National guidelines recommend that testing for HCV be limited to persons with identified risk factors, such as injection drug use, a blood transfusion prior to 1992, or elevated liver function tests[6]. Although these recommendations are based on epidemiologic data and 1998 Centers for Disease Control and Prevention (CDC) guidelines[7], barriers to risk-based screening have resulted in inadequate detection of HCV. Most importantly, patients with a remote history of injection drug use, the primary risk factor for HCV, are often reluctant to admit that behavior to a clinician; only 21% of respondents with HCV reported IDU in the National Health and Nutrition Examination Survey IV [8]. In all but the most complex guidelines, risk factor-based screening also fails to account for suspected transmission routes, such as remote iatrogenic transmission, intranasal drug use[9] or even a fist fight[10]. Overall, risk factor based screening for HCV might be too complex for routine clinical care.

Due to barriers to risk-factor based HIV screening, including the ability to reliably assess risk in the clinical setting, the CDC in 2006 recommended routine "opt-out" general population screening for HIV[11]. The requirement for separate consent to test for HIV in many states and inadequate time for counseling[12] continue to impede testing, with attendant reductions in the proportion of patients screened for HIV[13]. Such barriers may still be too onerous to ensure detection of the estimated 21% of HIV-infected Americans who are unaware of their infection[14]. Likewise, another set of complex screening criteria or a clinician-driven approach to HCV screening may fail us in the effort to diagnose and care for the two to three million U.S. residents unaware of their HCV infection.

The instrument was piloted with five patients, met a Flesh-Kincaid fifth-grade reading level, and was in English, a language accessible to 90% of this hospital's patients (personal communication, Harborview Interpreter Services, 2 July 2010). We collected patient demographics and expectations as to physician communication regarding laboratory testing.

The remaining sections addressed HCV, HIV, and diabetes. Each section was preceded by a brief description of the disease and a statement that some people do not learn about their condition until they are sick. Initial questions in each section asked subjects' disease status and risk factors, followed by a series of questions about aspects of universal screening detailed in the accompanying tables. All questions were asked of HCV, but to ensure brevity only a subset of questions were included in sections on HIV and diabetes. The primary outcome variable, asked of HCV and HIV, allowed respondents to select one of three screening options: (1) universal screening of all blood samples without patient knowledge of the test and without receiving negative results, (2) universal screening without receiving negative results but with a chance to refuse testing, or (3) screening based on clinician judgment. Comments were solicited at the end of the survey.

Forty surveys were collected from each of five clinics (General Medicine, Family Medicine, Womens', General Surgery, and Orthopedics), selected to represent the diverse nature of outpatient care, including primary care serving a largely inner-city population and surgical care serving five northwest states. Researchers sequentially approached all patients in the waiting room after they had checked into the clinic and completed registration paperwork. Eligible subjects were more than 15 years of age, able to communicate in English, and had not previously completed the survey. Interested subjects were provided an "information sheet" in lieu of signed consent and, if they still wanted to participate, a survey and pencil. Subjects completed the survey in the waiting area or a clinic room and received $5 compensation when they returned the completed survey to the researcher. All data collection activities were completed in August 2010.

Twenty-three (12%) respondents reported ever injecting drugs, 39 (20%) reported having had a blood transfusion, and 10 (5%) were men who reported ever having sex with another man. A majority of participants reported previous testing for HIV, HCV and diabetes (see Table ​Table2).2). Ninety-seven (50%) respondents reported that their doctor always told them about all of the tests being run on their blood and another 46 (24%) reported that happened most of the time; 174 (87%) reported that it was very important for them to know what tests were being done on their blood. The vast majority wanted to know if they had HCV, HIV, or diabetes. Most also indicated that the hospital should automatically test all patients for each condition, although analysis of matched pairs illustrated greater support for automatically testing all patients for HCV (p = 0.01) or HIV (p = 0.03) compared to diabetes.

Although almost two-thirds of respondents indicated that it would not be acceptable to test them for HCV without first telling them about the test, 75% indicated that they would prefer to be tested without knowing about it than not to be tested at all. More than three-quarters indicated that it would not be acceptable to be tested for HCV without receiving negative results. However, when presented with three screening options, the largest proportion favored universal screening without knowing about the test or receiving negative results and the smallest proportion favored relying on clinician judgment. Three-quarters of respondents indicated that they would accept being contacted with a positive result by a public health department representative.

There were no significant associations between demographic characteristics, risk factors, testing history or disease status and the acceptability of universal screening for HCV (see Table ​Table3).3). Respondents who wanted to know if they were infected with HCV were more likely to support universal screening (p < 0.01). Acceptance of universal screening for HCV was also associated with agreement that the hospital should test all patients for HCV, and that testing should be automatic. Results of the analysis applied to HIV testing were the same as for HCV testing, including the absence of associations with demographics, risk factors, testing history or disease status, and positive associations with desire to know disease status and belief that testing should be automatic and for all patients (data not shown).

We do not believe that these findings should immediately prompt health care providers or organizations to abandon efforts to inform patients and seek consent for testing. However, efforts to broadly screen populations for communicable diseases have met formidable barriers. Although the first studies documenting a high prevalence of undiagnosed HIV in some urban emergency departments were published almost 20 years ago[16], very few such departments have instituted expanded testing programs and most successful efforts have required hiring new staff, a cost that often makes the programs unsustainable. It remains uncertain whether medical institutions in the U.S. can widely screen patients for communicable diseases if such screening requires procedures that are not in place for other chronic conditions. While electronic medical record reminders have led to modest improvements in screening practices[17,18], more automated approaches or population-based public health interventions, possibly involving pooled ribonucleic acid screening,[19] may be necessary to address the burden of undiagnosed HCV. The results of this survey suggest that many patients would forego certain standards for consent to ensure timely diagnosis of HCV.