online at http://www.aidschicago.org/pdf/2006/fact_illinois.pdf.
Found on August 15, 2006.
 Cornelis Rietmeijer. Increased HIV
testing uptake in a busy urban STI clinic following the
introduction of rapid HIV testing and opt-out consenting. 2006
National STD Prevention Conference. Online at
Found on June 22,2006.
 Julie Subiadur, RN. Denver Public Health
Department. Interview in July 2006.
 Kay Caddell. Dallas County Health and
Human Services. Interview in July 2006.
 Gus Cairns. New directions in HIV
prevention: serosorting and universal testing. AIDSMAP News,
March 8, 2006. Online at
Found on July 6, 2006.
 Deborah Cohen, et al. Cost-Effective
Allocation of Government Funds to Prevent HIV Infection. Heath
Affairs 2005; 24: 915-926.
 Yvette Caldron, et al. An Educational HIV
Pretest Counseling Video Program for Off-Hours Testing in the
Emergency Department. Annals of Emergency Medicine 2006; 48:
 K. Manavi, et al. A rapid method for
identifying high-risk patients consenting for HIV testing:
introducing The Edinburgh Risk Assessment Table for HIV testing.
International Journal of STD & AIDS 2006; 17: 234-236.
 Anaya H. and Asch S. Improving HIV
Screening with Rapid Testing and Streamlined Counseling. United
States Department of Veteran’s Affairs. Abstract from XVI
International AIDS Conference website:
on August 24, 2006.