Since 2006, the Centers for Disease Control (CDC) has recommended that all people aged 13-64 be screened for HIV by their health care providers. That was supposed to help identify a lot of patients who had HIV, but didn’t know it. It would also allow them to get treated, and make them less likely to transmit HIV.
In theory, it was a great idea. In practice, it hasn’t worked as well as it could have.
Let’s look at how a patient might get screened today in areas where the current CDC screening guidelines are followed, without the extra fail safes that two sites have now implemented.
A 23 year-old male goes to his local county health department clinic because he’s developed a genital discharge and pain in the area. The doctor orders several tests, including an HIV test. The patient agrees. His doctor suspects a sexually transmitted infection (STI), and starts treatment. The patient leaves, completes treatment and does well. He never returns for his follow-up appointment. Three days later, the clinic gets a positive HIV test back on the patient. The staff at the clinic attempts to contact the patient several times by phone, mail and email. The patient never responds. He’s HIV positive but doesn’t know it and may be spreading the disease to several other sexual partners. And they won’t know that they’re infected.
The possibility also exists that the patient has HIV, but he’s in a “window” period when the tests the county health department will be negative, because the patient hasn’t yet produced the necessary antibodies that the HIV tests detect. So he can be positive, with a high viral load, yet his results are negative.
So, in either of these two instances, the patient is capable of unknowingly spreading HIV. And, since neither patient knows that he’s positive, he’s not receiving any treatment or counseling.
These patients are ones that fall into the group of about 15-20% of cases of HIV where the patient is unaware of their status and is not enrolled in treatment. In the above scenarios, even had the patient tested positive and been notified of the fact, many don’t go for treatment. They may elect not to get treated, there may be a communication failure by the testing site to contact or refer the patient for treatment, or there may be paperwork errors and/or other problems.
Two sites, one in New York City and one in New Orleans, received funding to look at and attempt to correct this problem. They were to look at:
1) institutional policy change reflecting an organization-wide commitment to routine HIV testing and diagnosis; 2) integration of HIV testing into existing clinical workflows to promote its normalization and sustainability; 3) use of electronic health records (EHR) to prompt testing, automate laboratory orders, and track performance; and 4) required staff education on best HIV testing practices and outcomes.
What they did was to ask every patient to agree to have HIV testing along with other necessary blood work. And the vast majority agreed (though all were offered the opportunity to opt out of HIV testing). The patient’s demographics and the lab tests (among other things) were entered into the electronic health record (EHR). The EHR would prompt staff to check the HIV test, contact the patient, have them come in to discuss test results and receive HIV education, set up follow-up appointments for future testing (if HIV negative), or enroll them in treatment (if HIV positive.) The screening test results are available at the same visit where the blood is drawn. So the patient knows their status even before they leaves the hospital or clinic. One site can even test for the acute phase of HIV infection that is positive before the antibody tests become positive. The sites have HIV counselors and navigators available to guide the patients through the initial paperwork and referral process, and get them connected to a clinic or doctor that can start HIV treatment. The EHR also prompts the staff to check with the patients after they are referred to a treating doctor to support them, and in general to follow them and help with other problems if they arise.
Instituting this plan caused an impressive increase in the number of patients screened, detected as HIV positive, and referred to treatment. At one site, the number of patients screened before this program was about 8% of all patients who were eligible for screening. After implementation of the program, they averaged 56% of patients getting screened (remember, patients can opt out and not give consent for HIV testing.) At one of the sites in one year, almost 150 patients were diagnosed with HIV, and about 125 of those were successfully enrolled in programs for HIV treatment and care.
This method seems to be much better suited to identify and treat HIV patients than others currently in use. Surprisingly, it is not much more expensive to use this method. Both sites used already-available resources (their EMRs, laboratory facilities, navigators, counselors, physicians, nurses, etc.) They did need to do some additional staff education, reconfigure some clinical pathways, spend more time doing follow-up and make some other changes, but the costs were relatively small and mostly just a one-time expense.
Perhaps, if this system gets used in more locations, we’ll be able to decrease the numbers of untested people who have HIV, get them into treatment more quickly, and have an impact on decreasing rates of HIV infection.