Testing for HIV is a crucial detection and preventive strategy. An estimated 1.2 million people within the United States have HIV infection, and approximately 20% are undiagnosed.1 The Centers for Disease Control and Prevention (CDC) revised HIV testing guidelines for health care settings in 20062 to shift HIV testing from targeting high risk groups to routine, nontargeted, opt-out screening in areas where the prevalence of undiagnosed infection was ≥0.1%. The American College of Physicians' position also encouraged clinicians to adopt routine HIV screening.3 The CDC recommended removing the requirement for separate written consent and pretest counseling for HIV testing, as early reports suggested that simplified consent procedures and opt-out screening strategies increase testing rates and showed screening to be cost effective.4–6
The Veterans Health Administration (VHA) cares for >8 million veterans, making this the largest integrated health care system within the United States. Historically, the VHA required pretest and posttest counseling with written informed consent for HIV testing as mandated by federal law since 1988.7 Screening was offered to patients who identified high risk behaviors, those receiving care for injection drug abuse, patients with HIV-associated diseases, and those requesting testing.7 With the change in VHA national HIV testing policy on August 17, 2009, written consent with pretest and posttest counseling was no longer required, although patients should still provide verbal consent and be given educational materials.8 Importantly, this policy promoted HIV testing as part of routine care rather than targeted to behavioral risks in a US national integrated health care system.
The primary goal of this study was to determine the impact of the revised HIV testing policy within the Veterans Affairs Medical Center in Washington, DC (VAMC-DC), by evaluating the testing percentages before and after this policy change. This assessment has significance, as the District of Columbia has the highest metropolitan rate of HIV/AIDS within the United States at 3.2%.9
The VAMC-DC is a tertiary care facility providing outpatient, emergency, inpatient, and long-term care to veterans with 137 acute care beds, 34 intermediate care beds, and 120 chronic care beds. This project was evaluated by the Institutional Review Board, deemed exempt from further review, and granted waiver of Health Insurance Portability and Accountability Act authorization, as this limited dataset posed minimal risk for patients and cannot be identified to specific individuals. This project was approved by the VAMC-DC Research and Development Committee.
We conducted a retrospective review using our local clinical database for all HIV test results and their linked inpatient or outpatient testing locations for the 1-year periods before and after August 2009. Deidentified patient demographic information in a separate dataset not linked to the HIV test results, included age at testing, gender, self-disclosed race, and ethnicity to assess any differences among veterans accepting testing before and after policy change. The period defined as before policy change was August 1, 2008 through July 31, 2009, and the period of September 1, 2009 through August 31, 2010, was defined as after policy change. All HIV tests included HIV-1/2 antibody from Serology Laboratory, rapid HIV point-of-care screening, and HIV-1/2 Western blots where confirmatory tests were linked to their screening tests to avoid duplicate counts.
Inpatient locations included all medical, medical and surgical intensive care, neurology, mental health, surgical, and long-term care wards. Outpatient locations included the emergency department, substance abuse rehabilitation program (SARP), Women's Clinic, Occupational Health, Infectious Diseases Clinic, all clinics in primary care, mental health, specialty clinics such as medical and surgical subspecialties, neurology, audiology, dental, and rehabilitation clinics, and outreach events and point-of-care testing. Outreach events which promoted HIV education and rapid testing for veterans, included various health fairs for veterans, National VA HIV Testing Day on June 27, 2009, and VA's National VA HIV Testing Week during June 27 through July 3, 2010. Point-of-care testing included week-day walk-in service for any veteran at the VAMC-DC requesting rapid oral HIV screening. HIV serology testing in the Infectious Diseases Clinic was performed for veterans referred for HIV care from outside VAMC-DC or was offered to the veterans at the time of Infectious Diseases consultation. Veterans presenting to establish HIV care in our Infectious Disease Clinic would have had a confirmatory HIV test, if none was previously documented. Testing in Occupational Health included persons who sustained an occupational exposure within VAMC-DC.
Descriptive statistics, Student's t test, Fisher exact test, or chi square with Yates correction on categorical data, and trend analyses were performed using statistical software (STATA8, STATA Corp LP, College Station, TX). All analyses were 2-tailed with significance taken at <0.05.
The VAMC-DC is a tertiary-care facility, which served 58,872 and 62,190 veterans receiving any medical care for the periods before and after VHA HIV policy change, respectively. During the year before VHA policy change, 3222 HIV tests were performed at VAMC-DC, and this increased by 99.5% to 6429 tests during the year after VHA policy change. The percentages of HIV testing among all veterans in care significantly increased from 5.5% before to 10.3% after this policy change (P < 0.0001 by χ2 analysis with Yates correction). In Table 1, the gender, race, and ethnicity of persons tested remained similar during these 2 periods and reflected our veteran population. Among all patients in care at our facility before and after VHA policy change, the majority were male (87% and 86%), African American (52% and 50%), and non-Hispanic (98%) for those who disclosed their information. The mean ages at testing were 49 and 51 before and after HIV policy change, respectively. The greatest increase in testing occurred among persons aged 61–70 after VHA policy change with a 2.96-fold rise. As VHA does not impose the CDC recommended limit of age 64 for screening in health care settings,2 veterans ≥65 accounted for 9.7% and 12.7% of those tested before and after VHA HIV policy change, respectively.
