HIV screening: not just for outpatients any more

March 2007

Published in the March 2007 issue of Today’s Hospitalist
Most hospitalists probably don’t consider themselves the "frontline" physicians for propelling routine HIV testing forward in their institutions. But in the wake of new recommendations from the Centers for Disease Control and Prevention (CDC) that call for universal and voluntary HIV testing, some say that hospitalists are ideally positioned to help orchestrate screening efforts.

"If routine HIV testing is not taking place in your ED, hospitalists should offer it to inpatients," urges Rochelle Walensky, MD, MPH, associate director of epidemiology and outcomes research at Harvard Medical School’s Center for AIDS Research. "As part of every initial evaluation, patients should be asked, ‘When was your last HIV test?’ "

To bolster her argument, Dr. Walensky points to research showing that newly diagnosed individuals may have received medical care as often as four times in
the year prior to their diagnosis “yet they haven’t been tested.

Other studies show that "internists and doctors in general are notoriously bad at getting an accurate and detailed sexual history when evaluating HIV risk," she says, another factor that supports routine inpatient screening.

Yet hospitalists who have championed routine screening at their hospital warn that there are logistical and cultural barriers they’ve had to overcome to get testing off the ground. And to hospitalists interested in spearheading a new screening protocol, they offer the following advice: Be prepared to "sell" the idea to your administration, not the other way around.

The move from risk-based screening
The CDC issued new recommendations in September 2006, calling for routine HIV testing in most health care settings for patients between the ages of 13 and 64. (The guidelines are online.)

The recommendations represent several key departures from previous guidelines. First, the CDC now recommends universal, voluntary screening instead of using risk assessment and community prevalence as the basis for testing.

The guidelines also recommend doing away with requirements for specific pre-test counseling and separate written consent. Those recommendations are designed to streamline the testing process and reduce the stigma of testing, thereby normalizing HIV screening as part of routine care.

And although the guidelines still call for voluntary testing, the CDC recommends using the "opt-out" vs. an "opt-in" approach, having patients specifically decline testing rather than being asked if they would like to receive it. (In previous recommendations, the CDC had advised using opt-out testing for prenatal HIV screening.) To date, the CDC has published no implementation guidance, although officials say such guidance will be issued this year.

In January, the American Hospital Association (AHA) began working with the CDC, as well as with physician organizations and insurers, to look at both implementation and regulatory issues. AHA officials point out that hospitals face barriers in adopting the recommendations: Insurers typically cover HIV screening only if a clinical indication is present, for instance, and several states require specific written informed consent before testing can take place.

Results with opt-in testing
While the CDC guidelines recommend opt-out testing, hospitals also report success with an opt-in approach. Consider the results of the voluntary opt-in ED screening grant demonstration project that the CDC sponsored at Alameda County Medical Center-Highland General Hospital in Oakland, Calif.

Principal investigator and emergency physician Douglas White, MD, has compiled preliminary numbers from a rapid-testing project that began in early 2005. Of the roughly 9,000 ED patients who accepted rapid testing when offered, 1.07% tested positive. The vast majority of those have gone on to be treated.

"Overall, we have identified more than 100 patients with newly diagnosed HIV," says Dr. White, who is also an assistant clinical professor of medicine at the University of California, San Francisco. "Eighty-five percent have been successfully linked to HIV specialty care, so our follow-up rate is very good."

And a Boston Medical Center (BMC) study of 243 patients, which was led by hospitalist Jeffrey Greenwald, MD, director of the hospital medicine unit, found that routine opt-in testing led to twice as many patients being diagnosed as HIV positive than would have occurred had routine testing not been offered.

Based on those results, which were published in the April 2006 Mayo Clinic Proceedings, HIV testing that started out on a strictly referral basis has been largely routinized at BMC, Dr. Greenwald notes.

What role for hospitalists?
Dr. Greenwald agrees with Dr. Walensky that hospitalists are well-suited to the task of advancing routine testing. Not only are hospitalists well-versed in their hospital systems, they’re also ideally positioned to organize and direct the multidisciplinary teams needed to support increased testing.

"If a hospital is going to try to adhere to the CDC recommendations, using hospitalists would be a logical, reasonable first start," says Dr. Greenwald, who is also associate professor of medicine at Boston University School of Medicine.

