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Switch to Opt-Out HIV Screening Promotes
Testing in Women of Washington, DC
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1st International Workshop on HIV and Women, January 10-11, 2011, Washington, DC
Mark Mascolini
Women in Washington, DC --the US city with the highest HIV prevalence-- proved much less likely to decline HIV testing in the emergency department after Howard University Hospital switched from opt-in testing to the opt-out approach recommended by the Centers for Disease Control and Prevention (CDC) [1].
Washington, DC has an HIV prevalence of 3.2% among people over 12 years old, and infection is 17 times more likely in black women than in white women in DC [2]. Across the United States, women now account for 27% of new HIV infections and 25% of all current cases [3].
To promote earlier detection of HIV in the United States, in 2006 the CDC recommended universal opt-out HIV screening for 13-to-64-year-olds at every medical encounter, regardless of perceived HIV risk [4]. In opt-out testing, patients are told their blood will be tested for HIV and they have the chance to decline screening. With opt-in testing, patients are asked whether they want to be tested.
Howard University Hospital cares for a largely black population in central Washington. The hospital may have been the first in the United States to offer hospital-wide HIV screening. This study compared screening acceptance among women offered opt-in testing in the emergency department from October 2006 through May 2007 versus women offered opt-out testing starting in June 2007.
The comparison involved 16,112 women at least 16 years old who were offered free, rapid HIV testing in the emergency department with the OraSure OraQuick Advance Rapid HIV-1/2 Antibody Test. Reflecting the demographics of Howard's patient population, 84% of these women were black, 4% Hispanic, 2% white, and 10% in another racial/ethnic group.
Among all women approached, 4269 (26%) declined screening. Of women who declined screening, 2872 (67%) did so during the first 7 months of the observation period, when workers used the opt-in approach. The remaining 1397 women (33%) declined screening in the last 3.5 years of the study, when workers offered opt-out testing.
Of the women who declined testing during the opt-in period, 1165 (41%) said no without stating a reason, 923 (32%) declined because they were screened before, 319 (11%) declined because they were screened on a regular basis, and the rest said no for other reasons. Among the 1397 women who opted out of testing in the second period, a majority of 735 (53%) declined because they were screened earlier, 413 (30%) declined for no stated reason, and the rest declined for other reasons.
The Howard University team believes their findings suggest that opt-out HIV testing "is more effective [than opt-in testing] in capturing an increased number of women for HIV screening." This result, they proposed, "suggests that the current CDC screening recommendations have the potential to reduce stigma by normalizing HIV testing in women screened in an urban hospital setting." If all women are offered opt-out testing, the Howard investigators maintained, individual women will not feel singled out for testing.
References
1. Maxwell C, Isom S, Retland N, Holt-Brockenbrough M, Shamil C, Phillips A. HIV screening in the emergency department: does testing methodology impact the refusal rate in women screened? 1st International Workshop on HIV and Women. January 10-11, 2011. Washington, DC. Abstract O_08.
2. District of Columbia Department of Health HIV/AIDS Administration, Bureau of Surveillance and Epidemiology. The District of Columbia HIV/AIDS Epidemiology Annual Update 2009. Washington, DC, 2009.
3. Centers for Disease Control and Prevention. Diagnoses of HIV infection and AIDS in the United States and dependent areas. HIV Surveillance Report. 2008.
4. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55:1-17.
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