Legislative barriers hinder progress in opt-out testing

Non-HIV doctors need education on opt-out

Opt-out HIV testing goals by the Centers for Disease Control and Prevention (CDC) of Atlanta, GA, would have greater success if states were to reduce legislative barriers, an expert says.

"We need to reduce legislative barriers so everyone can get an HIV test," says Ping Du, PhD, an assistant professor of medicine at Pennsylvania State University College of Medicine in Hershey, PA.

Since the CDC published its recommendations for nearly universal, routine HIV testing, some federal agencies have allocated money to promote HIV testing, Du says.

"So it's important to take into consideration these public health resources," she says. "To better understand HIV testing behavior, we need to understand individual factors and policy factors."

From the policy aspect, some states have requirements of having people sign a consent form and receive pre-test counseling. These can be a barrier to routine, opt-out HIV testing, Du says.

"Physicians might worry it will take too much time, especially if patients have many questions with regard to HIV testing or if they have concerns," she explains.

Many states have modified public health law to promote opt-out testing, but some lag behind with opt-in HIV testing requirements, Du notes.

According to data collected from the Behavioral Risk Factors Surveillance System, HIV testing has decreased since 2000, despite the CDC's 2006 recommendations for routine HIV testing in health care settings for everyone, ages 13 to 64 years.1

Of 284,688 adults asked about HIV testing in 2008, 38.7% reported having been tested for HIV. This compares with 40.25% of adults having been tested in 1996, 48.11% in 2000, and 35.38% in 2006.1

Blood donors were excluded from the analysis, Du says.

Du's research has found that people living in rural areas are less likely to have HIV testing.

"It could be related to resources," she adds. "They don't have regular access to health care, which may be the reason why rural residents are less likely to be tested for HIV."

Another policy barrier involves payment for HIV tests. Many insurers will not cover HIV testing unless there is a high risk indicated, she adds.

"In the United States population, only a small proportion of people have a high-risk situation, such as drug use, men having sex with men," Du says. "The majority of people do not perceive any high risk for HIV infection."

Routine HIV screening is available to women when they are pregnant, and this strategy has become accepted and widely implemented. So this serves as an example of how it could work in a general population.

"Physicians should promote HIV testing regardless of the individual's risk," Du says.

The study's findings suggest that non-HIV specialists are unaware of the CDC's recommendations for universal and routine HIV testing.

"It's been four years, and everyone should know it according to the literature, but some physicians may not be aware of it," Du says. "Also, physicians are concerned about some logistic issues like insurance and time allocated for counseling and testing."

The solution is a better public health infrastructure strategy, Du says.

There should be insurance coverage for the physician's time for pre-and-post-test counseling, as well as public health resources for testing, she adds.

"Doctors need to screen for HIV for all their patients at least once a year," Du says. "It should be as routine as cholesterol testing."


  1. Du P, Camacho F, Zurlo J. HIV testing behaviors among U.S. adults, 2008. Abstract presented at the 48th Annual Meeting of the Infectious Diseases Society of America, held Oct. 21-24, 2010, in Vancouver, Canada. Abstract:808.