April 2003

Current Knowledge

In 1987 the Public Health Service recommended that testing for HIV infection be conducted when requested by a patient or recommended by a health care provider on the basis of behavioral risks or clinical symptoms. Despite the number of persons tested on these grounds, many HIV-positive persons have not been diagnosed or have received a diagnosis late in the course of their disease: among persons reported with AIDS, 45% received their first positive HIV test result less than 1 year before AIDS was diagnosed.1 Thus, many persons, unaware of their HIV infection, are unable to benefit from prevention and care services that can reduce the morbidity and mortality from HIV disease. In addition, they may unwittingly contribute to the continued transmission of HIV infection.

Incorporating HIV screening into routine medical care services in facilities with high HIV prevalence is a promising complementary strategy for increasing the number of HIV-infected individuals who become aware of their infection.² Until now, testing, performing a test because of a person’s clinical symptoms or behavioral risk factors, has been the predominant paradigm for diagnosing HIV. Screening, or performing a test for all persons in a defined population, is a basic, effective public health tool used to identify an unrecognized condition so that treatment can be offered before symptoms develop.³ HIV screening meets all of the generally accepted principles that apply to screening⁴:

• HIV is a serious disease that can be detected before symptoms develop by using a screening test that is reliable, inexpensive, acceptable, and non-invasive.
• Treatment given before symptoms develop, rather than after symptoms develop, is more beneficial for reducing morbidity and mortality.
• Costs in relation to the anticipated benefits are reasonable.

HIV infection in clinics and facilities where the population served has a high prevalence of HIV is comparable to other infectious diseases such as syphilis, tuberculosis, and human papillomavirus, for which screening programs have substantially reduced disease burden and improved health. In low-prevalence facilities, HIV counseling, testing, and referral should continue to be offered to clients based on risk screening.⁵

HIV screening in high prevalence settings makes sense because testing solely on the basis of risks fails to identify many HIV-infected persons.^6,7,8 Persons with AIDS make multiple visits to hospitals, acute care clinics, and managed-care organizations before their AIDS diagnosis, but are never tested for HIV.6 Many providers are uncomfortable discussing risk behavior with their patients,⁹ and many persons may be unaware of, or do not disclose, their own or their partner’s risk behaviors.^10,11 Routine voluntary HIV screening presents an opportunity to reduce the stigma related to HIV testing.^3,12 Patients are not offended when testing is presented as a policy that applies to all patients because they do not feel singled out as “at-risk.”³ More patients accept HIV testing when it is offered routinely than when it is based upon risk assessments.^{11, 12}

Patients’ attitudes seem to support routine voluntary HIV screening. Focus groups indicate that many patients, especially those who have been tested for other sexually transmitted diseases (STDs), assume they have been tested for HIV, whether or not such testing was performed. In some communities where HIV infection is common, being screened for HIV is perceived as a part of routine care, similar to regular mammograms and blood pressure checks.¹³

Since 1993, CDC has recommended offering HIV testing routinely to all patients in acute care settings in areas of high HIV prevalence.^5,14,15 When HIV testing has been offered routinely in high-prevalence, high-volume health care facilities, the proportion of HIV-positive tests (2% to 7% in hospitals and emergency rooms)^{15, 16} is similar to or exceeds that observed nationally in publicly funded HIV counseling and testing sites (2.0%) and STD clinics (1.5%).¹⁷

Alternative strategies are necessary to help identify the estimated 25% of persons living with HIV who have not been diagnosed through existing efforts. Incorporating voluntary HIV screening into routine medical care represents a logical step toward achieving this goal.

