Elizabeth M. Begier

Why don't physicians test for Hiv? A review of the Us literature

Objective:In its 2006 HIV testing guidelines, the Centers for Disease Control and Prevention (CDC) recommended routine testing in all US medical settings. Given that many physicians do not routinely test for HIV, the objective of this study was to summarize our current understanding of why US physicians do not offer HIV testing. Design:A comprehensive review of the published and unpublished literature on HIV testing barriers was conducted. Methods:A literature search was conducted in Pubmed using defined search terms. Other sources included Google, recent conference abstracts, and experts in the field. Studies were divided into three categories: prenatal; emergency department; and other medical settings. These categories were chosen because of differences in physician training, practice environment, and patient populations. Barriers identified in these sources were summarized separately for the three practice settings and compared. Results:Forty-one barriers were identified from 17 reports. Twenty-four barriers were named in the prenatal setting, 20 in the emergency department setting, and 23 in other medical settings. Eight barriers were identified in all three categories: insufficient time; burdensome consent process; lack of knowledge/training; lack of patient acceptance; pretest counselling requirements; competing priorities; and inadequate reimbursement. Conclusion:US physicians experience many policy-based, logistical, and educational barriers to HIV testing. Although some barriers are exclusive to the practice setting studied, substantial overlap was found across practice settings. Some or all of these barriers must be addressed before the CDC recommendation for routine HIV testing can be realized in all US medical settings.

A mathematical model of comprehensive test-and-treat services and HIV incidence among men who have sex with men in the United States.

Background Early diagnosis and treatment of HIV infection and suppression of viral load are potentially powerful interventions for reducing HIV incidence. A test-and-treat strategy may have long-term effects on the epidemic among urban men who have sex with men (MSM) in the United States and may achieve the 5-year goals of the 2010 National AIDS Strategy that include: 1) lowering to 25% the annual number of new infections, 2) reducing by 30% the HIV transmission rate, 3) increasing to 90% the proportion of persons living with HIV infection who know their HIV status, 4) increasing to 85% the proportion of newly diagnosed patients linked to clinical care, and 5) increasing by 20% the proportion of HIV-infected MSM with an undetectable HIV RNA viral load. Methods and Findings We constructed a dynamic compartmental model among MSM in an urban population (based on New York City) that projects new HIV infections over time. We compared the cumulative number of HIV infections in 20 years, assuming current annual testing rate and treatment practices, with new infections after improvements in the annual HIV testing rate, notification of test results, linkage to care, initiation of antiretroviral therapy (ART) and viral load suppression. We also assessed whether five of the national HIV prevention goals could be met by the year 2015. Over a 20-year period, improvements in test-and-treat practice decreased the cumulative number of new infections by a predicted 39.3% to 69.1% in the urban population based on New York City. Institution of intermediate improvements in services would be predicted to meet at least four of the five goals of the National HIV/AIDS Strategy by the 2015 target. Conclusions Improving the five components of a test-and-treat strategy could substantially reduce HIV incidence among urban MSM, and meet most of the five goals of the National HIV/AIDS Strategy.

Unprotected Anal Intercourse and Sexually Transmitted Diseases in High-Risk Heterosexual Women

OBJECTIVES We examined the association between unprotected anal intercourse and sexually transmitted diseases (STDs) among heterosexual women. METHODS In 2006 through 2007, women were recruited from high-risk areas in New York City through respondent-driven sampling as part of the National HIV Behavioral Surveillance study. We used multiple logistic regression to determine the relationship between unprotected anal intercourse and HIV infection and past-year STD diagnosis. RESULTS Of the 436 women studied, 38% had unprotected anal intercourse in the past year. Unprotected anal intercourse was more likely among those who were aged 30 to 39 years, were homeless, were frequent drug or binge alcohol users, had an incarcerated sexual partner, had sexual partners with whom they exchanged sex for money or drugs, or had more than 5 sexual partners in the past year. In the logistic regression, women who had unprotected anal intercourse were 2.6 times as likely as women who had only unprotected vaginal intercourse and 4.2 times as likely as women who had neither unprotected anal nor unprotected vaginal intercourse to report an STD diagnosis. We found no significant association between unprotected anal intercourse and HIV infection. CONCLUSIONS Increased screening for history of unprotected anal intercourse and, for those who report recent unprotected anal intercourse, counseling and testing for HIV and STDs would likely reduce STD infections.

Undiagnosed HIV infection among New York City jail entrants, 2006: results of a blinded serosurvey.

