June 25, 2004 / 53(24);523-526

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5324a2.htm

Voluntary HIV Testing as Part of Routine Medical Care --- Massachusetts,
2002

In 2003, CDC released Advancing HIV Prevention: New Strategies for a
Changing Epidemic. One of the four strategies of this initiative is to
expand routine, voluntary human immunodeficiency virus (HIV) testing
(1). This report describes the results of a state-funded program in
Massachusetts that offered HIV counseling, testing, and referral (HIV
CTR) to patients entering one of four hospital-associated urgent care
centers. Among the 3,068 patients tested, the program identified an HIV
seroprevalence of 2.0%. The findings underscore the effectiveness of
routine HIV CTR in HIV case identification.

The Massachusetts Department of Public Health (MDPH) AIDS Bureau
identified the 15 cities in Massachusetts with the highest HIV
prevalence. On the basis of patient volume and existing HIV primary care
services, four hospital-associated urgent care centers in these cities
were selected for program implementation. The program, called "Think
HIV," was designed to assist centers in routine HIV counseling and
testing, facilitate patient follow-up for test results, and promote
strategies for linkage to care. Patient privacy and the availability of
adequate, expedient HIV care for those who tested positive were
essential components of the program.

After registration for urgent care, patients were offered the
opportunity to speak with a "health educator," a certified counselor
with case-management experience trained specifically in sexually
transmitted diseases, hepatitis C, and HIV. Counselors were available
weekdays and some weekends. Patients who agreed to speak with a health
educator were told that voluntary, confidential HIV CTR was now offered
routinely to urgent care patients. Patients who declined to speak with a
health educator were asked about their reasons for refusal, and those
who reported they were already known to be HIV-infected were asked if
they were receiving HIV care; if not, they were linked to care.

Upon completion of counseling, confidential HIV tests were performed by
using the oral swab, OraSure® HIV-1 antibody detection system (Epitope,
Inc., Bethlehem, Pennsylvania). Patients were instructed to return to
the urgent care center for test results 14 days later, when results were
provided and post-test counseling was performed. Substantial efforts,
including a minimum of four telephone calls and a follow-up letter, were
made to locate all patients testing negative or positive who did not
return for results. Additional efforts, including offering
transportation vouchers and contacting homeless shelters, were made for
persons testing positive who failed to return. At each center, an HIV
intake nurse from an HIV outpatient clinic provided assistance to
patients during posttest counseling, arranged follow-up HIV clinical
care appointments, and often brought patients to their care appointments.

During 2002, the first year of the program, 10,352 patients were offered
HIV counseling at the four centers, accounting for approximately
10%--15% of all patients entering these urgent care centers and a
percentage determined by counselor capacity. Of the 10,352 patients
offered HIV testing, 7,071 (68%) declined testing; 6,291 (89%) of these
7,071 were willing to answer inquiries about their refusal to undergo
testing. The reasons given for testing refusal included one or more of
the following: 1) did not feel at risk for HIV (2,974 [47%]), 2) tested
for HIV before (2,624 [42%]), 3) felt too ill (686 [11%]), 4) testing
takes too long (281 [4%]), 5) information too personal (120 [2%]), and
6) already known to be HIV-infected (86 [1%]). Of the 2,573 patients
reporting previous HIV testing who also provided the dates of the test,
1,542 (60%) reported their tests were performed in 2002 (Table).

Among the 3,068 patients with completed test results, 60 were
HIV-infected (HIV prevalence: 2.0%); of these, 49 (82%) returned for
their results. Of the first 42 patients for whom linkage-to-care data
were available, all 42 had at least one documented follow-up visit for
HIV care. During the interview process, the program also identified six
additional patients who reported they were known to be HIV-infected and
who described themselves as either not having a doctor or not being in
care. These patients were referred for follow-up HIV care. Four of these
six patients had confirmed attendance at their first HIV care appointment.

The program was funded by the MDPH AIDS Bureau. Overall, the cost of the
program for the first 12 months was $349,400, which amounted to $7,100
for each of the 49 new HIV-infected patients told of their diagnosis or
$5,800 for each of the 60 new cases identified.

Reported by: RP Walensky, MD, Massachusetts General Hospital; KA
Freedberg, MD, Harvard Medical School; E Losina, PhD, Boston Univ School
of Public Health; PR Skolnik, MD, JM Hall, Boston Univ Medical Center; L
Malatesta, MPH, GE Barton, CA O'Connor, MSN, JF McGuire, PhD, AIDS Bur,
Massachusetts Dept of Public Health.

Editorial Note:

This report describes results of the Think HIV program in Massachusetts,
which offered voluntary HIV CTR routinely to patients entering four
urgent care centers. Because these centers did not previously have
routine HIV CTR available, the majority of the 60 newly identified HIV
patients likely would not have been identified until later in the course
of their disease without the program. Health-care providers often
discourage HIV testing in urgent care centers because of concerns
regarding adequate training, pre- and post test counseling, and
follow-up for patients testing HIV positive (2). Because many medically
underserved patients at high risk for HIV use urgent care centers and
emergency departments for their primary care, repeated opportunities for
HIV diagnosis in these patients often are missed (3).