Objectives
The purpose of this document is to provide guidance for state and local health departments to

• Identify health care facilities that serve populations in which HIV prevalence is high and where routine HIV screening should be instituted
• Design and promote simplified HIV screening procedures to make routine screening feasible in high-volume, high-prevalence health care settings, which may reduce the stigma associated with HIV testing
• Increase the number of persons who undergo HIV screening in medical care facilities, the proportion of persons who receive their HIV test results, and the proportion of HIV-infected persons who receive care

Procedures
Steps for health departments

1. Work with community planning groups to identify health care facilities serving populations in which HIV prevalence is high. Several criteria may be used to guide selection:
   1. Prevalence data, when available, demonstrating HIV prevalence > 1% among patients served by the facility
   2. AIDS diagnosis rate of ≥ 1 per 1,000 discharges from hospitals, and in health centers and clinics in the hospital’s referral network
   3. Receipt of funds under Title I or II of the Ryan White Care Act
   4. Comparison data demonstrating that the facility’s patient population is similar to that of other medical care facilities where HIV/AIDS prevalence is high (e.g., demographics, high STD rates).
2. Promote routine HIV screening in the health care facilities through mechanisms such as assessments, social marketing, incentives, assistance with reimbursement, or availability for consultations and support services.
3. Collaborate with CDC and national medical and provider organizations to promote routine HIV screening in medical facilities serving populations in which HIV prevalence is high.
4. Develop guidelines for HIV screening with simplified procedures for risk screening and prevention counseling, when appropriate. Risk screening and prevention counseling may not be appropriate or feasible during episodic or acute care visits and should not become barriers to HIV testing. Medical visits in which prevention counseling is most appropriate are those in which HIV screening and counseling are consistent with the context of the health care visit, including
   1. In response to patient request
   2. When the reason for the visit is related to a behavioral or clinical risk, such as substance abuse or symptoms of an STD
   3. When other health promotion services are usually offered (e.g., as part of comprehensive health assessments, reproductive health care, or family planning)

Collaboration between the health department and the health care facility
Each health care facility where HIV prevalence is high will need to develop an individual plan for implementing routine HIV screening. Health departments should provide consultation and assistance to accomplish the following:

1. Establish the facility’s policy for routine HIV screening
2. Operationalize the plan for routine HIV screening:
   1. Assess patient flow to identify opportunities during the patient visit for incorporating routine HIV screening (e.g., after triage, during waiting periods, or when vital signs are measured).
   2. Specify which staff will recommend HIV testing (e.g., clinicians, nurses, or both)
   3. Specify which staff will obtain informed consent. During the visit
      1. Patients should be given written, culturally appropriate information about HIV infection, testing, and prevention.
      2. Patients should be told that HIV testing is routine and is recommended for all patients.
      3. Patients should be told that HIV testing is voluntary and that they have the right to refuse testing.
   4. Determine the HIV testing process best suited for the facility and the patients. The following factors should be considered:
      1. Type of HIV test (serum test, oral fluid, or rapid test). This may be influenced by whether phlebotomy is readily available, the likelihood that patients will return for results, and the usual duration of patient visits.
      2. Location where specimens will be collected or testing performed.
      3. Specific staff members who will collect the specimen and/or perform the test.
      4. Appropriate communication and documentation of HIV test results.
      5. Training required for facility staff who will be involved.
      6. Maintenance of confidentiality.
3. Promote routine screening to health care providers through informational sessions and by providing tools such as revised patient encounter forms.
4. Promote routine voluntary screening to patients through informational brochures, posters, and waiting room videos, among other communication tools.
5. Promote stepwise integration of routine screening: initially, financial support or health department personnel may be needed to initiate the process and demonstrate the acceptability, feasibility, and effectiveness of routine screening. CDC is funding demonstration projects that will help determine how best to integrate HIV screening into routine care.
6. Establish follow-up procedures for patients who test positive for HIV, including counseling consistent with CDC guidelines and appointment or referral procedures for prevention and care services. Recommendations for counseling and successful referral are outlined in the Appendix. On-site resources (e.g., through facility social workers) should be available for any patient who may require immediate counseling or support.
7. Establish procedures and responsibilities for reporting HIV cases to the health department and for requesting assistance with partner counseling and referral services where appropriate.
8. Establish mechanisms to monitor implementation of routine HIV screening, including the collection of information about the number of patients who are seen in the facility, are offered HIV testing, are tested, and receive their test results.
9. Establish mechanisms for monitoring maintenance of routine HIV screening, including tracking the proportion of patients tested per month.
10. Establish mechanisms to monitor outcomes of this strategy in the facility, including the number of newly diagnosed HIV infections, the proportion of patients who receive their confirmed HIV-positive test results, and the proportion of newly diagnosed patients who enter care and at what stage of disease.
11. Anticipate a decrease in the proportion of HIV positive tests when a facility transitions from risk-based testing to screening.

