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  49th ICAAC
San Francisco, CA
September 12-15, 2009
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DC Emergency Patients Who Decline HIV Test Have Twice Higher HIV Rate
  49th ICAAC (Interscience Conference on Antimicrobial Agents and Chemotherapy), September 12-15, 2009, San Francisco
Mark Mascolini
Emergency room patients in Washington, DC, who declined opt-out HIV testing had more than a 2 times higher HIV rate than people who agreed to testing. The most common reason for turning down the HIV test was the belief that they had no risk of infection.
In 2006 the US Centers for Disease Control recommended routine opt-out HIV testing for all adults who seek medical care, including those who visit emergency rooms. Researchers at George Washington University in downtown DC decided to test discarded blood samples of emergency room patients who did opt out of testing to calculate their HIV rate. Washington, DC, has the highest HIV prevalence in the United States-at least 3% among people over 12 years old [2]-and the population is predominantly African American.
The investigators unlinked discarded blood samples from patient identification, but for each sample they retained information on demographics, chief medical complaints, and reason for declining HIV testing. They used the Ora-Quick rapid HIV test to identify positive samples, then confirmed seropositivity by Western blot.
Forty-seven people who opted out of testing had HIV by Ora-Quick, as did 95 who agreed to testing. HIV prevalence by Ora-Quick among people who turned down testing was 1.9%, more than twice higher than the 0.79% prevalence among emergency room patients who agreed to testing, a significant difference (P = 0.01). Women were more likely to opt out (67%) than to agree to testing (28%) (P < 0 .05), and 81.8% of those positive were African American.
More than 40% of HIV-positive people who opted out of testing had no insurance, one third had Medicaid (government insurance for the poor) or were in local health maintenance organizations, and one quarter had private health insurance. Median age among positive test decliners was 40 years. They usually cited abdominal pain as the reason for coming to the emergency room.
When asked why they declined HIV testing, the largest proportion said they felt they had no risk of HIV infection.
The 2% emergency room rate and the 3% citywide rate surpass the 1% that signifies a "generalized and severe" epidemic. Two of 5 HIV-infected Washingtonians did not know they carried the virus in the survey that established a 3% prevalence [2]. Prevalence among black men in Washington is 7%, and the overall HIV rate rose 22% from 2006 to 2007.
The George Washington team believes "it is critical for public health issues to determine whether the opt-out population is truly HIV-negative or whether their personal risk is being underestimated."
1. Czarnogorskij M, Brown J, Lee V, et al. Higher prevalence of HIV infection in patients who decline routine HIV testing than in those who accept it in an urban emergency department. 49th ICAAC (Interscience Conference on Antimicrobial Agents and Chemotherapy). September 12-15, 2009. San Francisco. Abstract H-239.
2. Vargas JA, Fears D. HIV/AIDS rate in D.C> hits 3%. Washington Post. March 15. 2009. http://www.washingtonpost.com/wp-dyn/content/article/2009/03/14/AR2009031402176.html