Routine HIV testing making slow inroads

Guideline change still faces significant legal, financial and logistical hurdles.

By Victoria Stagg Elliott — Posted Oct. 8, 2007

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Susan Margletta, MD, a family physician in Norcross, Ga., a suburb of Atlanta, tests her patients for HIV if the slightest hint suggests that they could be carrying this virus. But does she offer to screen everyone ages 13 to 64 as recommended by Centers for Disease Control and Prevention guidelines? No. She is not convinced it is worth it.

"I'm not offering it to everyone who comes in the door. In 13 years of practice, I've diagnosed one person with HIV. How can I justify changing the way I practice? That's not logical or an appropriate use of resources," said Dr. Margletta, who is the board chair of the Georgia Academy of Family Physicians but was speaking personally.

A year after the CDC made a huge change to its HIV testing recommendations and called for the test to become a routine part of medical care available in a wide range of health care settings, many physicians are less than sold on the idea of offering it to all comers. Agency officials hope that removing the burden of risk assessment, along with the need for extensive counseling and explicit consent, will lead to screening and diagnosis of more of those who are infected but don't know it. An estimated 25% of those infected are unaware of their HIV status.

Data on the impact of this revision will not be available for another year, but early signs indicate that the reception has been mixed. The guidelines do allow physicians in areas with low rates of infection confirmed by routine testing to return to more traditional detection strategies, but CDC focus groups have found that many physicians are less than keen on attempting routine testing at all.

The American Medical Association and the HIV Medicine Assn. support routine testing. The American Academy of Family Physicians endorses simplified counseling and consent procedures, but, more consistent with the U.S. Preventive Services Task Force, recommends testing those at high risk for infection or who present for care in high-prevalence settings.

"The evidence that we have is that there is incremental adoption," said Bernard Branson, MD, the CDC's associate director for laboratory diagnostics. "We expect that physicians will use good judgment in implementing these recommendations."

Continuing challenges

Even for physicians who do want to make HIV testing more routine, the obstacles are significant. A paper in the July issue of AIDS identified 41 different hurdles. Most notably, many state laws require the kind of formal consent process that the CDC guidelines say is no longer necessary and that many doctors consider onerous. Laws are starting to change, although slowly. In June, Illinois scrapped its requirement for written consent. The law goes into effect next year. Other states are expected to follow suit.

"The state laws that serve as barriers to testing should be changed. Until that happens, we cannot make it a routine test in primary care," said Doug Campos-Outcalt, MD, MPA, associate chair of the Dept. of Family and Community Medicine at the University of Arizona, Phoenix and president of the Arizona Academy of Family Physicians. His state's laws call for specific verbal or written consent, but his medical society is pushing for change. "The more testing we can do the better. It's very, very difficult to know someone's true risk. They may not be frank about that, not even to their physician."

The issue of paying for the test is also in play. Several analyses have suggested that routine testing is cost effective, but reimbursement is not a done deal. A report published by the National Alliance of State and Territorial AIDS Directors found a lack of funding was by far the most important reason for physicians and other health care professionals to resist making testing more common.

"It's not been worked out who is going to pay for the test and the time to administer it. No one's getting extra money to do this," said Donna Futterman, MD, director of the adolescent AIDS program at Montefiore Medical Center in the Bronx, N.Y.

Early pilot programs in emergency departments in areas of high prevalence also have hit logistical hiccups. Several papers presented at the May meeting in Chicago of the Society for Academic Emergency Medicine found that many patients were willing, but connections to needed follow-up testing and care were problematic. Also, staff often didn't have time to administer the test, get results and communicate them to the patient. Those running HIV testing educational programs for primary care physicians say they frequently encounter doctors who can't test more frequently because of time constraints and the need to prioritize other screening.

"There's interest in it," said Dr. Futterman, who frequently speaks on this subject. "But [primary care physicians] have so many things on their plate."

Although these guidelines have yet to result in great numbers being tested who would not have been before, experts say an intangible but important impact is being felt.

"Testing is more in the minds of physicians and of institutions than it has been before," said Robert Garofalo, MD, president of the Gay and Lesbian Medical Assn. and director of adolescent HIV services at Children's Memorial Hospital in Chicago. "Some progress has been made over the past year."

The CDC is collaborating with various medical societies to develop implementation guidelines. An HIV testing toolkit for emergency departments was produced by the American Hospital Assn.'s Health Research and Educational Trust in August. A similar project intended for primary care physicians is expected within the year.

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HIV testing: Consent and counseling laws

State laws dictating how physicians handle HIV testing vary widely. Many are expected to change in response to guidelines issued by the Centers for Disease Control and Prevention a year ago recommending streamlined consent procedures. Here is how states stand as of the end of August.

Written or verbal informed consent required: Alabama, Alaska, Arizona, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Indiana, Louisiana, Maine, Missouri, Montana, New Mexico, North Carolina, North Dakota, Ohio, Oregon, Texas, Virginia, Washington, West Virginia, Mississippi (in most cases, measures include a counseling component)

Written consent required: Maryland, Massachusetts, Michigan, Nebraska, New York, Pennsylvania, Rhode Island, Wisconsin

No requirements for informed consent or counseling: DC, Idaho, Minnesota, New Jersey, South Carolina, South Dakota, Tennessee, Utah, Vermont

Counseling must be offered: Kansas, Nevada, Oklahoma, Wyoming, Arkansas

Laws are in accordance with CDC guidelines or have been enacted but not yet taken effect: Illinois, New Hampshire, Iowa, Kentucky

Notes: The Nebraska law includes a posttest counseling requirement for health care workers who acquire HIV on the job. The Arkansas measure requires that health care workers who are exposed to HIV receive counseling.

Source: "State HIV Testing Laws -- 2007," National HIV/AIDS Clinicians' Consultation Center, University of California, San Francisco, Aug. 23

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External links

"Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings," Morbidity and Mortality Weekly Report, Sept. 22, 2006 (link)

National HIV/AIDS Clinicians' Consultation Center, University of California, San Francisco (link)

"Improving Access to Rapid HIV Testing: An Update," AMA Council on Science and Public Health, November 2006 (link)

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