Primary care physicians' implementation of routine screening is crucial to reducing the incidence of and mortality from HIV. Here's how to implement routine testing in your practice.
Aiming to reduce the number of new HIV infections and save lives among those already infected, the Centers for Disease Control and Prevention recently issued new guidelines recommending that all Americans ages 13 to 64 be voluntarily screened for HIV as part of their routine medical care. The new guidelines mean big changes for primary care physicians.
"We need to convince physicians that routine testing is a rational approach that has significant benefits for patients and public health. It's a major change in the mindset about HIV testing," says Jeffrey Schouten, MD, clinical assistant professor of surgery at the University of Washington and board chair of the American Academy of HIV Medicine.
While physicians face obstacles in implementing the new guidelines -- including states' consent and counseling requirements, spotty insurance coverage, time management and communication issues -- leaders in HIV/AIDS medicine say the obstacles can be overcome or minimized. They emphasize that primary care physicians' compliance is crucial to reducing the incidence of and mortality from HIV.
The case for routine screening
Why is routine, widespread HIV screening needed? According to the CDC:
•Studies show that when people find out they are HIV-positive, most take steps to avoid infecting others.
•Up to 1.2 million people in the United States are living with HIV, and about 40,000 people become newly infected each year.
•50 to 70 percent of new sexually transmitted HIV infections are attributable to the 25 percent of HIV-infected people who don’t know their HIV status.
•Nearly 40 percent of those diagnosed with HIV are diagnosed within a year of progressing to full-blown AIDS, when it may be too late to fully benefit from life-saving anti-retroviral treatments.
The new guidelines: key provisions
•All Americans ages 13 to 64 should be voluntarily screened for HIV infection as part of their routine medical care. This is a significant change from the CDC's previous guidelines, which recommended HIV testing only for high-risk individuals -- such as intravenous drug users and people with multiple sex partners -- and for everyone in healthcare settings with an HIV prevalence of more than 1 percent.
•Individuals at high risk of HIV infection should be tested at least once annually. Others should be tested at least once.
•HIV testing must be voluntary and undertaken only with the patient’s knowledge. Patients should have the opportunity to decline testing.
•To overcome significant barriers to testing, pre-test counseling and written consent specifically for HIV tests should no longer be required. Consent for HIV testing should be included in the general consent for medical care. Currently, 14 states require separate signed consent for HIV testing, and 22 states require pre-test counseling, but some of those states will be revising their laws to conform to the new guidelines, CDC officials say.
Eight steps to implementing routine HIV screening:
1. Get informed, identify referral sources.
As key first steps, primary care physicians should become familiar with the new guidelines and with their state's laws governing HIV testing. Regional training sessions are offered by the AIDS Education and Training Centers. The National HIV/AIDS Clinicians' Consultation Center has compiled a digest of state HIV-testing laws.
Primary-care practices need to determine whether they have the capacity to care for HIV-positive patients or will need to refer those patients to other providers for their HIV care. The HIV Medicine Association and the American Academy of HIV Medicine provide state-specific listings of HIV medicine specialists.
2. Inform patients.
At patient visits, physician practices should inform their patients that HIV screening is now a routine part of recommended medical care. The CDC is developing posters for waiting rooms, and brochures to give to patients. A nurse or medical assistant should also mention the new policy to patients at check-in or when triaging them.
3. Implement new procedures and work-flow changes.
Despite the extra work involved, widespread HIV screening needn't be burdensome, says Donna Sweet, MD, a professor of internal medicine at the University of Kansas School of Medicine, and director of the Kansas AIDS Education and Training Center. "There's a lot you can do to systemize this and work with your staff so the doctor doesn't have to do everything," Sweet says. While it's the physician's job to recommend that their patients get tested, she says, other personnel can be trained to administer the test.
4. Raise the issue, without stigma.
Many physicians are still reluctant to suggest HIV testing for their patients, for fear of offending them. To avoid such reactions, HIV specialists recommend a simple, broad-based approach. "My message to patients would be, 'The CDC is recommending an HIV test for all patients, and we're complying because we think it's important,'" says Curt Beckwith, MD, an HIV specialist and an assistant professor of medicine at Brown Medical School. "That really reduces the stigma, because you're not singling out anyone."
5. Get consent.
In states that require signed consent specifically for HIV testing, physicians can streamline the process by first giving patients printed materials about the test, and then having a nurse or medical assistant get the form signed. Physicians in other states must either get verbal consent for HIV testing, documented in the patient’s chart, or (depending on state laws) they can simply include HIV testing in their practice's general consent for medical care.
6. Decide which test to use
There are two main types of HIV tests:
•A screening antibody test, also known as an ELISA test (enzyme-linked immunosorbent assay) -- tests blood or saliva, costs about $5 per test and takes 10-14 days to get results. Since patient follow-up is required, the test is not appropriate for medical settings that lack continuity of care.
•Point-of-care rapid testing -- uses a blood or oral swab sample, produces results within 20 minutes, and is the only type of test where no conventional lab is needed. Many HIV specialists recommend rapid testing because of its immediate results, with no need for patient follow-up. Drawbacks are the higher cost -- $15-$17 per test -- and the need to confirm positive results with an antibody test known as the Western blot assay.
7. Address coverage and reimbursement concerns.
Though Medicare, Medicaid, and most private health plans cover HIV tests for diagnostic purposes, many plans don't cover routine screening, nor does Medicare. Medicaid coverage varies by state. The CDC is pushing insurers and government agencies for adequate coverage and reimbursement for HIV screening. Bernard Branson, MD, associate director in the CDC’s Division of HIV/AIDS Prevention, notes that the agency has applied for a CPT code for HIV screening, and he predicts that coverage for the service will be nearly universal within a few months.
8. Deliver the results.
For rapid HIV testing, patients get the results on-premises within minutes. Practices that use other kinds of tests must decide how to inform patients of the results. For those who test negative, notification by mail or phone is appropriate -- or even by e-mail, but only if a secure connection is used to protect patients’ privacy. For patients who test positive, results should be conveyed in a supportive, personal way -- never by mail, e-mail, or voicemail. For these patients, a follow-up appointment is needed to discuss the implications, a plan of ongoing care, and prevention counseling to avoid infecting others.
Such visits should be at least 30 to 45 minutes long, recommends Beckwith. "You absolutely can't tell someone they're HIV-positive in 15 minutes. There needs to be an in-depth conversation." He acknowledges that "telling someone they're HIV-positive is scary for doctors.” But when breaking the news, he emphasizes the enormous progress that has been made in HIV care. "I tell my patients that in 2006, HIV is a manageable disease. If you take your medicines, you can live a long life with HIV."
Revised HIV screening guidelines from the Centers for Disease Control and Prevention
Regional HIV training centers, from the AIDS Education and Training Centers
Summary of state HIV testing laws, from the National HIV/AIDS Clinicians' Consultation Center
Searchable provider listing (physicians specializing in HIV care), from the HIV Medicine Association
Searchable provider listing, (physicians and other providers specializing in HIV care) from the American Academy of HIV Medicine
National HIV Telephone Consultation Service -- staffed by clinicians for clinicians
Information on HIV tests, from the CDC
Information on rapid HIV testing, from the CDC
Expanded HIV Screening in the United States: Effect on Clinical Outcomes, HIV Transmission, and Costs (Annals of Internal Medicine, vol. 145, no. 11, Dec. 5, 2006)
Cost-Effectiveness of Screening for HIV in the Era of Highly Active Antiretroviral Therapy (New England Journal of Medicine, vol. 352, no. 6, Feb. 2005)
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