The upside of hospitalist leadership, he adds, is the fact that hospitalists are "front-end ‘users’ " in hospitals. But one potential downside could be the fact that a hospitalist-driven program might include predominantly medicine or pediatric patients, excluding surgical and gynecological patients. Such a program, Dr. Greenwald points out, would thereby not be truly routine, and systems would need to be put in place to serve these patient populations as well.

In an article published in the March/April 2006 Journal of Hospital Medicine, Dr. Greenwald wrote that hospitalists could even act as role models in the routine testing process at admission, by explaining that testing is offered to and encouraged for all patients.

"I could see hospitalists, as part of their admission H&P, offering the screening HIV test if it hasn’t been done before," he says. While that might require hospitalists to coordinate efforts and communicate with other services, Dr. Greenwald acknowledges, it might at least expand routine, rapid testing beyond the population of pregnant patients.

Culture and stigma
However, Dr. Greenwald points to the many hurdles that must be cleared to get routine testing up and running.

In emergency departments, time constraints and privacy issues have been major concerns. But hospitalists who want to spearhead screening campaigns would face a more formidable barrier, at least initially, Dr. Greenwald warns: hospital culture.

"Routine testing for virtually anything is almost never seen as an inpatient phenomenon," he points out. He likens the prospect to the difficulties hospitals encounter when trying to implement more routine influenza or pneumococcal vaccination on inpatient services.

Hospitalists might even face hospital pushback on another cultural front: patient relations. One big concern is the persisting stigma about HIV.

"There’s a perception by many hospital administrators that if you go up to Mrs. Jones in Room 6, and say, ‘Hi, we are offering HIV testing to everybody,’ that there may be a lot of offense taken," Dr. Greenwald says.

But that concern may loom larger in administrators’ minds than in patients’, he points out. A survey taken before BMC implemented routine testing found that most patients were either not offended or had a fairly neutral response. In fact, only about one in 10 patients had a negative response to the survey question, and that was without any further explanation from the tester.

"A significant portion actually thought it was a good idea," says Dr. Greenwald, adding that those response patterns have persisted post-implementation. "Having done literally thousands of HIV tests on the inpatient service, our experience suggests that negative patient reactions are quite rare and easily managed."

He notes, however, that clinicians offering HIV testing should be aware of potential stigma and be ready to discuss both the importance of testing and the fact that screening is being offered routinely.

Logistical issues
To counter the hospital administration’s cultural concerns, Dr. Greenwald says that hospitalists should arm themselves with emerging data on the cost-effectiveness of HIV testing and early disease intervention. He also recommends that hospitalists get key hospital players, including the chief medical officer, on board before presenting initiative plans to the administration.

But he also points to logistical considerations as well. Even when rapid testing is used, hospital pharmacies and laboratories will have to gear up to be able to manage the newer point-of-care HIV tests. And here’s another issue to iron out in advance: Who will assume the testing and counseling roles, particularly when results are positive?

At Alameda County Medical Center, triage and bedside nurses handle all routine testing-associated tasks except the delivery of positive test results, says Dr. White. (Physicians deliver those results.)

"Often, our patients are consented, tested and given results before they’ve even seen a physician," he says. Although Alameda has run into some problems keeping staff motivated to offer universal testing, the system "works well," he says. But he urges physicians to pick the testing venue that will have the "highest yield."

"Figure out where the majority of patients are admitted from," Dr. White says. "In our case it’s the ED “70% of admissions come through there."

Based on Alameda’s experience, Dr. White maintains that hospitalists (as well as patients) have much to gain from routine testing, whether they lead the charge or just support it.

"From the hospitalists’ perspective, this is important because they now have access to an HIV test result that in the past they didn’t have," he says. "On many occasions, this not only has helped clarify a diagnosis that perhaps was in question, but has also led to an immediate change in management and treatment."

Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.


Quick facts about HIV
The rationale of the Centers for Disease Control and Prevention (CDC) for recommending universal HIV testing is borne out by the following statistics:

  • Studies suggest that routine screening is cost effective in terms of lifetime medical costs, quality of life and secondary transmission rates.
  • As many as 300,000 Americans are unknowingly infected.
  • According to CDC data, infected individuals who have not been diagnosed are responsible for up to 70% of new infections.
  • HIV/AIDS surveillance data published by the CDC in the June 27, 2003, Morbidity and Mortality Weekly Report showed that nearly half “45% “of AIDS patients were within 12 months of developing AIDS when they were diagnosed with HIV.
  • Several other studies have also found high percentages of "late testers."