Despite broad awareness of human immunodeficiency virus (HIV) and availability of testing and treatment, it is estimated that one in four people who are HIV infected are undiagnosed.1 Because early diagnosis results in improved survival2 and behavioral changes that reduce the risk of transmission,3 increased testing could improve survival and limit transmission.
Recent Centers for Disease Control and Prevention (CDC) guidelines support increased HIV testing through simplifying the consent process, including removal of the separate, HIV-specific written consent.1 However, laws in New York State and elsewhere require written informed consent prior to testing. While pretest counseling requirements and lengthy consent processes are cited by providers as barriers to HIV testing,4,5 there is limited evidence regarding whether the specific requirement for written informed consent poses a barrier.
From July to September 2006, the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) interviewed 162 family practice and general internal medicine physicians practicing in three selected high-HIV prevalence areas of NYC. The selected areas, in the Bronx, Brooklyn, and Manhattan, have estimated HIV prevalences of 2.1% to 2.9%, compared with an estimated 1.2% HIV prevalence for NYC overall (unpublished data, DOHMH HIV Surveillance and Epidemiology Program). Each physician's office was visited by a health department representative,6 who collected information about barriers to HIV testing prior to providing an educational session on HIV testing and prevention. The survey included the question: “If written consent were no longer required, would you offer more patients an HIV test?” One hundred thirty-seven physicians (85%) responded. Fifty-two (38%) answered “Yes,” that they would offer more patients an HIV test if written consent were no longer required.
If the physicians surveyed in these high-burden NYC neighborhoods who responded “yes” to the survey question (n=52) tested between one more patient per week and one more patient per workday, about 15 to 74 additional HIV infections would be diagnosed by these physicians annually, based on the HIV prevalence of the areas in which they practice and the estimate that 25% of HIV-infected people are undiagnosed. If 38% of all NYC family practice and general internal medicine physicians similarly increased testing, an additional 332 to 1,659 HIV infections would be diagnosed annually, based on the citywide 1.2% HIV prevalence and the estimate that 25% of HIV-infected people are undiagnosed. These projections may underestimate the impact of removing written consent requirements, as they do not consider potential increased testing by physicians in other specialties.
This survey does have limitations. The convenience sample of physicians may have introduced selection bias. And physicians might be more likely to respond with an answer that is perceived to be desired by the representatives. Also, physicians in these high-burden neighborhoods might not be representative of other NYC physicians.
Our data do, however, suggest that more than one-third of primary-care physicians in NYC would increase the frequency with which they offer HIV testing if the requirement for written informed consent were removed. These results add urgency to the need to reform HIV testing laws in New York State and elsewhere.