The Centers for Disease Control and others estimate that up to one million people in the United States are HIV infected. Approximately one-third of those infected are unaware of their HIV status. Heterosexual transmission is increasing, especially among young men and women without traditional risk factors, such as substance abuse or same-sex relationships. The outpatient primary care setting represents an ideal place to identify those who are HIV infected by offering routine testing for HIV. This setting could easily provide earlier identification of HIV infection and immediate linkage to healthcare of those infected.
The current risk-based approach to HIV testing has failed to identify approximately one-third of those who are HIV positive nationally. Routine testing for HIV has the potential to pick up thousands of patients who have been unknowingly infected or who were too fearful to find out the test results. This method of testing for HIV may reduce the barrier of risk-based inquiry prior to testing. While risk assessment is eliminated in routine testing, patient consent and appropriate discussion remain important components of testing.
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In a recent study in Providence, Rl, 29 patients admitted to urban hospitals were newly diagnosed with HIV during their hospitalization, and the majority had severe opportunistic infections. Although 45% percent of the patients had a primary care provider and 69% had received recent medical care, they had not been previously tested for HIV. The majority of those who tested positive during their hospitalization (65 %) did not have easily identifiable “traditional” risk factors for HIV This study underscores the not-so-rare “missed opportunities” for HIV testing that occur each day in primary care.
Routine testing for HIV indirectly influences the patient encounters by allowing avoidance of personal subjects that traditionally require more time, effort and energy to discuss or to manage. This leaves the larger, more detailed and invasive risk assessment to be done in the event of an HIV diagnosis. A recent inpatient study conducted in Boston, MA identified 19 additional HIV infections during a nine-month study period among low-risk patients by offering routine testing instead of risk-based testing. A similar study in Atlanta, GA assessed routine HIV testing among predominately underserved minority patients attending a primary care health center in a large urban setting. By offering routine HIV testing, 27 more patients were diagnosed and educated about HIV—double the previous year’s linkage to care. Although the CDC has recently advocated routine HIV testing, there has been very little published information on this practice and even less information on routine testing within the primary care setting. Our study sought to determine the attitudes towards routine testing for HIV in a primary care outpatient setting serving impoverished underserved minorities, particularly African Americans and Latinos, who are disproportionately affected by HIV/AIDS.