Personal accounts from the front lines on issues related to routine testing and linking to care.
Ligia Peralta, M.D., discusses the challenges she faces in adopting routine testing.
Real talk about routine HIV testing is key to wider provider adoption.
This is a transformative time for HIV, with tremendous scientific progress, new medications and treatment, and even newer strategies to reduce HIV transmission such as PreP (Preexposure Prophylaxis). The medical field has progressed in aligning resources with the epidemic, increasing access to care, and addressing additional factors that contribute to HIV risk. Furthermore, evolving noninvasive HIV testing technology allows providers to quickly identify their patients' HIV status. Yet, amid great strides, we primary care providers face many challenges to adopting routine HIV testing in our practices.
I write from the unique perspective of working as both a primary care provider and an academician, as well as director of an inner-city HIV program. As an HIV subspecialist, testing, treating, and managing HIV is second nature. However, as a primary care provider, I have quite a different experience, and it is through that lens that I cannot only clearly see some of the barriers that primary care providers face fighting the HIV epidemic, but also how to overcome them.
Do primary care providers want to implement routine HIV testing in their practices?
No doubt they do but not without hesitation. The priorities of busy primary care providers have changed over the years, as have the many requirements and regulations implemented at their practices. With the new demands of electronic medical records, and the pressures to increase patient volume and contain costs, many physicians are struggling to provide comprehensive care. For example, meaningful use mandates help clinicians identify common medical problems, and yet do not necessarily mandate HIV testing. The reduction of nurses and qualified staff that aid in the management of patients with chronic illnesses is compounded by increasing local, State, and Federal regulations for quality improvement, complicated requirements for payments, and insufficient reimbursement for physician time.
Even with the much-heralded advances in treatment and biomedical prevention, can managing newly diagnosed patients be complicated?
Clinicians understand that people living with HIV access treatment more easily now and live long lives, and that early treatment can prevent transmission to others. However, primary care clinicians may not be equipped to manage these patients on their own, or be familiar with the extensive protocols that cover patients' precise cocktails of medications and requirements for laboratory monitoring and testing frequency. Understandably, providers may feel overwhelmed by questions on bigger issues associated with managing an HIV-positive patient and getting the patient into care:
- Can I manage the patient and coordinate his/her care, or should I refer to a specialist?
- Do I have team members in my practice who can address related patient problems, such as coinfections, addiction, mental health, homelessness, and isolation?
- Who will accept referrals of my underinsured or uninsured patients?
- To whom can I refer patients who speak Spanish?
- How do I get reimbursed for treating an HIV-positive patient?
- How do I provide the best medical care with so much pressure to contain costs?
- What are my legal and ethical obligations/responsibilities?
- Where do I refer a patient who is experiencing stigma and discrimination?
- What are my legal responsibilities of reporting?
Can I overcome these barriers?
Yes! You can. It is important to acknowledge clinicians' many barriers to and questions about HIV testing, but we should not let these issues interfere with the critical responsibility of identifying HIV-positive patients and linking them to the very effective treatments now available. Routine screening allows many people with undiagnosed HIV infection to be identified who may have been missed by risk-based testing.
What are some tips?
Before administering an HIV test during a patient visit, you and your staff can explain that
- Anyone can be infected and not know it.
- CDC recommends HIV screening as part of routine care for all patients ages 13 to 64, similar to other screening tests such as cholesterol and blood glucose.
- Informed consent for HIV testing is covered by general consent for medical care.
- Early detection allows patients to stay healthy by starting effective HIV treatment right away and to prevent transmission to others
For those patients testing positive:
- Hold the session in a private area.
- Communicate the test result in a direct, neutral tone.
Patients may have questions about HIV infection and transmission such as
- How they can reduce the risk of transmission to their partners?
- HIV disclosure to partners (and how the health departments partner services can help notify their partners).
Thus, it is important for you to link the patient to care before they leave your office.
- Provide a referral, including the name and contact information of a physician or clinic.
- Ensure that a follow-up appointment is set up before they leave the office.
- Encourage the patient to contact you with any questions.
When I explain that HIV tests are not just for people at highest risk, my patients are fine with me running the test and more likely to wait for [rapid testing] or come back for their results because they don’t feel scared.
The CDC has developed a new program to help providers implement routine HIV testing and linkages to care, based on insights and appreciation for the range of complex issues that may challenge practice change. "HIV Screening. Standard Care.: Testing and Linking African American and Hispanic/Latino Patients to Care™": offers a resource kit that includes a provider brochure, resource list, and other materials, as well as an e-learning training module. I am part of the team developing these materials intended to empower those of us on the front lines to routinely test our patients and get them into treatment. It is primary care providers like ourselves who are needed to play the most critical role in truly stemming the tide of the HIV/AIDS epidemic by identifying and linking HIV-infected patients to care.
Ligia Peralta, M.D., F.A.A.P., F.S.A.H.M., A.A.H.I.V.M.S., is a Distinguished Fellow, Innovation in Global Health Care Fellowship of the Massachusetts Institute of Technology.