Opt-out system for HIV testing proves successful

More are tested and referred to care

The Denver (CO) Public Health Department has changed its HIV testing program over the past few years to an opt-out, rapid HIV test program, which has resulted in a 50% increase in HIV positive cases identified in the sexually transmitted infection (STI) clinic.

"The number of HIV positives has increased from 39 in 2003 to 48 in 2004 to 55 in 2005," says Kees Rietmeijer, MD, PhD, director for the STD Prevention Program.

"The people we find with HIV infection who initially tell us they are at low risk has increased over the years," Rietmeijer says. "In the old times, we excluded those people from testing because we thought they were low risk."

The STI clinic began to offer the rapid HIV test in November, 2003, after years of providing standard HIV testing with pre-test and post-test counseling.

"One of the problems with this, and it's something that's been acknowledged for a long time, is a lot of people — 66% — did not call back for the results," Rietmeijer says. "So there were quite a few people we missed."

With the rapid HIV test, 100% of people receive their results, so that was the first improvement to the clinic's HIV testing program, he says.

"I was concerned at the beginning about whether this type of testing would be acceptable because most people who come to the clinic do not necessarily come to get an HIV test," Rietmeijer says. "But the rapid test was quickly embraced by the clientele, and on July 1, 2004, we discontinued the standard test and only did rapid testing."

With a complete switch to rapid HIV testing, a major logistical change had to take place, he notes.

"In the old days, people came to the clinic, registered, and signed a consent form that said they will allow all of the tests that need to be done as part of a routine check-up, but the HIV test was excepted from that form," Rietmeijer says.

Instead, the previous method was to have the patient meet with the clinician, who would conduct a brief risk assessment and then offer the HIV test if the person was deemed at high risk, Rietmeijer says.

When the rapid test was introduced, this created a logistical problem: the rapid test takes 20 minutes, so if it the clinician offers it after a risk assessment, it generally will add unproductive time to the visit, he explains.

"So we said we needed to do something different here because that was not working," Rietmeijer says.

The solution was to move all of the blood tests to the beginning of the patient's visit, before the clinician even sees the patient, he says. This way the person has blood drawn only once for STIs and HIV, and the HIV test results are ready while the patient is still seeing the clinician.

Once this change was made, it seemed logical to change HIV testing from an opt-in process to an opt-out process. So the consent form was changed to include a statement that requests patients check the box if they choose not to receive an HIV test, Rietmeijer says.

"We saw an increase in HIV testing acceptance [among people who said they did not know their status] from 80% prior to the rapid testing to 97% currently," Rietmeijer says. "For gay men the acceptance rate was 90%, and my suspicion is there are men who know they are HIV positive, but they may not tell the clinician this."

The clinic's demographics include about two-thirds men and 10% to 15% are men who have sex with men (MSM). Most are in the 20-30-year age group. About 60% of the clinic's patients are not white, including 22% African American and 33% Latino, Rietmeijer says.

The Denver clinic's change from selected HIV testing accompanied by pre-test counseling to the current system of routine testing and no pre-test counseling could soon be the standard way HIV testing is done in many clinical settings, he notes.

"You will see increasingly a changing attitude toward HIV testing and counseling," Rietmeijer predicts.

"For most of the patients who come to an STD clinic, it's a no-brainer: HIV testing is part of the experience," Rietmeijer says. "They know HIV is by and large a sexually transmitted disease — we have a very low prevalence among injection drug users."

As a result of this understanding, there has been pattern of HIV testing becoming a more normal part of the STD clinic experience for patients, and clinicians have had to catch up with this shift in philosophy, Rietmeijer notes.

"I was the director of HIV prevention for a number of years, and when they had rapid HIV testing, I was critical and unsure about it," he says. "But our experience has been very positive."

Patients who are tested for HIV and receive a positive finding are automatically tested for viral load and CD4 cell count at the same visit, Rietmeijer says.

"Then we link them to our care manager for a visit in a week to discuss the results, and we link them to HIV services within the public health system or elsewhere," he says. "We follow-up with additional services if they need them, including prevention services, counseling, and mental health."

The Centers for Disease Control and Prevention (CDC) will publish new recommendations shortly, and Rietmeijer's study is part of a national effort of demonstrating the success of switching to routine HIV testing. The recommendations will suggest that in some settings, including emergency rooms, private physician practices, and STD clinics, HIV testing does not have to be accompanied by pre-test counseling.

"We've always known that the amount of counseling we could offer specifically related to HIV was more limited," Rietmeijer says.

"I'm a total proponent for counseling because I think it's very important, and we know good counseling can prevent STDs," Rietmeijer says. "But I think we should provide counseling to all patients in a clinic, regardless of whether they receive an HIV test."

The traditional way of handling HIV counseling was to provide it as a separate entity, developed around HIV pre-test and post-test, he notes.

Research has shown that patients who are at risk for STDs, but not at risk for HIV, had 20% lower rate of STDs if they received good prevention counseling, Rietmeijer says.

"We have an audience who come to the STD clinic for a certain crisis," Rietmeijer says. "For a majority of people, the diagnosis is a shocking thing, and it's a moment when they're susceptible to counseling messages, if they're done well."

Rather than provide HIV pre-test counseling, the clinic has a good risk assessment process with open-ended questions, Rietmeijer says.

"We get patients to open up with the risks they are engaging in and get them to identify a risk they think they can work on and change," he explains. "And we negotiate a risk reduction plan around that behavior."

Since STD clinics frequently provide risk assessments and counseling services, the Denver clinic is working with clinicians to incorporate the essence of good prevention counseling into their daily interactions with patients, Rietmeijer says.

"The whole interaction takes 20 to 45 minutes, depending on the complexity of the case," he says. "If we get into substance abuse or mental health problems or alcohol issues, it could take a while longer."