During our study, the majority of HIV tests were performed in the outpatient setting, mainly in the primary care clinics, as seen in Table 2. There was a significant difference before and after VHA policy change for tests performed in outpatient clinics versus inpatient wards (P < 0.001 by χ2 analysis with Yates correction). In addition, an increase in testing was performed at outreach events after the policy change (5.4% vs. 10.1%, P < 0.0001), and a significant decrease was noted in SARP after policy change (5.5% vs. 0.9%, P < 0.0001).
As the numbers of HIV tests performed increased after VHA policy change, HIV seropositivity decreased from 1.5% of those tested before VHA policy change to 1.1% after VHA policy change (P > 0.05), but actual numbers of HIV cases increased from 47 to 69 in Table 2. Both the number and percentage of confirmed HIV increased among inpatients. The numbers of confirmed HIV among outpatients rose from 36 to 56 after VHA policy change, whereas the percentage fell from 1.4% to 0.9%. False-positive results and other test performance characteristics during the study periods were within ranges previously reported at VAMC-DC.10
Due to testing requirements of written consent and pretest/posttest counseling and targeted testing to behavioral risks before the revised VHA policy, there were likely many missed opportunities for HIV diagnosis as reflected in the mean annual HIV testing percentage of 4.25% at VAMC-DC between 2000 and 2007.11 Among HIV-infected veterans enrolled in care at the VAMC-DC, 41.5% had disclosed no risk factors for HIV.11 A retrospective review of VA Medical Centers nationwide for newly diagnosed veterans between 1998 and 2002 found that only 12.5% had a condition suggesting increased HIV acquisition risk before their initial HIV presentation.12
Nontargeted rapid HIV screening in an urban emergency department was reported to be associated with 30 times the number of rapid tests performed with a modest increase in newly identified HIV infection.5 Inpatient routine testing programs are scarce, though several programs in high prevalence areas have increased the yield of new HIV diagnoses.13–15 In our study, the percentage of HIV diagnoses fell slightly from 1.5% to 1.1% after the policy change, but the actual numbers of HIV cases rose from 47 to 69. This is an important and expected outcome of the VHA policy change as implemented in our routine testing at the VAMC-DC. Our data is supported by VHA national data showing a rise in national HIV testing from 9.2% in 2009 to 13.5% in 2010 with a fall in seropositivity among those tested from 1.2% in 2009 to 0.7% in 2010 and an increase in positive HIV test results from 1739 in 2009 to 2233 in 2010.16
Persons who had HIV testing at VAMC-DC were primarily African American and men, reflecting our veteran population. In contrast to the 2009 National Health Interview Survey which reported testing rates to be inversely related to age,17 >70% of our veterans were aged ≥40 at the time of HIV testing. This is particularly significant given higher rates of sexually transmitted infections including HIV among men aged ≥40 on erectile dysfunction drugs18 and the increasing mean age of injection drug users with the highest prevalence among persons born between the late 1940s and early 1960s.19 During our study, the mean testing age rose by 2 years after policy change with the largest increase of 49% among veterans aged 61–70. Contrary to the lowest HIV screening of 13.3% previously reported among persons aged ≥65 compared with other adults,20 veterans in this age group had a 31% testing increment after VHA policy change.
In assessing our testing percentages with the VHA HIV Testing Policy change, we recognized our study had several limitations. Given the retrospective nature and use of deidentified HIV testing results, we cannot ascertain the number of tests offered or tests declined. Testing acceptance percentages of 23.8% and 54% were reported in prior studies of inpatient21 and outpatient22 point-of-care HIV testing at the VAMC-DC. In addition, we could not determine how clinicians made HIV testing part of routine care or if more patients were requesting testing, thus leading to increased screening. Factors other than the VHA national policy change may have influenced our testing percentages. There may have been greater testing efforts because clinicians perceived the ease of testing without the prior mandated written consent and counseling process, point-of-care testing was convenient for patients, funding was available for broadening testing at VAMC-DC, and more outreach events promoted HIV education and testing. In addition, there were shifts in testing locations such that more veterans who had HIV screening in primary care clinics and outreach events may not have been tested in other settings, such as SARP, after VHA policy change.
VHA noted the clear and urgent need to improve HIV testing within its health care network and revised its national HIV testing policy in 2009 to make HIV testing part of medical care for veterans. Making HIV screening routine will likely change culture, reduce stigma, and bring normalcy to testing over time. HIV screening at our medical center in the city with the highest HIV prevalence increased 2-fold during the year immediately after this policy change, reflecting a significant testing increase from 5.5% to 10.3% of all veterans in our care. Importantly, the numbers of persons found to have HIV also increased. As VHA is the largest US health care provider, broadening HIV screening as part of routine care may serve as a model to other health care systems to improve HIV diagnosis and prevent transmission.
We thank Katherine Hare, BS, and Robert E. Williamson, PhD, for providing clinical database extractions of testing and demographic data.
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