Our study aimed to assess the degree to which the veteran population at risk was tested for HIV and whether testing was based on identifiable risk behaviors among patients who were tested. Our reviews of testing were performed in 4 relatively large VA Health Care Systems that care for substantial numbers of patients with HIV. Although these sites are not likely to be representative of all VA centers, we have no reason to believe that testing or screening would be more extensive at other VA centers than in the ones included in our study.
The most important finding of our study is that only about one-third to one-half of patients we identified as being at risk for HIV, based on ICD-9 diagnoses of substance abuse, hepatitis, or sexually transmitted diseases, had been tested for HIV within a 5-year period in the VA. This finding was consistent in the 4 sites we studied. Even when we used more restrictive definitions of risk factors, slightly less than one-half of at-risk patients had been tested within the VA. Because the finding was consistent across our 4 study sites, and because we have no reason to believe that testing rates would be higher at smaller VA centers with less-active HIV programs, we believe that rates of testing of at-risk patients are likely to be too low in many VA centers. Our finding of low testing rates is of concern because early identification of HIV infection enables patients to access life-prolonging therapy at the earliest appropriate time. Our result is also consistent with studies from non-VA settings that indicate that patients with HIV are often identified late in the course of disease.12–14
For example, Klein and colleagues13
found that 43% of patients diagnosed in a large health maintenance organization had CD4 counts of less than 200 cells/μL. They also found that risk factors were present before diagnosis in about 25% of patients; our focus was whether testing occurred when risk factors were known.
We evaluated testing of at-risk patients during the period from 1995 to 2000, which raises the question of whether testing practices have changed since that time. Two recent analyses suggest strongly that they have not. An analysis of a cohort of 3,760 HIV antiretroviral naïve patients presenting for HIV care in the VA found that 55% presented late in the course of disease, with CD4 counts less than 200 cells/mm3
, and 40% of the patients had used VA services before, for a median duration of 3.7 years.22
These findings suggest that a large proportion of patients were both in care and were not identified until late in the course of disease. Furthermore, only about 11% of the HIV-infected patients had clinical symptoms or findings suggestive of HIV infection prior to diagnosis, which highlights the importance of testing patients based on risk behaviors. In addition, an analysis of a national sample of at-risk patients seen in primary care in the VA during 2004 to 2005 found lower rates of testing than in our study (Gifford and Asch, unpublished).
We had no way to determine whether patients had been tested in non-VA facilities or whether patients had been offered testing and refused. However, unlike the military, there are few if any disincentives for testing within the VA, and our experience is that it is rare for patients to be tested elsewhere and refuse testing at the VA.
We found that among patients who were tested, the rationale for testing was clear and based on risk behaviors or patient request for approximately 90% of patients. Site 4 had a modestly lower rate of documentation of the rationale for testing, but a higher prevalence of positive tests than other sites, which suggests that testing in this site did identify patients at risk. We do not know why documentation rates were lower in site 4. Overall, testing was most often performed because of documentation of substance abuse, with patient request and infection with hepatitis C as other important reasons for testing. Because some clinicians may not document risk behaviors, or because patients may not volunteer risk behaviors, the rate of appropriate testing may be even higher than we estimated. Consistent with non-VA populations, race (African American), age (30 to 49), risk behaviors (men who have sex with men), and a history of opportunistic infections were strong predictors of HIV infection (Table ).23–26
Our central finding that only about one-third to one-half of patients at risk had been tested raises the question of whether there are barriers to HIV testing. Current VA regulations require informed consent for testing and pre- and posttest counseling; documentation of consent and counseling was variable. The regulations for pre- and posttest counseling specify required elements of counseling and have been interpreted at many VA health care systems as requiring face-to-face counseling by specially trained personnel. In this respect, testing for HIV is nearly unique among medical conditions, with much more cumbersome requirements for diagnosis than diseases, such as hepatitis C virus infection, which do not require this process. The new CDC guidelines released in September 2006 recommend dropping separate informed consent for HIV testing.15
In related research, we have found that the time required for informed consent and counseling are significant barriers to testing,27
as have others.28
We also note, however, that the quality-of-care literature finds that failure to perform indicated tests and interventions is common across many diseases in many health-care delivery systems,29
so other factors may be important.
We cannot determine which barriers are responsible for the low testing rates, but we believe that methods for pre- and posttest counseling should be reexamined. Furthermore, the availability of rapid HIV tests that may eliminate the need for a second visit should also be considered as an approach to HIV testing. Procedures developed almost 20 years ago may now present an important impediment to testing. The CDC has revised its screening guidelines and recommends that separate informed consent not be required for testing.
In conclusion, we examined practice patterns for HIV testing in a large integrated health-care system with a notable record in improving quality of care16
and a specific focus on improving quality of care for patients with HIV. The VA may, therefore, be better positioned to address the identification of HIV infection than many health-care systems. Nonetheless, although the vast majority of patients who were tested for HIV were tested for a well-documented reason, a substantial proportion of at-risk patients had not been tested. In these patients, a critical opportunity to provide early therapy and risk-reduction counseling for HIV-infected patients may have been missed. This finding suggests that substantially more ambitious programs for testing will be needed if more at-risk patients are to be identified early in the course of HIV infection.3,9
The dramatic advances in therapy for HIV warrant robust new approaches to identify patients early in the course of HIV disease so that they may receive the full benefit of life-prolonging therapy and counseling.