Objective:Since 2004, when all New York City jail entrants began being offered rapid testing at medical intake, HIV testing has increased 4-fold. To guide further service improvement, we determined HIV prevalence among jail entrants, including proportion undiagnosed. Methods:Remnant serum from routine syphilis screening was salvaged for blinded HIV testing in 2006. Using HIV surveillance data and electronic clinical data, we ascertained previously diagnosed HIV infections before permanently removing identifiers. We defined “undiagnosed” as HIV-infected entrants who were unreported to surveillance and denied HIV infection. Results:Among the 6411 jail entrants tested (68.9% of admissions), HIV prevalence was 5.2% overall (males 4.7%; females: 9.8%). Adjusting for those not in the serosurvey, estimated seroprevalence is 8.7% overall (6.5% males, 14% females). Overall, 28.1% of HIV infections identified in the serosurvey were undiagnosed at jail entry; only 11.5% of these were diagnosed during routine jail testing. Few (11.1%) of the undiagnosed inmates reported injection drug use or being men who have sex with men. Conclusions:About 5%-9% of New York City jail entrants are HIV infected. Of the infected, 28% are undiagnosed; most of whom denied recognized HIV risk factors. To increase inmates acceptance of routine testing, we are working to eliminate the required separate written consent for HIV testing to allow implementation of the Centers for Disease Control and Prevention-recommended opt out testing model.

HIV Counseling and Testing: Less Targeting, More Testing

Approximately 25% of persons infected with HIV nationwide remain undiagnosed.1 Identifying these individuals represents the biggest challenge for HIV control in the United States. More timely diagnosis of HIV can improve treatment and care of those infected with HIV, prolong survival, and reduce the spread of HIV. The impact of these late testers on the dynamics of the epidemic is well characterized by the number of persons who are identified with HIV only when they have progressed to AIDS. Each year, more than 1000 New York City residents—3 per day—are diagnosed with concurrent HIV and AIDS,2 and nationally 40% of new diagnoses are concurrent.3 Many of these late testers have been infected for 10 years or longer, unknowingly exposing their partners to HIV. Indeed, most HIV infections are transmitted by people who are unaware of their status.4 Thus, despite substantial progress in HIV treatment and prevention of maternal–child transmission, little progress has been made in identifying the reservoir of those infected and unaware of their serostatus. We propose that the largest barrier to advancement of this central goal is a continued reliance on a single HIV counseling and testing model. Ironically, the system initially put into place to protect the rights and safety of individuals has now become an impediment to the public health control of HIV. Laws governing HIV testing were developed at a time when the infection was untreatable and intensely stigmatizing. As a result, a very cautious approach to testing was adopted from the genetic-counseling model of testing for untreatable conditions.5 Yet, even though the HIV epidemic has not remained static, the testing process has, having not changed appreciably since the introduction of the ELISA and Western blot in 1985. Legislation continues to mandate lengthy pretest counseling that varies state to state and by funding stream. A separate written informed consent is still a requirement in more than a dozen states including New York, home to 1 in 6 persons living with HIV. The imposition of these extra steps has prevented HIV testing from becoming a routine part of medical care resulting in numerous missed opportunities to diagnose, treat, and stop the spread of HIV. We advocate for standardization of verbal informed consent and shifting resources from mandated pretest counseling to effective posttest counseling and linkage to care for those found to be HIV positive.

Missed opportunities for HIV testing among high-risk heterosexuals.

Background: HIV testing is an important HIV prevention strategy, yet heterosexuals at high risk do not test as frequently as other groups. We examined the association of past year HIV testing and encounters with institutional settings where the Centers for Disease Control and Prevention recommends annual testing for high-risk heterosexuals. Methods: We recruited high-risk heterosexuals in New York City in 2006 to 2007 through respondent-driven sampling. Respondents were asked the date of their most recent HIV test and any potential encounters with 4 testing settings (homeless shelters, jails/prisons, drug treatment programs, and health care providers). Analyses were stratified by gender. Results: Of the 846 respondents, only 31% of men and 35% of women had a past year HIV test, but over 90% encountered at least one testing setting. HIV seroprevalence was 8%. In multiple logistic regression, recent HIV testing was significantly associated with recent encounters with homeless shelters and jails/prisons for men, and encounters with health care providers for both men and women. Conclusions: HIV testing was low overall but higher for those with exposures to potential routine testing settings. Further expansion of testing in these settings would likely increase testing rates and may decrease new HIV infections among high-risk heterosexuals.

Comparing the National Death Index and the Social Security Administration's Death Master File to Ascertain Death in HIV Surveillance

