POPS Chapter 4 - HIV Testing in STI Clinics
Notifying the patient that an HIV test will be performed unless the patient declines (opt-out screening) is recommended and should be routine for persons attending STI clinics and those seeking treatment for STI in other health-care settings. All patients seeking treatment for STI, should be screened routinely for HIV as defined by the September 2006 CDC Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings (MMWR; 55(RR14);1-17).
Routine testing in health care settings is defined as HIV testing offered to the entire patient population with no requirements for HIV-specific pretest counseling or separate written consent. Texas law has required routine testing of pregnant women for HIV, syphilis, and hepatitis B since 1996. Routine testing is not mandatory testing, Texas law requires informed consent for HIV testing. For routine opt-out testing, patients may be told that HIV testing is a routine part of care and the patient may elect to opt-out (decline or defer) testing.
Opt-out HIV testing in STI settings benefits the client, the community, the clinic and associated health care providers.
Client - Early detection is important for effective medical intervention. With combination therapies, the amount of HIV virus in a person's bloodstream is often reduced to undetectable levels (often referred to as undetectable viral load). These advances may improve the health of those who are HIV-positive and decrease the efficiency of HIV transmission.
Community - When persons with HIV infection know their status, they often take necessary precautions to avoid transmission to others. Reducing transmission and decreasing viral load can lower HIV community viral load and significantly reduce the cost of long term HIV care.
Clinic - Prevention counseling is not required as part of HIV testing in STI clinics. Providing clients with voluntary and selective discussion of risk reduction options allows STI clinics with a large client volume and limited resources to direct staff toward clients who want to discuss personalized risk reduction plans or provide referral to a DIS/community based organization (CBO) that offers HIV counseling, testing and referrals.
Health care providers - Co-infection with HIV can affect the management of concurrent conditions. HIV testing helps providers diagnose and treat patients.
HIV testing does not require Prevention counseling. Counseling will be offered to persons that may benefit from additional support as it relates to personal risk for HIV or select populations at increased risk for HIV.
4.2.1 Referrals for Prevention and Risk Reduction Counseling
The following groups may benefit from further discussion of their risk:
Persons not sure if they want an HIV test - Most persons expect they will be tested for HIV in STI clinic settings; those unsure about whether to test may benefit from appropriate problem solving assistance and additional information about the confidentiality of their information.
Persons refusing an HIV test - Counseling may help address reasons for refusal and clarify misconceptions. Counseling may also provide useful information about STI clinic services received and areas for improvement.
Pregnant females - Refer to Health and Safety Code §81.090 Diagnostic Testing During Pregnancy and After Birth.
Select populations - Based on local initiatives and epidemiological data, priority populations with high HIV seropositivity and populations designated by HIV prevention plans may benefit from counseling.
4.2.2 Pregnant Clients with STI’s
If pregnancy is determined during the initial client assessment:
- The client will be asked about whether she is enrolled in prenatal care; if she is not enrolled, she must be referred for prenatal care. The prenatal care provider will be contacted to determine if the referral was successful; this can be done by the clinician, Disease Intervention Specialist (DIS) or qualified staff that made the referral.
- The client will be told that according to Texas law, a confidential HIV test will be part of her prenatal follow-up and delivery unless she refuses to be tested.
If the client is pregnant and HIV-positive, it is critical to ensure successful referral for case management and prenatal care, including the provision of prophylactic and antiviral therapy.
STI clients will be informed that an HIV test will be performed if the client does not object. Signs should be posted in appropriate languages listing all tests routinely performed. No separate consent form for HIV is required. The Department of State Health Services (DSHS) recommends listing HIV testing in the general written consent form along with other routine tests. The medical record will contain documentation that HIV testing has been explained to the client and will document whether the client accepted or declined testing.
These guidelines recommend opt-out HIV testing for all STI clients. If the client refuses to test confidentially, an anonymous test can be done for HIV or the client can be referred to a site that offers anonymous testing. Agencies funded by DSHS to conduct HIV counseling and testing offer anonymous HIV testing. Confidential testing is the preferred method because the results can be entered in the medical record and the client can be located if they do not return for results.
In the client waiting room, videos and written material will be available. Local community based organizations or health department staff will give culturally appropriate educational presentations. Topics will include basic information on HIV and testing, risk assessment, prevention, a brief description of clinic procedures (e.g., testing for syphilis, HIV, gonorrhea, and chlamydia) and important terms (e.g., the meaning of positive and negative test results). Materials and presentations will emphasize staff availability to answer questions and provide more information.
Known HIV-positive clients who are diagnosed with an STI or return to STI clinics for examination will be referred to a DIS. DIS will:
- Determine whether the client is accessing HIV medical care. If not, DIS will explore with the client the reasons these services have not been accessed and will provide a written referral to HIV medical care.
- Determine if the returning HIV-positive client is pregnant. If pregnant, DIS will determine if client is enrolled in prenatal care and taking medication to decrease maternal transmission. Efforts to ensure the successful outcome of these referrals must be documented on the interview record or accompanying case management forms.
- Determine whether the client may have exposed themselves or others to HIV/STI by engaging in unprotected sex or sharing needles. DIS will counsel appropriately, conduct partner elicitation and notification, and concentrate on partners exposed since the last counseling session including any previously unnamed partners.
Specific arrangements should be made to ensure all clients receive their HIV test results in a timely and appropriate manner. Negative HIV test results may be given by telephone or other technology. Policies and procedures must be in place and describe under what circumstances negative results will be made available by telephone and outlining the protocol for giving negative results by telephone. Programs that wish to provide negative test results over the telephone must make available their program’s policies and procedures to DSHS.
A reliable process for verifying the client’s identity before providing test results and protecting client confidentiality must be established prior to providing any test result, whether in person or over the phone.
Negative test results may be given to the client in person or by telephone. Programs that provide negative test results by telephone must implement procedures that address:
- Client confidentiality; and
- How they will ensure they are speaking with the client to whom the results belong.
STI programs that wish to provide negative test results over the telephone must make available their program’s procedures to DSHS upon request.
Positive results will be given in person only. Clients will be referred to a DIS who will provide test results and conduct prevention counseling and partner elicitation.
DSHS requires all STI programs to enter information on the risk behaviors of all clients in data systems that will allow the retrieval of such information. The notation of risk in medical records is an example of a retrievable system. The systematic collection of client risk information assists programs in planning and evaluating clinic performance, allowing the local program and DSHS to access and compile information about STI client risk behaviors. This information would be in an aggregate form if published, no individual level data would be shared publicly.
Centers for Disease Control and Prevention: cdc.gov
Texas Constitution and Statutes: statutes.legis.state.tx.us
Health and Safety Code: statutes.legis.state.tx.us/?link=HS
Texas Family Code: statutes.legis.state.tx.us/?link=FA
U.S. Code: law.cornell.edu/uscode/tex