HIV Screening and Access to Care Exploring Barriers and Facilitators to Expanded HIV Testing (2010) / Chapter Skim
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HIV Screening and Access to Care:Exploring Barriers and Facilitators to Expanded HIV Testing
HIV Screening and Access to Care:Exploring Barriers and Facilitators to Expanded HIV Testing
Pages 1-46
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Specifically, the committee was asked to examine • the extent to which federal and state laws and policies and health insurance policies pose a barrier to expanded HIV testing; • the capacity of the health care system to administer a greater num ber of HIV tests and to accommodate new HIV diagnoses; and • federal and state policies that inhibit entry into clinical care or the provision of continuous and sustained clinical care for people with HIV/AIDS. The statement of task includes more specific questions for the committee to consider within each of these three areas as well (see Box 1)
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HIV SCREENINg AND ACCESS TO CARE BOX 1 Statement of Task 1. What is the extent to which federal, state, and private health insurance policies pose a barrier to expanded HIV testing?
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This is the first of three reports that will be prepared by the committee. It focuses on the first part of the committee's task: the extent to which federal and state laws and policies, private health insurance policies, and other factors pose a barrier to expanded HIV testing.
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issued revised HIV testing guidelines in 2006 recommending routine testing in health care settings for people ages 13 to 64. Because of their relevance to the discussion of facilitators and barriers to expanded HIV testing, the revised CDC guidelines were frequently brought up by workshop participants and are discussed in several places throughout this report.
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compared with the overall percentage undiagnosed (21 percent) , although heterosexual males had the highest overall percentage of undiagnosed HIV infection (26.7 percent)
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. In 2006, the CDC issued revised HIV testing guidelines that recommend routine testing in health care settings for individuals between the ages of 13 and 64 (see the following section on the CDC's revised HIV testing guidelines)
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. Possibly due to risk-based approaches to HIV testing, certain population groups who may be at higher risk for HIV, such as young adults aged 18 to 29, African Americans, and Latinos, have been more likely to report having been tested in the past 12 months (KFF, 2009f)
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. CDC Revised HIV Testing Guidelines The 2006 CDC HIV testing guidelines recommend routine opt-out HIV screening in health care settings of individuals between the ages of 13 and 64, unless prevalence of undiagnosed HIV infection in that setting is documented to be less than .1 percent.8 The guidelines also recommended yearly screening for individuals in high-risk groups,9 and that opt-out HIV screening be included in the routine panel of prenatal screening tests for pregnant women (CDC, 2006c)
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. The CDC's HIV testing recommendations differ from the current USPSTF guidelines, which recommend routine screening for pregnant women and high-risk groups, and make no recommendation for or against routine screening for adolescents and adults who are not known to be at increased risk for HIV infection (USPSTF, 2007)
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" Laws and policies that can impede HIV testing include • state legal requirements for HIV testing; • discordant federal HIV testing recommendations; • public and private health insurance policies; • policies inhibiting use of rapid HIV tests; and • policies and practices in corrections settings. A lack of programs and policies to promote clinician education and training and reduce constraints on practice environments, as well as policies to reduce HIV stigma and discrimination, are also barriers to expanded HIV testing.
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For example, in Colorado, written informed consent and pretest counseling are required for HIV testing provided at public health testing sites (NCCC, 2010)
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,b Nebraska Written Informed Consent (HIV-specific written consent required; RRS §71-531) ,a New York (for HIV testing that will not provide results within 1 hour; PBH §2781 10 NYCRR 63.3)
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. In a 2008 survey of health departments, most states reported conducting routine HIV testing in health care settings, but this varied by population with few states reporting routine testing for the general population (adolescents and adults ages 13–64)
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For HIV testing, the USPSTF has assigned a grade A for screening of high risk groups and pregnant women. However, whereas the CDC guidelines for testing in medical settings recommend routine HIV testing for all individuals age 13 to 64, the USPSTF has assigned a grade of C for routine screening of those who are not at increased risk for HIV (i.e., it does not make a recommendation for or against routine HIV testing)
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Andrew Baskin of Aetna, Inc., discussed the slow rate of diffusion of changes in practice recommendations, including for routine HIV testing, into practice by health care providers, noting that it can take several years for a clinical recommendation to become implemented as a standard of care. Public and Priate Health Insurance Policies Workshop participants noted a number of policies related to the financing of HIV testing, including reimbursement for routine testing by public and private health insurers, that are possible barriers to expanded HIV testing.