Objectives. New York City (NYC) maintains a population-based registry of people with human immunodeficiency virus (HIV) infection to monitor the epidemic and inform resource allocation. We evaluated record linkages with the National Death Index (NDI) and the Social Security Administrations Death Master File (SSDMF) to find deaths occurring from 2000 through 2004. Methods. We linked records from 32,837 people reported with HIV and not previously known to be dead with deaths reported in the NDI and the SSDMF. We calculated the kappa statistic to assess agreement between data sources. We performed subgroup analyses to assess differences within demographic and transmission risk subpopulations. We quantified the benefit of linkages with each data source beyond prior death ascertainment from local vital statistics data. Results. We discovered 1,926 (5.87%) deaths, which reduced the HIV prevalence estimate in NYC by 2.03%, from 1.19% to 1.16%. Of these, 458 (23.78%) were identified only from NDI, and 305 (15.84%) only from SSDMF. Agreement in ascertainment between sources was substantial (kappa = [K] 0.74, 95% confidence interval [CI] 0.72, 0.76); agreement was lower among Hispanic people (K=0.65, 95% CI 0.62, 0.69) and people born outside the U.S. (K=0.60, 95% CI 0.52, 0.68). We identified an additional 13.62% of deaths to people reported with HIV in NYC; white people and men who have sex with men were disproportionately likely to be underascertained without these linkages (p<0.0001). Conclusion. Record linkages with national databases are essential for accurate prevalence estimates from disease registries, and the SSDMF is an inexpensive means to supplement linkages with the NDI to maximize death ascertainment.

Barriers to HIV testing among HIV/AIDS concurrently diagnosed persons in New York City.

Objectives: To assess barriers to human immunodeficiency virus (HIV) testing, health care contacts history, and HIV testing history among patients diagnosed concurrently with HIV and acquired immunodeficiency syndrome (AIDS). Methods: We surveyed patients concurrently diagnosed with HIV/AIDS who had participated in the partner notification program of the New York City Department of Health and Mental Hygiene, between January 2008 and December 2008. Results: The most common reason interviewees volunteered for delaying testing (64%) was that they did not believe they were at risk for HIV. When read a list of potential barriers, 69% of interviewees replied affirmatively that they did not test for HIV because they did not believe they were at risk, and 52% replied affirmatively that they did not test because they thought their behaviors kept them safe from getting HIV. Half of all interviewees reported having insurance during part or all of the year before they were diagnosed with HIV/AIDS, and 70% had at least 1 health care visit in the year before they were diagnosed with HIV/AIDS. Conclusions: A lack of perception of risk was the most common reason for not testing for HIV sooner among these concurrently diagnosed patients. The majority of these patients were accessing medical care, indicating that this population could have benefited from routine HIV testing.

Written informed-consent statutes and HIV testing.

BACKGROUND Almost 1 million Americans are infected with HIV, yet it is estimated that as many as 250,000 of them do not know their serostatus. This study examined whether people residing in states with statutes requiring written informed consent prior to HIV testing were less likely to report a recent HIV test. METHODS The study is based on survey data from the 2004 Behavioral Risk Factor Surveillance System. Logistic regression was used to assess the association between residence in a state with a pre-test written informed-consent requirement and individual self-report of recent HIV testing. The regression analyses controlled for potential state- and individual-level confounders. RESULTS Almost 17% of respondents reported that they had been tested for HIV in the prior 12 months. Ten states had statutes requiring written informed consent prior to routine HIV testing; nine of those were analyzed in this study. After adjusting for other state- and individual-level factors, people who resided in these nine states were less likely to report a recent history of HIV testing (OR=0.85; 95% CI=0.80, 0.90). The average marginal effect was -0.02 (p<0.001, 95% CI=-0.03, -0.01); thus, written informed-consent statutes are associated with a 12% reduction in HIV testing from the baseline testing level of 17%. The association between a consent requirement and lack of testing was greatest among respondents who denied HIV risk factors, were non-Hispanic whites, or who had higher levels of education. CONCLUSIONS This studys findings suggest that the removal of written informed-consent requirements might promote the non-risk-based routine-testing approach that the Centers for Disease Control and Prevention (CDC) advocates in its new testing guidelines.

An intervention to improve cause-of-death reporting in New York City hospitals, 2009-2010.

Introduction Poor-quality cause-of-death reporting reduces reliability of mortality statistics used to direct public health efforts. Overreporting of heart disease has been documented in New York City (NYC) and nationwide. Our objective was to evaluate the immediate and longer-term effects of a cause-of-death (COD) educational program that NYC’s health department conducted at 8 hospitals on heart disease reporting and on average conditions per certificate, which are indicators of the quality of COD reporting. Methods From June 2009 through January 2010, we intervened at 8 hospitals that overreported heart disease deaths in 2008. We shared hospital-specific data on COD reporting, held conference calls with key hospital staff, and conducted in-service training. For deaths reported from January 2009 through June 2011, we compared the proportion of heart disease deaths and average number of conditions per death certificate before and after the intervention at both intervention and nonintervention hospitals. Results At intervention hospitals, the proportion of death certificates that reported heart disease as the cause of death decreased from 68.8% preintervention to 32.4% postintervention (P < .001). Individual hospital proportions ranged from 58.9% to 79.5% preintervention and 25.9% to 45.0% postintervention. At intervention hospitals the average number of conditions per death certificate increased from 2.4 conditions preintervention to 3.4 conditions postintervention (P < .001) and remained at 3.4 conditions a year later. At nonintervention hospitals, these measures remained relatively consistent across the intervention and postintervention period. Conclusion This NYC health department’s hospital-level intervention led to durable changes in COD reporting.