Working with Partners and Integration into Existing Services
To integrate HIV screening into routine medical care, health departments must rely on medical facilities and community partners. Health departments can facilitate this collaboration by

1. Coordinating activities with programs funded by the Health Resources and Services Administration, including Ryan White Planning Councils and other HIV service delivery organizations, state primary care associations, community and migrant health centers, health care for the homeless, and public housing primary care clinics
2. Coordinating training efforts with AIDS Education and Training Centers
3. Developing a strategy for promoting the support of advocacy groups and community leaders for routine voluntary HIV screening
4. Obtaining endorsements from local medical societies, health care facility administrators, and managed care organizations
5. Supporting implementation through allocation of health department HIV counseling and testing resources.

Programmatic Considerations
Before establishing routine HIV screening, health departments and medical care facilities must consider how to address policy, financial, and resource barriers.

1. Legal, regulatory, and logistical barriers, such as separate informed consent for HIV testing, may challenge the integration of HIV screening into routine medical care in some areas.
2. Individual insurance plans will have different reimbursement policies for HIV tests performed under various International Classification of Disease (ICD) and Current Procedural Terminology (CPT) codes. Some insured patients may prefer not to submit claims for HIV testing. Resources must be identified for patients who do not have the financial resources to pay for the HIV test.
3. Linkages and resources for HIV care need to be in place. HIV care includes prevention and treatment services for persons who test HIV-positive and prevention services for high-risk persons who test HIV-negative.
4. Health departments, medical institutions, and other community agencies must consider how to allocate the resources necessary to appropriately implement HIV screening.

Vignette
In 2000, health care providers at Grady Memorial Hospital in Atlanta, Georgia, recommended voluntary HIV screening for all patients aged 18 to 65 years who were not known to be HIV-positive or who had not been tested during the preceding 6 months.15 Information brochures and posters encouraging HIV testing were used to promote the new policy. Patients who accepted HIV testing signed a consent form and were tested with either a rapid or a standard enzyme immunoassay (EIA) test. Patients were not charged for the tests. Clinicians, counselors, or trained research staff delivered test results. A physician’s assistant contacted HIV-positive persons who had not returned for their test results. Approximately 20,000 clinic visits occurred during both the study period and during the same period in the preceding year when HIV testing had been risk- and symptom-based. During the study period 1,687 more patients were tested during the study period, 27 more HIV infections were diagnosed, and 27 more patients were informed of their HIV-positive test result. Twice as many HIV-positive patients (26 versus 13) entered care, and a higher proportion were tested earlier in the course of infection (based on CD4 T cell counts of >200 cells/ml).

Monitoring Implementation
CDC grantees receiving HIV prevention funds will be required to routinely report the following indicators to monitor their HIV testing programs in medical care facilities.

CDC’s HIV Prevention Program Performance Indicators*:

1. Number and percent of newly diagnosed HIV infections in high prevalence settings implementing routine HIV screening (B.1)
2. Percent of newly identified, confirmed HIV-positive test results returned to patients tested (B.2)

Other program measures:

3. Percent of newly identified HIV-positive patients who enter into care, as documented by either a CD4 count or a visit to an HIV-care clinic
4. Stage of infection at time of diagnosis as indicated by CD4 count or presence of AIDS-defining clinical criteria
5. Summary data on the comparison between the performance indicators collected in routine medical care settings to the same performance indicators for all tests reported by CDC-funded HIV counseling, testing, and referral sites in the jurisdiction

* The CDC Technical Assistance Guidelines for Health Department HIV Prevention Program Performance Indicators provides information on setting baseline, target, and indicator specification including appropriate data sources, calculations and reporting issues. Note: Performance indicators may have been modified to reflect specific population or setting characteristics.


