Many barriers have hindered routine widespread implementation of opt-out HIV testing in the U.S.3
In the past, these have included low levels of physician awareness, lack of reimbursement, as well as state and local laws. Lately, several of these barriers have been removed, including the recent decision by the Centers for Medicare and Medicaid Services (CMS) to reimburse routine HIV testing. In addition, many states have changed, or are in the process of altering, state laws that restrict opt-out testing because of the requirement for separate consent.
However, other obstacles exist. Physician attitudes, logistic problems, and funding issues associated with the extra personnel and effort associated with opt-out testing (e.g. properly obtaining consent, laboratory quality control and management, and communication of test results) continue to threaten the long-term sustainability of many opt-out HIV testing programs.3
In 17 published studies evaluating barriers to routine opt-out HIV testing, U.S. physicians reported 41 different barriers.5
Although many were specific to a particular practice setting, four non-policy barriers were identified in all practice settings: insufficient time, lack of knowledge or training, perceived lack of patient acceptance, and competing priorities 5
However, many of these barriers can and have already been addressed. For example, implementing an opt-out approach obviates the need for pretest counseling or obtaining separate consent, thereby eliminating the time consumed by these procedures. In addition, Burke et al5
have suggested that establishing reminder systems for HIV testing, similar to other routine health maintenance practices such as immunization, would eliminate the issue of competing priorities. Finally, despite the perception that patients may have a negative opinion about opt-out HIV testing, in one survey study, patient acceptance rates for the concept of opt-out testing were 100% in the prenatal setting and 91% in the hospital setting.10
Indeed, several successful large scale opt-out HIV testing programs are ongoing in the U.S. Sponsored by the CDC, City of Houston, and Harris County Hospital District, an opt-out HIV testing program was implemented in the emergency center at the Ben Taub General Hospital, in Houston Texas, in October 2008. This program uses standard blood testing rather than rapid testing, and currently tests about 3000 patients per month, with over 40,000 tests completed. The new HIV positivity rate is about 0.8%. Furthermore, similar programs are operational at public and private institutions in Houston, together performing about 6000 tests per month11
Cancer centers and oncology clinics may be able to replicate these successful opt-out testing programs.