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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”


      

ADDRESSING HIV TESTING, INFORMED CONSENT AND COUNSELING

Approximately one 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.

Text Box: Revised CDC recommendations include:[1] 
§         Making HIV testing routine in all healthcare settings, and using opt-out testing procedures, which offer HIV testing to all patients unless they choose to decline;
§         Not requiring specific written informed consent (HIV test included in general consent);
§         Informing patients verbally or in writing that the HIV test will occur, and providing them with information regarding possible results verbally or in writing;
§         Prevention counseling is not recommended/required in conjunction with HIV testing and not required as a part of routine screening in healthcare settings.
Text Box: What is Routine HIV Testing?
 
HIV tests are preformed in healthcare settings for all people ages 14-65, regardless of an apparent risk for HIV/AIDS.

 

 

  


 

 SHAPE  \* MERGEFORMAT

Emergency 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.

Routine HIV 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.

    

Text Box: CALL TO ACTION:
Illinois Must Expand HIV Testing, While Maintaining Informed Consent and Pre/Post-Test Counseling
Illinois should commit to reducing the number of people unaware of their HIV status by making HIV testing routine. In this process, however, it must still maintain laws which protect the individual rights of people being tested.  The AIDS Foundation of Chicago (AFC) stresses the importance of informed consent and linkages to care and prevention: 
§         Written informed consent is vital to HIV testing, because of potential discrimination and stigma attached to a positive result. It is necessary to confirm that a patient is aware of his or her rights and has knowledgably consented to the HIV test and its results.
§         Pre-test counseling is essential to inform an individual about HIV/AIDS, transmission modes, and the HIV test and its consequences;
§         Post-test counseling then provides further information about the meaning of a positive or negative result, risk-reduction techniques, and, if necessary, links an individual to additional care services.
§         Pre- and post-test counseling should be adapted for use in routine HIV testing in all healthcare settings;
§         If any of these aspects to HIV testing are eliminated or short-sided, an individual’s rights are impeded, and an opportunity is lost to better inform the public about HIV/AIDS prevention, risk-reduction, and care. 
 
 
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Text Box: CURRENT HIV TESTING POLICIES IN ILLINOIS
 
An estimated 40,000 to 42,000 people are living with HIV/AIDS in Illinois. This includes 26,617 reported living HIV/AIDS cases, approximately 10,000 Illinoians who are unaware of their positive HIV/AIDS status, and 3,000-5,000 individuals with known but unreported HIV diagnoses.* 
 
The following laws apply to HIV testing in Illinois:*
§         Specific written informed consent is required;
§         Pre/post-test counseling is mandatory for everyone tested, including pregnant women
§         Mandatory offering of HIV test for pregnant women in prenatal care (opt-in) and for women entering labor and delivery with undocumented HIV status.
 
 

 

 

 

 

 

 

 

 

STRATEGIES TO INCREASE HIV TESTING IN HEALTHCARE SETTINGS: WHAT WORKS

Opt-out testing: 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 over 50%.

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 counseling, 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 department.


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.

Brochures or 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.

    

Triage 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.

 

Provider Training: 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 found at   http://www.adolescentaids.org/healthcare/acts.php

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.”

[1] CDC. Revised Recommendations for HIV Testing of Adults, Adolescents and Pregnant Women in Health Care Settings, Draft 3/7/06.

[2] HIV/AIDS Policy Fact Sheet: The HIV/AIDS Epidemic in the United States. The Henry J. Kaiser Family Foundation, September 2005.

[3] 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.

[4] Gabor D. Kelen, et al. Feasibility of an Emergency Department-Based, Risk-Targeted Voluntary HIV Screening Program. Annals of Emergency Medicine 1996; 27: 687-692.

[5] 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.

[6] 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; 352: 586-595.

[7] Ray Y. Chen, et al. Distribution of Health Care Expenditures for HIV-Infected Patients. Clinical Infectious Diseases 2006; 42: 000-000.

[8] Rochelle P. Walensky, et al. The Survival Benefits of AIDS Treatment in the United States. The Journal of Infectious Diseases 2006; 194: 11-19.

[9] 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.

[10] Illinois: State Policies Relating to HIV Testing, 2005. Health Research and Educational Trust. April 6,2006. Online at http://www.hret.org/hret/about/states/Illinois.pdf. Found on July 28, 2006.

[11] HIV/AIDS Confidentiality and Testing Code Section 697.10 Applicability. Illinois Department of Public Health. Online at http://www.ilga.gov/commission/jcar/admincode/077/07700697sections.html.

[12] CDC. Reducing HIV Transmission From Mother-to-Child: An Opt-Out Approach to HIV Screening. On website:  http://www.cdc.gov/hiv/projects/perinatal/materials/OptOut.htm.  Found on August 24, 2006.

[13] 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 http://cdc.confex.com/cdc/std2006/techprogram/P10901.htm.  Found on June 22,2006. 

[14] Julie Subiadur, RN. Denver Public Health Department. Interview in July 2006.

[15] Kay Caddell. Dallas County Health and Human Services. Interview in July 2006.

[16] Gus Cairns. New directions in HIV prevention: serosorting and universal testing. AIDSMAP News, March 8, 2006. Online at http://www.aidsmap.com/en/news/506BAAS4-163A-422E-8D5F-B874E401A9C6.asp. Found on July 6, 2006.

[17] Deborah Cohen, et al. Cost-Effective Allocation of Government Funds to Prevent HIV Infection. Heath Affairs 2005; 24: 915-926.

[18] 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: 21-27.

[19] 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.

[20] ACTS: A Rapid System for HIV Counseling and Testing. Adolescent AIDS Program. Online at http://www.adolescentaids.org/healthcare/acts.php.  Found July 27, 2006.

[21] 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: http://www.aids2006.org/PAG/Abstracts.aspx?AID=31772. Found on August 24, 2006.