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In terms of reimbursement of HIV testing under Medicaid, adults with identified risk factors are covered under a mandatory laboratory benefit. Routine HIV testing is also reimbursable under federal Medicaid law; states have the option of covering routine HIV testing of Medicaideligible adults as a preventive or screening benefit under section 1905(a)
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initiated a national coverage analysis to evaluate the existing evidence on HIV screening to determine if the evidence was sufficient for Medicare coverage 14 A review of current state Medicaid program coverage for HIV testing was not available at the time of this report. In 2000, 32 state Medicaid programs covered HIV testing in some fashion (Palen et al., 2004)
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According to a 2009 presentation by the CDC, of 11 large healthcare plans, all have established policies to reimburse for targeted HIV screening and six have established reimbursement policies for routine HIV testing (CDC, 2009d)
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If passed, the bill would require group health plans, as well as health insurance issuers that offer group health insurance, to provide coverage for routine HIV screening under terms and conditions no less favor 16 Under the Employee Retirement Income Security Act an employer may pay employee health care claims directly out of company assets rather than paying a premium to an insurance company.
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The bill would not preempt state laws that require coverage at least as comprehensive as that required under the bill (H.R. 2137, Routine HIV Screening Coverage Act of 2009)
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Reimbursement rates for services provided in hospital EDs are often bundled, and payment rates are prospectively negotiated between facilities and purchasers. These bundled rates are not necessarily up to date and may not be adequate to cover recently introduced clinical services such as routine HIV tests.
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While many of the people on ADAP waiting lists are able to receive drugs from pharmaceutical patient assistance programs, such programs are not meant to be a permanent or primary source of treatment access.17 Policies Inhibiting Use of Rapid HIV Tests Rapid HIV tests make it possible to provide results at the time that testing is done, while conventional tests can take several days to produce results. Thus, rapid testing can help to reduce the number of people who fail to receive their test results (Branson et al., 2006)
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Giberson stated that rapid HIV tests are not widely utilized in the IHS, where conventional testing has been instrumental to expansion of testing. According to a survey conducted by Bogart and colleagues in 2005– 2006, rapid tests were used infrequently in nonprofit community settings (Bogart et al., 2008a, 2008b)
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Providing HIV testing services in correctional facilities may help to increase the use of HIV prevention services among some high-risk groups for whom the rate of incarceration is higher, and therefore also help to reduce HIV/AIDS health disparities (Macgowan et al., 2009)
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Consequently, if HIV screening is to be conducted among detainees, it needs to be done rapidly. In contrast, most individuals sentenced to prison have a term of at least 1 year and there are structures in place to provide opportunities for HIV testing.
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Primary care physicians are at the forefront of the HIV/AIDS epidemic, yet a lack of education, training, and resources were cited by several workshop presenters as barriers to routine HIV testing in clinical practice. del Rio described several areas where there may be a need for primary care provider training and education, as demonstrated in the HIV/AIDS research literature, including • awareness of potential risks of HIV infection in patients; • the CDC guidelines and the benefits of early HIV diagnosis with linkage to care; • tools for disclosing a positive diagnosis and discussing risk behav iors, such as sexual practices and drug use, with patients; • technical training on rapid HIV tests; • knowledge of state laws regarding consent and counseling; and • availability of HIV care resources in the community (e.g., Ryan White grantees)
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were identified as potentially being more effective than physicians in facilitating the expansion of testing. Expanded HIV testing leads to increased numbers of individuals who need HIV care services.
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. Some individuals with HIV may feel blamed for their HIV infection and encounter fears of contagion by others, including within the medical community (Sayles et al., 2007)
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• State and local regulations and institutional laboratory policies may inhibit the use of rapid HIV tests in clinical settings. Flex ibility in the use of the full range of HIV testing technologies and algorithms (point-of-care and laboratory-based algorithms)
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Programs and policies aimed at the medical community and the public that raise awareness about HIV and HIV-related risks, provide social support, and are culturally sensitive are needed to facilitate expanded testing and improve the quality of life for those affected by the disease. Methods and Policies to Increase HIV Testing and Identification of HIV Positive Individuals The second specific question posed to the committee was, "What effective HIV testing methods and/or policies should be implemented by federal, state, or local agencies, federal programs, or private insurance companies that can be used to reach populations with a high HIV prevalence and/or high prevalence of undiagnosed HIV infection." Methods and policies that might increase HIV testing and identification of HIV positive individuals include • wider availability of rapid HIV testing; • partner notification and social network strategies; • linkage of HIV testing with other care and social services; • media and social marketing strategies; • strategies that encourage HIV testing by providers; • federal and state privacy and discrimination laws; and • corrections-specific strategies.
