D.C. hospital starts all-inclusive HIV screening

Most patients readily agree to a free HIV test and are surprised that their physicians haven't tested them already.

By Susan J. Landers — Posted June 23, 2008

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It's a good thing that Celia Maxwell, MD, assistant vice president for health sciences at Howard University Hospital in Washington, D.C., didn't have a clue about all the obstacles she would need to overcome to implement an HIV screening program throughout the hospital.

Otherwise, she freely admits, when the task fell to her in the fall of 2006, she probably would have run the other way. The hospital's senior vice president had urged her to develop the initiative after the Centers for Disease Control and Prevention issued sweeping guidelines calling for HIV screening of almost everyone in the nation.

Now, thanks to intense planning and some important CDC and city health department aid, Howard's program is up and running. In its first 16 months, about 20,000 people, ages 14 to 84, who arrived at the hospital for emergency or routine care, have been offered the free tests. About 13,000 have agreed to take the 20-minute oral HIV antibody test. So far, about 260 have showed signs of infection.

The hospital's efforts have been praised by D.C.'s HIV/AIDS Administrator Shannon Hader, MD, as well as President and Laura Bush. Mrs. Bush toured the hospital to see the program for herself last year.

Widespread agreement surrounds the importance of screening. The AMA and other medical societies endorse testing in multiple venues. By the end of 2003, an estimated 1 million people in the U.S. were living with HIV or AIDS, according to figures released at a national HIV conference. About a quarter of those infected were unaware of their status, the CDC estimated in 2005.

Catching the infection early means not only that treatment is more effective but also that most people who find they harbor the virus will take steps to guard against infecting others. The latest CDC estimates indicate that at least 40,000 people in the nation become infected each year. By offering the test to everyone, stigma also is largely avoided.

And what better place to implement what is believed to be the nation's first hospital-wide screening program than Howard University Hospital. The facility, which is located on the campus of a historically black college, also serves a largely black population in a city that has the highest AIDS case rate in the United States -- 128.4 cases per 100,000 population compared to 14 cases per 100,000 population in the country as a whole. The black community has been hit hardest by the disease.

Starting from scratch

But where to begin, thought Dr. Maxwell, who also is director of the hospital's Women's Health Institute. "I had no template to work from. This has never been done before so I could not go somewhere and read about it. It was trial and error."

She first had to gain the support of the hospital's division chiefs and chairs who were understandably concerned about the time it would take an already stretched staff to test all patients. And then came little things. The rapid HIV antibody test had to be approved by pathology, and a Clinical Laboratory Improvement Amendments waiver obtained. "I would never have known that," she said.

She ultimately developed several testing protocols: confidential testing for patients coming to the emergency department and for inpatients; anonymous testing for patients coming to clinics and other outpatient departments. Another anonymous protocol was developed to test hospital employees, whose circumstances presented a dilemma, said Dr. Maxwell, since some of them may not have felt comfortable being tested on site. The city health department helped resolve this issue by parking a medical van on the street where this testing could be done.

But additional hurdles also had to be confronted. The organizers learned the hard way that patients whose initial tests were positive should be given the definitive Western blot test before they left the hospital because they might not return for their follow-up appointment. "We lost about 80 people," Dr. Maxwell said.

That's when the "street team" went into action, visiting neighborhood fast-food restaurants and other venues. About 70 of these missing patients were found.

Patients who are HIV positive are referred immediately to the hospital's Center for Infectious Disease Management and Research, where they receive treatment.

In general, the response from patients has been overwhelmingly positive, a twist that surprised Dr. Maxwell. "My thought was that most patients would decline the test," she said. "But most didn't." Plus, they returned to the hospital with family members and significant others, and some even brought in children for testing. That meant a protocol for adolescents younger than 18 was needed.

Many patients even expressed surprise that their physicians hadn't already tested them for the virus. They say, "You mean I've been coming to the doctor and they've been drawing all this blood but never tested me before?" Dr. Maxwell said.

She also tailored the program for her particular patients. For example, she decided to tell those whose results on the rapid test indicated exposure to the virus that they were "preliminarily reactive" instead of "positive," since false positive results are not uncommon, and she didn't want to raise unnecessary alarms.

And even though the District of Columbia, unlike many states and localities, doesn't require that people be counseled either pre- or post-test, Dr. Maxwell decided to include counseling. "I wanted patients to be clear that we weren't doing a test without their knowledge. We wanted to give patients a chance to say no."

Although the Howard program has been a trailblazer, the question of sustainability remains. Many insurers don't cover the tests in these settings.

"If I didn't get the [testing] kits from the D.C. Dept. of Health, I could not do it," Dr. Maxwell said. "If I did not get staff that is funded through the CDC, I couldn't do it. There are true barriers."

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The ABCs of HIV screening

Howard University Hospital in Washington, D.C., is believed to be the first facility in the nation to institute a comprehensive HIV screening program. With no template to follow, the program blazed a new trail, and a few lessons were learned along the way. Among them:

  • The response from patients has been overwhelmingly positive with most readily agreeing to be tested.
  • The support of hospital division chiefs and chairs is important.
  • Those who preliminarily test positive using the 20-minute oral test should be given a Western blot test before leaving the hospital. If the diagnosis is confirmed, the patient should be referred for treatment immediately.
  • Until insurance coverage for the tests is widely provided, grant funds likely will be necessary to support a broad screening program.

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