John W. Hogan, M.D
Howard University College of Medicine
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Upon conclusion of this module participants will be
able to:
 Describe the epidemiology of HIV/AIDS among diverse
populations
 Discuss the rationale for the CDC recommendations
 Understand the need to promote HIV testing
Current statistics on HIV/AIDS in the United States
Why revise current guidelines?

Revised guidelines are an attempt to routinize
testing with the ultimate goal of reducing the
number of persons who are unaware.
 The majority of persons who are aware will
reduce risk behaviors that can transmit disease.
 Risk behavior- 68% lower for persons who were
aware than for persons who were unaware
Source: CDC recommendations (2006)

Maximize the number of persons who are aware
of HIV status, particularly those who are HIV
infected, and increase the number of HIV
infected persons who receive care and
prevention services.

Approx. 1-1.2 million persons are living with HIV
in the US.
 ¼ of these are unaware of their infection
▪ Unable to benefit from clinical care
 These persons who are unaware may transmit
disease unknowingly.
Source: CDC recommendations (2006)

What do people perceive to be the current level of
prejudice/discrimination?
 45% believe there is “a lot” of prejudice against
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those living with HIV/AIDS.
36% believe there is “some”
11% believe there is “only a little”
5% “Don’t know”
3% “None”
Universal agreement: Stigma poses a serious
challenge to testing acceptance.
Source: Kaiser Foundation Survey 2006)

How would being tested for HIV affect other’s
perception of you?
 62% “No difference”
 21% “Think less of me”
 9% “Think more of me”
 7% “Depends/don’t know”
Source: Kaiser Foundation Survey 2006)

Destigmatizes HIV testing process
 Assessment of risk behaviors
▪ Many people do not perceive themselves to be at risk
or do not disclose risks
 More patients accept HIV testing when it is offered to
everyone
▪ Opt-out policy

Reduces HIV transmission
 Ignorance is not bliss!

Prolongs life
Source: CDC recommendations (2006)

Testing is voluntary
 Patient should have full knowledge and
understanding that test will be performed.
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Opt-out screening
Consent incorporated into general informed
consent (no separate test form)
Informational materials should be made
readily available (language appropriate)

Opt-in HIV testing. Requires HCW to provide
counseling and a separate written informed consent,
which patients must sign before being permitted to
have an HIV test.

Opt-out HIV testing. Patients are informed either
orally or via general medical consent that HIV testing
will be included as part of the routine blood tests.
Patients can decline the HIV test (opt-out). Assent is
inferred unless the patient declines testing.

Prenatal HIV testing for
pregnant women:

Meta-analysis of 27
studies of HIV-CT

Participants who tested
HIV negative and
received pre-test
counseling did not
change their risk
behaviors
 RCT of 4 counseling
models with opt in
consent:
▪ 35% accepted testing
▪ Some women felt
accepting an HIV test
indicated high risk
behavior
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When testing was
offered as Opt Out:
▪ Kl v88 % accepted testing
▪ Reported significantly less
anxiety about testing
Simpson W, et al, BMJ June 1999
Weinhardt et al, 1999, Am J Public Health
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According to the CDC:
 The use of highly active antiretroviral therapy
(HAART) since 1996 has significantly improved
survival for persons infected with HIV.
 Schackman et al. estimated life expectancy from
the time of infection (at age 33) to be 32.1 years,
versus 42.9 for HIV uninfected, from a large dataset
of persons in routine outpatient care in the current
treatment era.
Schackman BR, Gebo KA, Walensky RP, et al. The lifetime
cost of current human immuno-deficiency virus care in the
United States. Medical Care 2006; 44: 990-997.
Giving a positive test results

Positive test results should NOT be delivered in an
inappropriate manner (e.g., over the telephone, via
a clerk, etc.)

Positive test results should always be given face to
face by an experienced clinician (RNP, MD, PA) or
trained counselor who can refer patients
appropriately for care.
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Linkage to HIV care is essential.
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“Your test for HIV was positive”
 Give patient time to process results.

Answer questions and concerns, discuss support
services they can access.
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NOTE: A positive test result is from a
confirmatory test, not a rapid test or screening
test. A patient should never be told he or she is
positive based on the results of a rapid test.

“This means that you have the HIV virus but do
not necessarily have AIDS. There is treatment
available.”
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“I will refer you to the following treatment
center for continued support and care.”
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“We should also discuss methods you can adopt
to prevent the spread of the virus…”

“You have the choice to notify your partner.
You may choose to tell him/her yourself, we
can assist with notification, or the health
department can notify partner(s)
anonymously.”
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Linking of infected patient with preventive
and care measures is essential.
 HIV screening without linkage to care confers
little to no benefit to patient.
 Ensure immediate access to clinical care.
Source: CDC recommendations (2006)
Opt out testing will increase the number of
people tested.
 Opt out testing will increase new HIV diagnoses
when patients are asymptomatic and prevent
new transmissions.
 Entire staff (medical assistants, nurses, PA’s and
MD’s) should all be conscious of HIV testing.
 Referral system should be updated/practiced by
staff and available for ALL patients who test
HIV+.
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
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