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Physicians Reluctant to Follow CDC Call for Routine HIV Testing
  MedPage Today
WASHINGTON, Nov. 20 -- The CDC's 2006 recommendation that HIV testing should be essentially universal in healthcare, even for low-risk patients, has been largely unheeded, in part because many clinicians have declined to go along, said researchers here.
Action Points
* Explain to interested patients that the CDC has recommended that virtually all patients younger than 65 be routinely tested for HIV on an opt-out basis when they come into contact with the healthcare system.
* Explain that several studies have shown that HIV testing even among high-risk patients is infrequent, except when they specifically request it.
* Explain that many insurers, including Medicaid, do not pay for HIV tests for low-risk individuals. Explain that, according to these studies, clinicians cite financial and time constraints as well as ethical reasons for not automatically testing patients for HIV.
* Note that these studies were published as abstracts and presented orally] at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
The reasons vary, with payment and reimbursements issues, staff time constraints, and concerns about informed consent and availability of counseling all contributing to low compliance with the recommendations, according to several studies presented here at the Forum for Collaborative HIV Research's national summit.
The summit focused on the extent of HIV testing in the United States and how it could be improved.
Although much of the summit was devoted to testing and follow-up among people at high risk for HIV infection, those issues would largely vanish if the CDC's 2006 recommendations were widely followed.
The CDC called for virtually all patients younger than 65 admitted to hospitals or seen in primary care and emergency departments to be routinely tested for HIV on an opt-out basis. (See CDC Urges HIV Tests as Routine in Health Care)
It said patients should automatically be tested unless they specifically refuse, an approach called opting out. Of course, patients who request HIV testing should continue to receive it as well.
Out of 5,000 emergency departments in the U.S., about 50 to 100 -- mostly concentrated in a few areas -- are routinely testing all patients for HIV, according to Richard Rothman, M.D., Ph.D., of Johns Hopkins.
A survey of staffers at a big emergency department in Cleveland shed some light on the reluctance to follow the CDC recommendations in emergency departments.
Among 34 staff members who responded -- including 19 nurses, five attending physicians, and 10 other clinical professionals -- only nine believed the emergency department should offer HIV testing, reported Vicken Totten, M.D., of University Hospitals of Case Medical Center.
About one-third of respondents said the testing would take too much time.
Half said there was not enough time to provide adequate counseling, and about the same number worried that routine testing would bring an "avalanche" of patients just seeking to be tested.
In addition, one-third of staff members said they had confidentiality concerns.
But when Dr. Totten and colleagues asked 256 patients whether they wanted the emergency department to offer HIV testing, 88% said yes.
Clinical staff members elsewhere have not shown much enthusiasm for the CDC recommendations either, suggested two other studies reported here.
Kenneth Mayer, M.D., of Brown in Providence, R.I., and colleagues conducted a survey of 228 resident and attending physicians and 13 nurse practitioners and physician assistants from three hospitals affiliated with Brown.
They found that 39% favored the opt-out approach recommended by the CDC, whereas 44% preferred the traditional opt-in method.
Nearly 60% of respondents thought patients should provide specific written consent.
With one exception, there were no major differences in the pattern of responses among subgroups, including emergency medicine versus internal or family medicine, or practicing physicians versus residents and fellows.
The exception was that female respondents were twice as likely as males to prefer opt-out testing.
Another study, led by Lynn Sullivan, M.D., of Yale also pointed to physician reluctance to embrace routine, opt-out testing.
Eight generalist physicians were recruited at several sites nationally to participate in a "clinical adviser" program on HIV prevention. Part of the program was to encourage implementation of the CDC's recommendation on testing.
At baseline, two of the eight participants said they performed HIV testing on all patients.
After three months in the program, only one of the other six had been persuaded to start testing all patients.
When the eight participants were asked about the barriers to universal testing, all said competing priorities during patient visits was a problem. Six each also cited patient refusal and lack of time.
Dr. Rothman, an emergency physician, suggested that many of the physician objections boil down to money and resources.