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Several rapid HIV tests have waivers to the CLIA quality standards, allowing them to be administered by nonlaboratory personnel including in nonmedical settings. Testing in community settings such as bathhouses, bars, homeless shelters, and churches has in several studies been found to be feasible and effective for reaching populations who are at high risk for HIV and who have a higher prevalence of undiagnosed HIV infection (Aguirre et al., 2007; Bowles et al., 2008; Bucher et al., 2007; Daskalakis et al., 2009; Hatcher et al., 2008; Huebner et al., 2010)
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For example, partner services have been found to be routinely provided in publicly funded HIV counseling and testing sites, but less likely to be provided outside of public health sites, unless providers contact health departments for assistance (Dooley et al., 2007; Golden et al., 2004)
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. Although further research is needed, there is evidence from studies of HIV testing in STD clinics that HIV testing can be included in the routine battery of tests with high patient acceptance and can help to identify those who are unaware of their HIV-positive status (CamposOutcalt et al., 2006)
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One study that used a social marketing campaign (Spanish-language radio, print media, a website, and a toll-free HIV-testing referral hotline) to promote HIV awareness and testing among Latinos living in the U.S.-Mexico border region documented increased HIV testing at partner clinics, with 28 percent of testers reporting exposure to the campaign (Olshefsky et al., 2007)
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According to a flyer about the campaign, social marketing materials spurred increases in referrals for testing through the campaign's 1-800 number.24 A similar initiative called Test Miami was begun in 2009 to increase HIV testing in Miami-Dade County using social marketing strategies as well as efforts to mobilize the health sector and recruit and engage members of the community.25 In a discussion of facilitators of HIV testing among Latino MSM, Magnus noted the importance of adequate translations of social marketing media and related materials, as well as culturally appropriate messages and modes of dissemination. Bogart emphasized that establishing partnerships between providers and communities, such as through the use of health advisors from the communities being targeted, remains key to identifying FIGURE 3 Municipal HIV/AIDS test scale up campaigns.
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the establishment of a standard of care regarding HIV screening by national credentialing and accreditation bodies and (2) the development and adoption of quality metrics based on HIV testing and/or early detection.
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The approach, called "Advise, Consent, Test, and Support," has been found to facilitate improvements in HIV testing in both clinical and community-based settings (AHRQ, 2010) (see Figure 4)
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Such programs could improve providers' cultural competence and communication skills related to risk behaviors and attitudes that limit acceptance of HIV tests. Blank pointed out that individuals coming from the community in which patients reside may be viewed as less threatening and without the "social distance" often seen between patients and their physicians.
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Individuals who test positive also receive counseling. An additional HIV screening is routinely administered as inmates are released.
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. Conclusions • Several strategies show promise for increasing identification of indi viduals with HIV, including rapid HIV testing (including in commu nity settings)
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. As discussed previously, most states have HIV testing laws that are consistent with the CDC's opt-out HIV testing guidelines, while a few require written informed consent.
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. In one of the largest studies of opt-out HIV testing to date, nontargeted opt-out HIV screening in an ED was associated with a modest increase in the number of patients newly diagnosed with HIV infection, compared with physician-directed diagnostic HIV testing.
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5Figure R01760 editable vectors African Americans with the goals of conducting 1.5 million HIV tests to identify 20,000 new HIV positive individuals (NASTAD, 2009)
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Starting with availability of effective treatment and the fact that the effective clinical management of HIV infection requires early identification, and that the prevention of HIV transmission necessitates a reduction in the number of individuals who are unaware of their HIV status, some began to assert that the standards of consent that defined HIV testing in the earliest stages of the HIV epidemic should be rethought (Bayer and Fairchild, 2006)
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Several laws, policies, and procedures in settings where HIV tests are administered may impede expanded HIV test
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There are evidence-based approaches to facilitate HIV testing that may be considered as part of an expanded HIV testing strategy. Before implementation of a program of expanded HIV testing, consideration should be given to whether individuals who are diagnosed as HIV positive can be provided timely access to care.
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