References

1. CDC. Late versus early testing of HIV–6 Sites, United States, 2000-2003. MMWR 2003; 52:581-6.
2. Freedberg KA, Samet JH. Think HIV: Why physicians should lower their threshold for HIV testing. Arch Intern Med 1999;159:1994-2000.
3. Institute of Medicine, National Research Council. Reducing the odds: Preventing perinatal transmission of HIV in the United States. Washington, DC: National Academy Press, 1999.
4. Wilson JM, Junger CT. Principles and practice of screening for disease. World Health Organization Public Health Paper 34; 1968.
5. CDC. Revised guidelines for HIV counseling, testing, and referral. MMWR 2001:50(No RR-19);1-58.
6. Klein D, Hurley LB, Merrill D, Quesenberry Jr CP. Review of medical encounters in the 5 years before a diagnosis of HIV-1 infection: Implications for early detection. JAIDS 2003;32:143-152.
7. Chen Z, Branson B, Ballenger A, Peterman TA. Risk assessment to improve targeting of HIV counseling and testing services for STD clinic patients. Sex Transm Dis 1998;25:539-543.
8. Alpert PL, Shuter J, DeShaw MG, Webber MP, Klein RS. Factors associated with unrecognized HIV-1 infection in an inner-city emergency department. Ann Emerg Med 1996;28:159-164.
9. Epstein RM, Morse DS, Frankel RM, Frarey L, Anderson K, Beckman HB. Awkward moments in patient-physician communication about HIV risk. Annals of Internal Medicine 1998;128(6):435-442.
10. Kellerman SE, Lehman JS, Lansky A, Stevens MR, Hecht FM, Bindman AB, Wortley PM. HIV testing within at-risk populations in the United States and the reasons for seeking or avoiding HIV testing. JAIDS 2002:31(2), 202-10.
11. Walensky RP, Losina E, Steger-Craven KA, Freedberg KA. Identifying undiagnosed human immunodeficiency virus: The yield of routine, voluntary inpatient testing. Arch Intern Med 2002;162:887-892.
12. Irwin KL, Valdiserri RO, Holmberg SD. The acceptability of voluntary HIV antibody testing in the United States: A decade of lessons learned. AIDS 1996;10(14):1707-17.
13. Vernon KA, Mulia N, Downing M, Knight K, Riess T. “I don’t know when it might pop up”: Understanding repeat HIV testing and perceptions of HIV among drug users. Journal of Substance Abuse 2001;13:215-27.
14. CDC. Recommendations for HIV testing services for inpatients and outpatients in acute-care hospital settings. MMWR 1993;42(No. RR-2):1-6.
15. CDC. Routinely recommended HIV testing at an urban urgent-care clinic – Atlanta, Georgia, 2000. MMWR 2001;50:538-541.
16. Kelen GD, Shahan JB, Quinn TC. Emergency department-based HIV screening and counseling: experience with rapid and standard serologic testing. Ann Emerg Med 1999;33:147-155.
17. CDC. Anonymous or confidential HIV counseling and voluntary testing in federally funded testing sites – United States, 1995-1997. MMWR 1999;48(24):509-13.

Resources
Patient Flow Analysis (PFA).

Recommendations for HIV testing services for inpatients and outpatients in acute-care hospital settings. MMWR 1993;42(no. RR-2).

Revised Guidelines for HIV Counseling, Testing, and Referral. MMWR 2001: 50(No. RR-19);1-58.

Routinely recommended HIV testing at an urban urgent-care clinic – Atlanta, Georgia, 2000. MMWR 2001;50:538-541.

CDC. Technical Assistance Guidelines for CDC’s HIV Prevention Program Performance Indicators.