Routine testing shows benefits in urban hospital

Atlanta effort finds more HIV-positives

Following up on its 1993 recommendations that hospitals and clinics in areas with high rates of HIV prevalence offer routine HIV testing to patients, the Centers for Disease Control and Prevention in Atlanta conducted a recent study of such a practice. From March 20, 2000, to Sept. 1, 2000, clinicians at Grady Memorial Hospital in Atlanta were encouraged to recommend HIV testing to all urgent-care clinic patients between the ages of 18 and 65. Those who had been tested for HIV within the previous six months were not included in the recommendation.

CDC researchers compared the HIV-positive results for this 24-week period with a 24-week period in 1999 in which HIV testing was conducted only when clinicians were concerned about patients’ symptoms or risk behaviors. The study found that in 2000, 1,687 more patients were tested, 27 more infections were newly detected, and twice as many HIV-positive patients entered into medical care.1

"The 1999 data was our comparison group, and because it was data retrospectively collected, physicians were not aware we were looking at that information," says Sheryl Lyss, MD, an epidemiologist formerly with the CDC’s Division of HIV/AIDS Prevention. Lyss was an author of the CDC study, published in the Morbidity and Mortality Weekly Report.

The CDC study was prompted by findings in 1997, also from a study done at Grady Memorial Hospital, that nearly two-thirds of inpatients newly diagnosed with AIDS had received medical care within the Grady health system during the 12 months preceding admission, Lyss says. "That was a wake-up call," she explains. "These were opportunities to diagnose them before they become symptomatic, and the earlier we diagnose them, the earlier we can help them take advantage of medical care to protect their own health and to encourage them to adopt behaviors that will protect their partners."

Both the 1999 and 2000 periods that were studied had about 20,000 clinic visits. During the study period, the hospital displayed posters encouraging patients to be tested for HIV. Patients also were given a brochure about HIV testing. When patients accepted testing, they provided written consent and were not charged for the test, which was conducted with either a Single Use Diagnostic System HIV-1 test or a standard enzyme immunoassay. All positive tests were confirmed with Western blot.

Based on these data, the CDC continues to encourage routine HIV testing at clinics located in areas with high HIV prevalence. The recommendation is even more important now than it was in 1993, Lyss says. "The HIV landscape has changed considerably to make this recommendation more important, more feasible, and more necessary," Lyss says. "First, we have HIV therapy now to offer infected individuals, and we know now that HIV counseling services can help patients protect their partners, and we know that more of the public is aware of HIV."

However, the CDC is aware of the fact that various barriers may impede routine testing. These include the following:

• Even the rapid HIV test didn’t have results quickly enough to provide most patients with an HIV diagnosis during their urgent care visit. About 27% received their rapid test results on the same day. "We think that if there were a test available in which patients could be tested and receive results rapidly, the clinicians would more strongly recommend the HIV test," Lyss notes.

• Clinicians are unaware of the benefits of routine HIV testing in these high-prevalence areas. The Atlanta hospital had a 2.7% HIV-positive rate among the HIV tests conducted, and physicians need to be taught how this is a very high rate from an epidemiological perspective, Lyss says. "I think clinician education is one way of addressing barriers both in terms of helping them integrate this into their clinical routine in a positive and not time-consuming way and to help them understand the importance of this kind of approach," Lyss adds.

• The cost of HIV testing also is a barrier. While it may provide a cost savings to society in the long term, it requires individual health care institutions to absorb a short-term cost that may be difficult to justify given the current tight financial restraints facing many health care systems, Lyss says.

"We hope this data will encourage more collaboration between public health departments and clinical settings, and perhaps public health departments through their financial and human resources could help in the implementation of this kind of strategy," Lyss explains.

CDC investigators will continue to assess the routine HIV testing results, studying patients’ exit interviews to determine how they felt about HIV testing and what their issues were with regard to acceptance and barriers, Lyss says. "In our study, 60% of patients declined HIV testing, so a 40% acceptance is a pretty high rate, but we think there is room for improvement there," Lyss adds. "Certainly one of our hopes is that by incorporating HIV test recommendations routinely in clinical settings, it will help to make HIV testing more routine and more acceptable to patients."

Reference

1. Routinely recommended HIV testing at an urban urgent-care clinic — Atlanta, Georgia, 2000. MMWR 2001; 50:538-541.