HIV Screening in the Health Care Setting: Status, Barriers, and Potential Solutions

Abstract

Thirty years into the human immunodeficiency virus (HIV) epidemic in the United States, an estimated 50,000 persons become infected each year: highest rates are in black and Hispanic populations and in men who have sex with men. Testing for HIV has become more widespread over time, with the highest rates of HIV testing in populations most affected by HIV. However, approximately 55% of adults in the United States have never received an HIV test. Because of the individual and community benefits of treatment for HIV, in 2006 the Centers for Disease Control and Prevention recommended routine screening for HIV infection in clinical settings. The adoption of this recommendation has been gradual owing to a variety of issues: lack of awareness and misconceptions related to HIV screening by physicians and patients, barriers at the facility and legislative levels, costs associated with testing, and conflicting recommendations concerning the value of routine screening. Reducing or eliminating these barriers is needed to increase the implementation of routine screening in clinical settings so that more people with unrecognized infection can be identified, linked to care, and provided treatment to improve their health and prevent new cases of HIV infection in the United States.

HIV Testing Trends: Southeastern Pennsylvania, 2002–2010

“…Our findings are consistent with previously reported data which demonstrate increased testing specifically among Blacks. 7,8,23 However, contrary to national trends showing stable HIV testing, 4,24 we found that testing increased in Pennsylvania. Similarly, HIV testing rose in Washington DC, which, like Pennsylvania, received financial and structural support from the CDC-led Expanded Testing Initiative.…”

“…[30][31][32] Factors that could have slowed adherence to the CDC recommendations during the study time period include the persistence of policies at the state and health institution level in favor of a separate written informed consent for HIV testing, the lack of awareness of the CDC recommendations among physicians and patients, 24 the stigma associated with HIV testing, 33,34 and challenges with financial reimbursement for opt-out testing. 24 Pennsylvania only removed the provision for written informed consent for HIV testing in 2011, 5 a year after completion of our last survey wave. Old data indicate that states where consent procedures were either streamlined or eliminated saw increases in HIV testing compared to states where written informed-consent statutes were enforced.…”

Missed opportunities for earlier diagnosis of HIV in patients who presented with advanced HIV disease: a retrospective cohort study

“…These studies demonstrate that significant barriers to implementation of universal HIV testing in healthcare settings still exist. One of those barriers may be connected to the insecurity that healthcare professionals may feel while discussing the topic of HIV testing with their patients, particularly those from low-risk backgrounds, citing that discussing HIV testing would be uncomfortable for the patient and might damage the patient–physician relationship 26. In our study, we found that the two most common barriers to send or offer an HIV test were under-recognition of the patients as belonging to a risk group mainly by primary care physicians and not thinking on HIV at all, which was more common among specialists.…”

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

“…The incorrect assumptions concerning routine HIV testing and the false reassurance might influence patients' decisions not to undergo appropriate screening, disclose high-risk behavior, or seek appropriate testing for sexually transmitted diseases in the future [18,19]. These factors have potentially important implications and could conceivably contribute to late diagnosis of HIV, delayed initiation of ART and preventive care for HIV-infected individuals, continued risky behavior, and onward transmission of infection [6,20]. Other potential consequences of patients' misperceptions regarding routine HIV testing include unintentionally misinforming healthcare providers about previous HIV tests and providing inaccurate self-report when surveyed for surveillance estimates [20].…”

“…Identified provider-related barriers include lack of familiarity with current HIV screening guidelines, uncertainty about consent recommendations, and concerns about patients' perception and refusal [5,6]. In fact, despite recommendations for universal HIV screening, risk-based screening persists and screening rates remain unsatisfactory [7].…”