"Physicians in general believe testing is important," he said. "It's the process by which testing can occur that's really the issue.
"In an emergency department that's busy where physicians have to take care of life-threatening illnesses, if the resources aren't in place to make testing happen in a streamlined fashion ... it's a potential barrier."
What's needed, he said, are the resources to make routine testing seamless and fully integrated into standard care.
He pointed out that most insurers, including state Medicaid programs, do not pay for HIV testing in low-risk individuals. Having a mechanism to reimburse for testing is vital to its widespread adoption, he suggested.
State laws are another barrier, according to a separate study reported here.
Laws in 10 states currently mandate or imply an opt-in procedure, or otherwise contradict the CDC recommendations.
But, reported Sarah Neff, M.P.H., and Ronald Goldschmidt, M.D., of San Francisco General Hospital, eight states are now considering legislation that would at least bring them closer to the CDC's recommendations.

U.S. Lags on HIV Testing Goals
Despite call for routine exams, 60,000 Americans were infected last year

November 20, 2008
By Amanda Gardner
HealthDay Reporter
THURSDAY, Nov. 20 (HealthDay News) -- Two years after U.S. health officials recommended routine HIV testing for Americans 13 to 64, such testing remains hit-and-miss, and the AIDS epidemic marches on.
This, despite the new testing guidelines and better testing methods, according to participants at a conference in suburban Washington D.C. The meeting was designed to review the state of the AIDS epidemic and the unmet role that routine testing can play.
More than 1.1 million Americans are now living with HIV, the virus that causes AIDS. And more than 56,000 Americans were newly diagnosed with the virus in 2006, officials said.
Statistics show that before 2006, hospital emergency rooms tested patients for HIV at a rate of just 3.2 per 1,000 visits -- or 0.32 percent. In the two years since, there's been slight improvement, with an estimated 50 to 100 out of 5,000 emergency rooms nationwide routinely testing for HIV, according to Dr. Richard Rothman, of the Johns Hopkins University Department of Emergency Medicine.
A lack of testing occurs in other settings as well, such as correctional facilities and Veterans Administration hospitals. Other research presented at the conference found that just 36 percent of insured individuals seeking treatment for sexually transmitted diseases -- a high-risk group -- were tested for HIV.
And under-testing, of course, means that people who are infected don't start their treatment until later. One study found that 40 percent of patients newly diagnosed with HIV were "late testers," meaning they had AIDS diagnosed within one year of their test.
"Seventy-five percent of those patients had had health-care visits and the most frequent site of visits was the emergency department. There were many missed opportunities," Rothman said.
Despite legislative, medical and social barriers, there have been some successes. They include a voluntary rapid HIV testing program in New York City jails that increased testing from 6,500 to 25,000 inmates between 2004 and 2006. And a Chicago hospital added two health educators to its emergency room, offering rapid testing to patients admitted for medical services. Over 15 months, nearly 2,000 patients were tested, and 15 percent were confirmed HIV-positive. They were set up with care,

HIV tests not yet as routine as cholesterol checks
By LAURAN NEERGAARD - 14 hours ago
WASHINGTON (AP) - Two years after the government urged making HIV tests as common as cholesterol checks, there are small gains but still one in five people infected with the AIDS virus doesn't know it, scientists said Thursday.
(only) Eleven states that once required special consent for HIV testing have changed their laws, a key step to making an HIV test part of the standard battery that patients expect.
But HIV specialists meeting Thursday said other barriers include physician confusion about the ease of today's rapid tests, which can cost as little as $15 - although many patients seem to accept them.
No more than 100 of the nation's 5,000 emergency rooms routinely test for HIV in patients who aren't critically ill, said Dr. John Bartlett of Johns Hopkins University, who co-chaired the Forum for Collaborative HIV Research meeting. Yet because so many HIV patients are poor or uninsured, ERs are the health-care setting most likely to find them.
And while every pregnant woman is supposed to be tested so steps can be taken to protect her unborn baby, about 40 percent aren't, he added.
