Should you be testing everyone for HIV? Guidelines disagree, for now, and there are many challenges to doing so. Here is some guidance to overcoming barriers to HIV testing in primary care.
According to its current recommendations for HIV screening, last updated in April 2007, the US Preventive Services Task Force (USPTF) only “strongly recommends” that clinicians screen all adolescents and adults “at increased risk for HIV infection,” and makes no recommendation for or against HIV screening in adolescents and adults who are not at increased risk. (It does recommend routinely screening all pregnant women).
Even after the CDC released new screening guidelines in 2006 calling for all individuals between 14 and 64 years of age to be screened, regardless of recognized risk factors, the USPTF stuck to its own recommendation. Meanwhile the American Academy of Family Physicians (AAFP) guidelines follow those of the USPTF, while the American College of Physicians’ fall in line with the CDC’s.
With the approval of Truvada for pre-exposure prophylaxis for non-HIV infected individuals, however, as well as the growing body of evidence attesting to the benefits of early treatment on transmission rates, it appears the USPTF is about to change its recommendations. The AAFP may then follow.
The change is important because of evidence showing that risk-based screening/testing simply is not effective, while early diagnosed and treatment can significantly reduce the secondary transmission of the virus.1-3
Regardless of which agency recommends what in the area of HIV screening, however, the challenge for primary care physicians is how to implement those recommendations in their practices.
The data attests to the challenge. Studies find that nearly one-third of HIV diagnoses occur late in the infection, often after progression to AIDS, despite evidence that these individuals visited a healthcare professional several times in the past year.4-6 In addition, just 54% of US adults report ever having been tested for HIV, while about 20% of those living with HIV are unaware they are infected.7,8
Primary care physicians are on the front lines of the epidemic, perfectly situated to increase screening and testing so that individuals can begin treatment earlier in the course of the disease. Plus, they generally support routine HIV testing.9 Yet a recent survey of 465 primary care physicians found that 22% of providers who offer regular HIV care did not routinely test patients for the virus, while those provided no HIV care did not do any testing at all.10
But there are many barriers to testing in the primary care setting, including time constraints (particularly the time required to get informed consent and provide pre-test counseling); assumptions about age and marital status; consent requirements; lack of funding, staff, and space; concerns how such discussions might impact the patient/provider relationship; lack of awareness of the CDC recommendations; inadequate HIV education and training; and discordance between the CDC recommendations and state consent statutes.9-13
However, studies find there are several opportunities to overcome those barriers and improve primary care based testing, including:
• Nurse-initiated HIV testing. A pilot program at a Veterans Affairs outpatient clinic allowed nurses to order, administer, interpret, and document HIV rapid testing. After one year, such testing increased significantly, as did all types of HIV testing.14
• Routinely offering the testing. Focus groups with patients found that they wished their providers routinely offered such testing so they could decide whether they wanted to be tested, noting that it would also de-stigmatize testing.13
• Using rapid HIV testing. A web-based survey of 406 internists found that just 15% had access to rapid HIV testing. Those that did have access reported fewer barriers to HIV testing, and at least 25% of their patients received such testing.9
• Using the electronic resources. Focus groups with patients in the Veterans Affairs medical system found that patients thought information about HIV risks and testing delivered electronically was more convenient and understandable than verbal information.15
One approach to routine screening is a six-step process developed by Bokhour et al:13
1. Raise the topic of HIV testing
2. Reassure the patient that he/she is not showing clinical signs of the disease
3. Provide Rationale that many patients infected with HIV are not aware of their status
4. Respond to any questions that the patient may have about HIV disease
5. Request permission to order the test
6. Tell the patient when he/she can expect to get the Results.
1. Duffus WA, Weis K, Kettinger L,
Risk-based HIV testing in South Carolina health care settings failed to identify the majority of infected individuals. Aids Patient Care STDS. 2009;23(5):339-345.
2. Sheth PM, Kovacs C, Kemal KS,
Persistent HIV RNA shedding in semen despite effective antiretroviral therapy. AIDS. 2009;23(15):2050-2054.
3. Quinn TC, Wawer MJ, Sewankambo N,
Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Engl J Med. 2000;342(13):921-929.
4. Vital signs: HIV testing and diagnosis among adults--United States, 2001-2009. MMWR Morb Mortal Wkly Rep. 2010;59(47):1550-1555.
5. Persons tested for HIV--United States, 2006. MMWR Morb Mortal Wkly Rep. 2008;57(31):845-849.
6. Late HIV testing - 34 states, 1996-2005. MMWR Morb Mortal Wkly Rep. 2009;58(24):661-665.
7. Kaiser Family Foundation. 2011 Survey of Americans on HIV/AIDS; 2011.
8. HIV testing among men who have sex with men--21 cities, United States, 2008. MMWR Morb Mortal Wkly Rep. 2011;60(21):694-699.
9. Simmons EM, Brown MJ, Sly K,
Barriers and facilitators to HIV testing in primary care among health care providers. J Natl Med Assoc. 2011;103(5):432-438.10. HealthHIV. HealthHIV 2nd Annual state of HIV in Primary Care Suvey; 2012.
11. Johnson CV, Mimiaga MJ, Reisner SL,
Barriers and facilitators to routine HIV testing: perceptions from Massachusetts Community Health Center personnel. Aids Patient Care STDS. 2011;25(11):647-655.
12. Hudson AL, Heilemann MV, Rodriguez M. Missed Opportunities for Universal HIV Screening in Primary Care Clinics. Journal of clinical medicine research. 2012;4(4):242-250.
13. Bokhour BG, Solomon JL, Knapp H,
Barriers and facilitators to routine HIV testing in VA primary care. J Gen Intern Med. 2009;24(10):1109-1114.
14. Knapp H, Anaya HD, Feld JE,
Launching nurse-initiated HIV rapid testing in Veterans Affairs primary care: a comprehensive overview of a self-sustaining implementation. Int J STD AIDS. 2011;22(12):734-737.
15. McInnes DK, Solomon JL, Bokhour BG,
Use of electronic personal health record systems to encourage HIV screening: an exploratory study of patient and provider perspectives. BMC Res Notes. 2011;4:295.