Simply making a diagnosis of HIV, however, does not ensure the
individual and public health benefits of HIV care. Previous reports have
indicated that a mean delay of entry into HIV care of 3 months occurs
after HIV diagnosis, with 32% of patients delaying >2 years and 18%
delaying >5 years (4). To combat this lag to care, the program
emphasized a formal linkage-to-care mechanism. An identified intake
nurse at each center confirmed that newly HIV-diagnosed patients had
rapid, immediate communication with members of their future health-care
team. Success with the linkage component of the program is evidenced by
a first appointment attendance rate of 100%, compared with 34% in
another urgent care routine testing program in Atlanta (5). Results from
CDC's Antiretroviral Treatment and Access Study also demonstrated
substantial improvements in entry into HIV care with the presence of HIV
case-management personnel. Patients who had two to three visits with a
case manager during a 3-month period attended more HIV care visits,
compared with patients who did not have these encounters (6).

HIV testing as part of routine care has been delegated to primary care
providers. In a 10- or 15-minute provider visit intended to cover many
components of medical care, HIV CTR typically is not performed. By using
counselors committed to this effort, the program had an estimated cost
per new HIV patient identified of <$6,000, a figure that would be
reduced with more streamlined pretest procedures of providing
information about HIV testing (as recommended in CDC's Advancing HIV
Prevention initiative) rather than the previously recommended extensive
pretest counseling (1). Model-based cost-effectiveness analyses of
routine HIV screening in primary care, outpatient, and inpatient
settings have projected cost-effectiveness ratios of $22,000--$36,700
per quality-adjusted life year gained, which is more cost-effective than
screening for colon cancer (7--10).

The findings in this report are subject to at least two limitations.
First, although efforts were made to test all patients entering the
urgent care centers, access to HIV testing was based on counselor
availability. Second, centers with suspected high HIV prevalence were
chosen, and results should not be generalized to all urgent care centers
throughout the United States.

CDC's initiative Advancing HIV Prevention: New Strategies for a Changing
Epidemic calls for including HIV testing as a routine part of medical
care to increase the number of HIV-infected persons who are aware of
their positive serostatus (1). The diagnosis of HIV in HIV-infected
persons is a priority in the United States. Routine, voluntary HIV
screening programs in urgent care centers in areas of high HIV
prevalence are feasible and can be successful at diagnosing persons with
HIV and linking them to appropriate HIV care. CDC is currently funding
such projects in out-patient care clinics and emergency departments in
four states. In addition, CDC will be funding community-based
organizations and health departments to assist with linkage and
referrals in facilities in areas of high HIV prevalence and will
evaluate the cost-effectiveness of this strategy.

References

    1. CDC. Advancing HIV prevention: new strategies for a changing
epidemic---United States, 2003. MMWR 2003;52:329--32.

    2. Fincher-Mergi M, Cartone KJ, Mischler J, et al. Assessment of
emergency department health care professionals' behaviors regarding HIV
testing and referral for patients with STDs. AIDS Patient Care STDS
2002;16:549--53.

    3. Liddicoat RV, Horton NJ, Urban R, et al. Assessing missed
opportunities for HIV testing in medical settings. J Gen Intern Med
2004;19:349--56.

    4. Samet JH, Freedberg KA, Stein MD, et al. Trillion virion delay:
time from testing positive for HIV to presentation for primary care.
Arch Intern Med 1998;158:734--40.

    5. CDC. Routinely recommended HIV testing at an urban urgent-care
clinic---Atlanta, Georgia, 2000. MMWR 2001;50:538--41.

    6. Gardner LI, Metsch L, Loughlin A, et al. Initial results of the
Antiretroviral Treatment Access Studies (ARTAS): efficacy of the case
management trial [Abstract no. M3-B13-08]. Presented at the National HIV
Prevention Conference, Atlanta, Georgia, 2003.

    7. Phillips KA, Fernyak S. The cost-effectiveness of expanded HIV
counseling and testing in primary care settings: a first look. AIDS
2000;14:2159--69.

    8. Walensky RP, Weinstein MC, Kimmel AD, et al. Routine inpatient
HIV testing: a clinical and economic evaluation of national guidelines
[Abstract no. T3-E11-02]. Presented at the National HIV Prevention
Conference, Atlanta, Georgia, 2003.

    9. Paltiel A, Weinstein M, Kimmel A, et al. Expanded screening for
HIV disease in the United States: clinical impact and cost-effectiveness
[Abstract no. T3-E11-04]. Presented at the National HIV Prevention
Conference, Atlanta, Georgia, 2003.

   10. Frazier AL, Colditz GA, Fuchs CS, et al. Cost-effectiveness of
screening for colorectal cancer in the general population. JAMA
2000;284:1954--61.

Acknowledgments

This report is based in part on contributions by HE Smith, Massachusetts
General Hospital, the hospital staff, urgent care center staff, and HIV
counselors at Boston Medical Center, Baystate Medical Center, Univ of
Massachusetts Medical Center, Cambridge Hospital, Whidden Hospital,
Boston; AIDS Bur, Partners/Fenway/Shattuck Center for AIDS Research,
Massachusetts Dept of Public Health. National Institute of Allergy and
Infectious Diseases, National Institute of Mental Health, National
Institutes of Health.


http://www.cdc.gov/mmwr/preview/mmwrhtml/figures/m324a2t.gif
TABLE. Number and percentage of patients* who accepted or declined human immunodeficiency virus (HIV) testing, by selected characteristics and
test result — Massachusetts, 2002†