"Those are what we call missed opportunities," Bartlett said. Today, the test is "much better, it's much easier, it's much cheaper. The treatment is really great now."
Just over 1.1 million Americans are estimated to have HIV and 232,000 don't know it, according to the Centers for Disease Control and Prevention.
The CDC for years recommended routine testing mainly for people at high-risk, such as intravenous drug users. Then, finally, came drugs potent enough to keep HIV patients healthy for years, postponing the slide into full-blown AIDS. Yet nearly half of new infections still were being discovered too late for patients to benefit. Not to mention that people who don't know they're infected unwittingly spread the virus.
So in September 2006, the CDC recommended routine testing for everyone ages 13 to 64, whether they think they're at risk for HIV or not.
There is no nationwide data yet on the new guidelines' impact, CDC's Dr. Bernard Branson told The Associated Press.
But Branson listed encouraging signs:
--New York City's Health and Hospitals Corporation, the nation's largest municipal health system, has nearly tripled HIV testing - and late diagnoses dropped by about a third.
--New York's state Medicaid program has increased testing by 30 percent.
--Early results from a federal survey suggest 2.4 million more people in 2007 said they had ever been tested for HIV than said so in 2006.
--President George W. Bush in October signed a law allowing Veterans Administration clinics to ease testing requirements.
"I don't think anyone at CDC anticipated that we would test the whole country in a single year," Branson said.
But in pilot projects around the country, "people are taking the recommendations to heart and implementing them as much as was feasible for them," he added. Moreover, "we find people are very receptive to being tested, and there was concern about that before."
Indeed, studies presented Thursday suggest more than 80 percent of emergency-room patients were amenable to an HIV test while most ER workers opposed testing them. Why? Presumably because ERs are so busy and there's confusion about how much HIV counseling is needed.
But Bartlett demonstrated how to quickly give people a chance to either opt out or request counseling: "Mr. Jones, you're going to have a cholesterol test, a blood count, and an HIV test - and by the way we do the HIV test on everybody because that's what the CDC has recommended. Is there any part of this that you want more information about or you don't want to have?"
HIV Testing Not 'Routine as a Flu Shot' at Hospitals
"....Despite federal regulations that virtually all adults be routinely tested for HIV in emergency rooms and doctors' offices, people at risk for contracting the virus are not getting tested.....testing is the key to ending the epidemic in the United States. Of the nation's estimated 1.1 million people living with HIV, one in five do not know it and those who are being diagnosed are learning the news too late, the group said.....widespread testing is not happening because of a lack of health insurance reimbursement and lingering stigma associated with the disease...(rapid testing is key) takes too much time and the reluctance of some insurers to pay for the tests..... This year, the city stopped requiring written consent for HIV testing. "Many felt that the consent was stigmatizing in itself; you don't need a consent form for other blood tests," said Dr. Laura Herrera, chief medical officer for the city's Health Department. "The goal is to normalize it and remove a barrier to HIV testing so the perception is that HIV testing isn't any different than any other testing."...."
By John Lauerman
Nov. 20 (Bloomberg) -- Routine HIV testing recommended by the U.S. government isn't done at most hospitals and clinics because some insurers won't pay and many doctors are wary of spending time on it, AIDS officials said.
About 100 of 5,000 emergency rooms in the U.S. have fully implemented guidelines for testing from the Centers for Disease Control and Prevention, said Richard Rothman, a Johns Hopkins University researcher, at a Washington conference.
About 1.1 million people in the U.S. are infected with HIV, the virus that causes AIDS, and one in five doesn't know it, according to the CDC. Treatment delays can lead to immune system damage and higher risk of cancer and heart disease, said Veronica Miller, director of the Forum for Collaborative HIV Research at George Washington University Medical Center in Washington.
``Testing for HIV should be as routine as a flu shot,'' Miller said today in an interview at the conference. ``A few hospitals are implementing routine testing in their emergency departments, but these are few and far between.''
