Letter to the Editor
To the Editors:
Over 1 million people are living with an HIV diagnosis in the United States, yet as many as 25% of persons infected with HIV may be unaware of their status.1,2 The prevalence of HIV in the Coachella Valley of Inland Southern California is substantially higher than the national rate, in part because of the large older HIV-positive gay male population in Palm Springs, yet less than half (44.9%) of the residents were tested in 2013.3 We examined physician survey findings about HIV testing from Get Tested Coachella Valley, a region-wide public health campaign to promote voluntary HIV testing and linkage to care. A convenience sample of 50 physicians responded to a brief survey (18 questions) focused on HIV testing conducted between November 2014 to February 2015, with most of the participants being male (88% male, 12% female), and nearly half (49%) treated primarily teens and adults. The most common specialties of participants were family medicine (14.6%), internal medicine (12.5%), emergency medicine (8.3%), and surgery (8.3%) with 68% of participants working in office settings. Among their patients, 48.9% had Medicare which covers the cost of routinely recommended HIV screening.4
Participants treated an average of 234 patients in the past month, and provided 8 HIV tests in the same period (3% of patients). When asked what factors would facilitate HIV testing, respondents reported that training in counseling and reimbursement for counseling time (24%), having HIV testing literature for patients (20%), having better understanding of Centers for Disease Control and Prevention recommendations (16%), and having information about consent requirements (8%) would help. Physician barriers to HIV testing included other priorities at the patient visit and lack of time (32%), that most patients were already tested (28%), concern about patient reactions when offered the test (10%), and discomfort on broaching the HIV topic (4%). In addition, individual physicians reported patient refusal, that the test was not appropriate or necessary, that their patients were low risk, or they had difficulty with the electronic record. Nearly all (95.3%) physicians reported lack of a standard protocol for HIV testing at their training institution.
When asked their opinion on HIV testing, nearly half (48.8%) reported that routine HIV testing was critical, and that every teen and adult should be tested for HIV at least once, whereas 7% did not believe it was important or were opposed to the Centers for Disease Control and Prevention recommendation. Physicians thought that Get Tested Coachella Valley could increase routine HIV testing by educating the public and providers and through stigma reduction (Table 1).
Our findings suggest significant barriers to HIV testing by physicians to patients in the Coachella Valley, an area where providers likely have more exposure to patients with HIV. This is consistent with barriers listed in the literature, including insufficient time, a burdensome consent process, lack of knowledge and training, lack of patient acceptance, and competing priorities.5 An interesting finding is that our participants listed a burdensome consent process as a barrier even though California is an opt-out state and separate written consent for HIV testing is not required.6 Future efforts should focus on sustainable interventions to overcome HIV testing barriers for physicians including the suggestions by physicians in our study. Additional physician education both at training and practicing institutions provide a starting point to normalize HIV testing as part of routine care and identify undiagnosed cases of HIV.
2. Marks G. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006;20:1447–1450.
4. Moyer VA; U.S. Preventive Services Task Force. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013;159:51–60.
5. Burke RC, Sepkowitz KA, Bernstein KT, et al.. Why don't physicians test for HIV? A review of the US literature. AIDS. 2007;21:1617–1624.