1. What Are the Barriers to Opt-out HIV testing?
Cade A, Bosworth M, MacClements J, Gentry D, Menard R, Tompkins R, Olusola P, Liles M
The project described was supported by Grant Number from Department of State Health Services

2. The Scope of the Problem
1.2 million people are living with HIV in the US, this is higher than ever before
The incidence of HIV has remained stable at about 48,000 people infected per year
20% of people with HIV do not know they are infected
One third of new HIV cases are diagnosed late and develop AIDS within 12 months

3. Texas HIV Trends

4. CDC Recommendations
In September of 2006 CDC published new guidelines for HIV testing
Routine HIV screening should be performed for people ages if local prevalence is greater than 0.1%
Annual screening for high risk patients
Separate written consent is not necessary, instead opt-out testing is recommended
Prevention counseling should not be required with HIV testing

5. UTHSC Tyler
The Family Medicine Clinic at UTHSC Tyler is home to 23 residents and 6 faculty
UTHSCT is located in the Northeast corridor of Smith county, but also serves Gregg, Wood, Upshur and Rusk counties among others

6. Gregg County, Texas Ranks 17th of 254 counties for incidence of HIV
Ranks 17th for number of people living with HIV
Prevalence 0.268%

7. Smith County, Texas Ranks 21st for incidence of HIV infection
Ranks 20th for number of people living with HIV
Prevalence 0.149%

8. Routine HIV testing
Given CDC recommendations for opt-out testing and our high local prevalence:
We applied for DSHS grant to fund routine HIV testing
We excluded patients ages 13-17
Estimated 3000 HIV tests in one year assuming a 20% opt out rate

9. Implementation
The Family Medicine Clinic (FMC) implemented opt-out HIV testing for patients ages in August 2011
UTHSCT ER implemented opt-out testing January 2012
Patients choosing to opt-out complete a form
Screening is done using a rapid serologic test, positive tests are confirmed by Western Blot

11. Implementation
A grant from the Department of State Health Services provided 3000 free test kits
All positive tests are reported to DSHS and the patients are brought in for counseling
Signs are posted in all exam rooms

13. Measures for Compliance
Rapid HIV test added to EMR lab favorites list
Multiple and verbal reminders
Signs posted in all exam rooms
January 2012 routine testing implemented in ER

14. Results of Routine Testing: FMC
Assessment for first 6 months (9/1/11-2/29/12)
FMC Clinic visits of patients ages 18-64
5131
FMC HIV tests ordered
385 (7.5%)
Number of Opt-outs
8 (2.1%)
Positive HIV

15. Results of Routine Testing: ER
ER visits for patients ages 18-64
ER HIV tests ordered (1/1/12-2/29/12) 71
Positive HIV 1
CD4 count 59

16. Reasons for Opt-Outs “I’m not at risk” (3/8) “I don’t want to know”
“I already have it”
“Unnecessary”
“Already tested”
No reason given

17. Physician Survey Completed surveys Estimated number of tests ordered
Faculty 6 (100%)
Resident 21 (91%)
ER 6 (75%)
Estimated number of tests ordered ER
Faculty 293
Resident 200

18. Top Reasons for not Testing
“I forgot”
“No reminder in EMR”
“My patients are not at risk”
“Patient opted out”
“Awkward to bring up”
“Takes too long”

19. Perceived Barriers “Forgetting” (3) “Too time consuming” (3)
“Do not feel my patients are at risk” (2)
“Too busy”
“Administrative barriers”
“Order and process are not clear”
“Patients fear of cost”

20. Suggestions for Improvement
“Reminder in EMR” (2)
“Wider acceptance of testing by patients”
“Physician reminders” (2)
“Patient education”
“Fool proof follow up on positive tests”
“Streamline order process”
“Reminder signs in ER doctor area”
“Repetitively asking patient even after opting out”

21. What are the barriers to Routine HIV Testing?
We had a grant providing FREE tests
We educated our physicians (resident and faculty) on multiple occasions
Despite this we only performed a total of 456 tests in FMC and ER combined
< 10% of the target population received the test
Only 2.1% of patients opted out

22. We are the Barrier!
Barriers lie with physicians and NOT patients

23. Solutions EMR reminders Educate patients to ask for routine testing
Pop-up box
Concern: pop-up fatigue
Educate patients to ask for routine testing
Take the order out of the physician’s hand
Standing orders in the lab with all blood draws on patients ages 18-64
Concern: Duplicate testing

24. References
CDC. HIV surveillance-United States, MMWR. 2011; 60:
CDC. Revised Recommendations for HIV Testing of Adults, Adolescents and Pregnant Women in Health Care Settings. MMWR. 2006; 55: 1-17
Texas DSHS. Texas HIV Surveillance Report

25. The project described was supported by Grant Number from Department of State Health Services