The testing issue was addressed today at a national summit convened in Washington by the Forum for Collaborative HIV Research, a public-private partnership studying emerging issues in HIV research. Some 300 leading HIV researchers, health care providers, and policy makers shared new data on the advances and barriers to early, routine HIV testing, which many consider a key to slowing the U.S. epidemic of AIDS.
HIV attacks the human immune system, disabling the CD4 cells that direct the body's protective response. Many patients are diagnosed after their CD4 cell levels have dropped below 200 per cubic milliliter of blood, making them susceptible to other dangerous infections, Mayer said.
Some Insurers Cover
Two years ago, the CDC recommended testing for everyone aged 13 to 64. Still, only about 2.3 percent of emergency room patients are tested for HIV, Miller said.
Large private insurers, such as UnitedHealth Group Inc., Aetna Inc. in Hartford, Connecticut, and Cigna Corp. of Philadelphia, began covering routine testing soon after the guidelines were announced. Many smaller insurers and federal programs such as Medicare and the Federal Health Employees Benefit program don't pay for routine HIV testing, said Kevin Fenton, CDC's director of AIDS prevention.
``We've seen tremendous change on this over the past few years and we need to build on this momentum,'' he said in an interview at the conference. ``We need more peer pressure to make this the standard of care.''
At least three doctors groups, the American Academy of Family Physicians, the American College of Emergency Physicians, and the American College of Obstetricians and Gynecologists, support the guidelines, said Bernard Branson, a CDC testing specialist, at the conference today. The American College of Physicians is expected to make a statement next month, he said.
Doctors Cautious
Still, many doctors think positive HIV test results might be too shocking to patients, who might resist care, Hopkins' Rothman said. Studies have shown that's not true, he said at the conference.
``Patients are clamoring for the test,'' Rothman said in an interview. ``My experience is that patients accept the news, and we're able to deliver them to HIV specialty care quickly.''
Until 2006, the CDC only recommended testing people at high risk of getting HIV, along with those with symptoms, said Ken Mayer, a Brown University AIDS doctor, in a conference with reporters at the meeting today. The agency rejected that philosophy in 2006, along with removing requirements for written patient consent and pretest counseling, saying they endangered public health.
About 40 states have changed laws so that patients can be tested without advance counseling, Branson said. Seven that haven't -- Hawaii, Massachusetts, Nebraska, New York, Pennsylvania, Rhode Island and Wisconsin -- have unsuccessfully proposed legislation to remove the counseling requirement. California and Illinois also still have the requirements in place.
OraSure Technologies Inc., Trinity Biotech Plc and Chembio Diagnostics Inc. make rapid screens to detect signs of the AIDS virus in blood. OraSure's can also test the virus in saliva, according to the CDC. Positive tests for the virus must be confirmed by more accurate testing.
``It's fast, it's cheap, it's easy and it detects a lethal disease that's treatable,'' said John Bartlett, a Johns Hopkins University AIDS doctor, at the conference today. ``This is a slam-dunk.''

Many People Disregard Advice to Get HIV Tests, Studies Show
Washington Post Staff Writer
Friday, November 21, 2008
Two years after the federal government recommended that patients in emergency rooms and doctors' offices be routinely tested for HIV, the advice is generally not being followed, according to a large number of studies presented this week at a conference in Arlington.
Only about 5 percent of patients with evidence of serious illness are being routinely tested in hospital emergency rooms for the virus that causes AIDS, said Veronica Miller, director of the Forum for Collaborative HIV Research, an independent public-private partnership based at the George Washington University School of Public Health and Health Services.
"HIV is a life-threatening disease that is so grossly underdiagnosed and undertreated in this country," Miller said in a briefing on the two-day Summit on HIV Testing.
In 2006, the Centers for Disease Control and Prevention recommended that everyone age 13 to 64 be routinely tested in medical encounters, with the choice to opt out if they want.
Among the many reasons for the general neglect of the recommendations, the studies indicate, are the perception of many clinicians that it takes too much time and the reluctance of some insurers to pay for the tests.
