Little progress is being made in the United States to expand routine HIV testing and cut the rate of late HIV diagnoses, according to a number of studies presented to the National Summit on HIV Diagnosis, Prevention and Access to Care this week. Information presented to the summit showed that two years after routine HIV tests were recommended for all individuals between the age of 13 and 64, there has been only a marginal increase in the number of patients attending emergency rooms who are offered HIV tests. The summit also heard that when HIV diagnoses were being made in emergency room settings, they mostly involved individuals who had already progressed to AIDS.
Much of the HIV-related illness and death seen in the US and Europe involves individuals who only have their HIV infection diagnosed when they are already severely ill because of HIV. Latest US figures suggest that 21% of HIV-positive individuals in the US are undiagnosed. In 2006, the US Centers for Disease Control and Prevention issued guidance recommending opt-out HIV testing for most adolescent and adult patients accessing primary, emergency, and specialist care.
This guidance does not, however, appear to have had a significant impact on levels of testing. Investigators at Johns Hopkins University found that only between 50 and 100 of 5,000 emergency departments surveyed routinely tested for HIV. A review of almost 8 million private insurance claims made in 2006 found that only 5% of patients with serious illnesses suggestive of HIV were tested for the infection.
Furthermore, a little over a third of patients seeking treatment for sexually transmitted infections were being offered HIV tests, and over 40% of pregnant women were not being tested for HIV.
Although HIV prevalence in prison is two and a half times that seen in the general population, researchers found that most federal and state prisons are not routinely testing inmates for HIV.
Another US population with a high HIV prevalence is veterans, and the US Department of Veterans’ Affairs being one of the country’s largest providers of HIV care. However, investigators found that fewer than 10% of inpatients and 5% of outpatients were tested for HIV in 2006 at Veterans' facilities.
Very high rates of advanced HIV disease were present in patients having their HIV diagnosed in US emergency rooms. At the emergency room of one Veterans’ Affairs hospital in Washington D.C. every patient diagnosed with HIV was diagnosed so late that they had already progressed to AIDS.
The investigators identified a number of barriers to testing. The co-chair of the summit, Dr John Bartlett of Johns Hopkins University said: “When it comes to HIV testing, the health care system is stuck in the past.” Lack of funding and trained staff were also identified as problems in some areas.
And a survey conducted amongst the staff of 40 emergency rooms showed that the resistance of staff could be a major barrier to the expansion of routine testing. The survey showed that majority of staff opposed increased testing, citing pressure on staff and lack of financial resources as reasons.
But there were also reasons for optimism. The number of inmates accepting voluntary HIV tests when incarcerated in New York City jails increased from 6,500 in 2004 to 25,000 in 2006. Use of health educators offering rapid HIV tests significantly increased rates of HIV testing in a Chicago emergency room and programmes targeting individuals from high risk groups led to an increase in HIV testing in Oakland, Washington and New York City.
“Model programmes have demonstrated what is possible”, said Dr Ken Mayer of Brown University’s AIDS Programme”, now it is time to move from isolated successes to a national movement. The barriers [to testing] must be removed.”