The study flow is outlined in . For the opt-in versus the opt-out screening phases, results were as follows: there were 23,236 potentially eligible patients versus 26,757; screening offer rate was 27.9% (6,479/23,236) versus 75.8% (20,280/26,757) (P < 0.001); screening acceptance rate was 62.7% (4,061/6,479) versus 30.9% (6,273/20,280) (P < 0.001); testing completion rate was 99.8% (4,053/4,061) versus 74.6% (4,679/6,273) (P < 0.001); overall screening rate was 17.4% (4,053/23,236) versus 17.5% (4,679/26,757) (P = 0.90).
During the opt-in phase, research volunteers approached 293 of the 4,053 patients that completed HIV screening to participate in the survey. Of these, 208 were eligible and 207 consented and completed the survey. During the opt-out phase, research volunteers approached 273 of the 4,679 patients that completed HIV screening to participate in the survey. Of these, 190 were eligible and 188 consented and completed the survey. Reasons patients were ineligible for survey administration were similar between both phases and included: patient unavailable (61%), language barrier (31%), too ill (7%), and altered mental status/confusion (2%). Of the 207 patients who completed surveys during the opt-in phase, 199 (96%) tested negative and 8 (4%) had reactive test results. Of the 188 patients who completed surveys during the opt-out phase, 160 (85%) tested negative and 28 (15%) had reactive test results.
Characteristics of patients accepting screening and characteristics of patients surveyed in both opt-in and opt-out HIV screening phases are shown in . Patients accepting opt-in screening were similar to patients accepting opt-out screening with respect to age and gender; however, there were differences in race/ethnicity. There were no differences with respect to age, race/ethnicity, education level, HIV risk, or previous HIV testing between patients surveyed during the opt-in and the opt-out phases; however opt-out surveyed patients were more likely to be male, uninsured, and single.
Comparison of opt-in and opt-out patients.
Patient satisfaction ratings were available for 393 of the 395 surveyed patients and are shown in . One patient testing negative in each phase chose the option “prefer not to answer/I do not know” when asked to rate their satisfaction. The majority of patients in the opt-in phase (95.1%, 95% CI = 92.0–98.0) and the opt-out phase (93.6%, 95% CI = 89.3–96.7) were satisfied with the HIV screening program. A higher proportion of patients who experienced opt-in screening rated the experience as excellent rather than very good, as compared to the opt-out ratings which were more frequently very good rather than excellent. Overall satisfaction ratings remained similar between opt-in and opt-out phases even after adjusting for age, gender, race/ethnicity, and HIV test result (adjusted odds ratio 1.3, 95% CI = 0.5–3.1, data not shown).
Patient satisfaction with HIV screeninga, n = 393.
Responses to questions assessing patient attitudes toward HIV screening are shown in . Among the domains, most attitudes towards opt-in and opt-out screening were similar. These similarities persisted after adjusting for age, gender, race/ethnicity, and HIV test result. Although a significantly higher proportion of patients during the opt-in phase would have liked additional discussion about HIV risk and HIV prevention, most patients in both phases felt that the information they were given about testing was adequate. The majority of patients in both phases reported being satisfied with the HIV testing received and would recommend the ED as a place to get HIV tested. Patients completing opt-out HIV screening did not report feeling any more pressured into testing and still felt like they had a choice about getting tested when compared with patients completing opt-in screening. Most patients also agreed that HIV testing did not interfere with the overall care received and perceived the testing process to be confidential. Over 90% of patients in both phases felt that HIV testing should be a regular part of health care and that routine testing should be performed in the ED.
Patient attitudes towards opt-in and opt-out HIV screening, n = 395.