Point-of-service testing consists of a saliva test, followed if possible by a confirmatory blood test. If a patient is charged, the cost is about $80 to $120.
"Reimbursement is a major barrier to routine testing," said Kevin Fenton, director of HIV prevention at the CDC.
In urban emergency rooms, infection rates run from 0.5 to 1 percent of people tested, although many choose not to be tested, studies presented at the conference found.
When the emergency department at George Washington University Medical Center began offering the saliva test, 0.8 percent of those accepting were infected, far below the District's estimated 5 percent HIV prevalence rate.
About half the people from the District's wealthiest ward opted out of testing, compared with one-third of those from the poorest ward. The researchers speculated that the reason the infection rate was unexpectedly low may be that HIV prevalence is higher in people who decline testing.
At Hahnemann University Hospital in Philadelphia, where trained counselors offered rapid testing to emergency room patients in an interaction that lasted slightly more than five minutes, 83 percent of patients said yes. Half were women, 80 percent were black, and the average age was 36. About one-quarter had never been tested, and 0.7 percent were infected.
The research also suggests that routine testing, if implemented, would detect the infection at a much earlier stage in many patients.
At John H. Stroger Jr. Hospital of Cook County, in Chicago, about 2,000 patients who went to the emergency room and were ill enough to be admitted were offered HIV tests. Just under 1 percent were infected, and more than 90 percent of them had CD4 cell counts below 200. At that level, a person has severe immune system damage and is considered to have AIDS.
In the two years before the test, those patients had visited the emergency room three times on average -- each visit a missed opportunity to diagnose their infection earlier.

Routine HIV testing not performed, forum says
By Kelly Brewington
November 21, 2008
Despite federal regulations that virtually all adults be routinely tested for HIV in emergency rooms and doctors' offices, people at risk for contracting the virus are not getting tested, a coalition of researchers and health experts has warned.
The Forum for Collaborative HIV Research, based at George Washington University's School of Public Health, said yesterday that testing is the key to ending the epidemic in the United States. Of the nation's estimated 1.1 million people living with HIV, one in five do not know it and those who are being diagnosed are learning the news too late, the group said.
Those who do not know they have the virus are responsible for transmitting 50 percent to 70 percent of new sexually transmitted infections, the group said.
"It's a call to action that the test will be offered on a more regular basis," said Dr. John G. Bartlett, chief of infectious diseases at the Johns Hopkins School of Medicine and co-chairman of the meeting.
Dr. Kenneth H. Mayer, director of the Brown University AIDS Program, said many of the people who are infected with HIV do not consider themselves high risk and are unlikely to seek testing. For instance, African-American women, who have disproportionately high rates of HIV, are often infected in the context of a monogamous relationship, he said.
In 2006, the Centers for Disease Control and Prevention reported 56,300 new cases in the U.S., reflecting shifting HIV demographics. A quarter were women and a third people younger than 30. Blacks and Latinos accounted for 63 percent of new infections.
The same year, the CDC revised testing recommendations from a focus on at-risk groups to encouraging routine testing of people ages 13 to 64 in all health care settings, asserting that a universal approach would be more effective in prevention.
Experts say widespread testing is not happening because of a lack of health insurance reimbursement and lingering stigma associated with the disease.
Emergency rooms tested patients at a rate of 3.2 per 1,000 visits, according to 2006 data shared at the conference by Dr. Richard Rothman, associate professor in Hopkins' emergency medicine department: "There are many missed opportunities in recognizing patients earlier in the course of their illness."
Still, some cities - including Baltimore - are having success making HIV testing the norm.
This year, the city stopped requiring written consent for HIV testing. "Many felt that the consent was stigmatizing in itself; you don't need a consent form for other blood tests," said Dr. Laura Herrera, chief medical officer for the city's Health Department. "The goal is to normalize it and remove a barrier to HIV testing so the perception is that HIV testing isn't any different than any other testing."
Also this year, the department began working with five city emergency departments to offer rapid HIV tests, which provide results within a half-hour. The program was launched with a grant from the Maryland AIDS Administration.
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