Frequency of HIV screening in the Veterans Health Administration: implications for early diagnosis of HIV infection.
ABSTRACT We evaluated the frequency of HIV testing across the Department of Veterans Affairs (VA), the largest provider of HIV care in the United States. An electronic survey was used to determine the volume and location of HIV screening, confirmatory testing, rapid testing and laboratory consent policies in VA medical centers between October 1, 2005, and September 30, 2006. One hundred thirty-five VA laboratories reported that 112,033 HIV screening tests were performed (81% outpatients vs. 19% inpatients, p<.0001). Overall HIV prevalence was 1.49% (1.62% in inpatients vs. 1.46% in outpatients, p=N.S., range=0.2-3.8%). Rapid testing was available in 67% of facilities, 60% of which took place in the clinical laboratory. Sixty-four percent of labs required a copy of the informed consent in order to perform testing. We estimate that fewer than 10% of VA inpatients and fewer than 5% of VA outpatients were tested for HIV during the survey period. Substantial opportunities for increasing routine HIV testing exist in this population.
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ABSTRACT: Individuals with substance use disorders (SUDs) are at higher risk of HIV infection, yet recent studies show rates of HIV testing are low among this population. We implemented and evaluated a nurse-initiated HIV oral rapid testing (NRT) strategy at three Veterans Health Administration SUD clinics. Implementation of NRT includes streamlined nurse training and a computerized clinical reminder. The evaluation employed qualitative interviews with staff and a quantitative evaluation of HIV testing rates. Barriers to testing included lack of laboratory support and SUD nursing resistance to performing medical procedures. Facilitators included the ease of NRT integration into workflow, engaged management and an existing culture of disease prevention. Six-months post intervention, rapid testing rates at SUD clinics in sites 1, 2, and 3 were 5.0%, 1.1% and 24.0%, respectively. Findings indicate that NRT can be successfully incorporated into some types of SUD subclinics with minimal perceived impact on workflow and time.International Journal of STD & AIDS 11/2012; 23(11):799-805. · 1.04 Impact Factor
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ABSTRACT: The Centers for Disease Control and Prevention (CDC) recommends routine HIV screening in primary care but little is known about general internists' views of this practice. We conducted a national, cross-sectional, Internet-based survey of 446 general internists in 2009 regarding their HIV screening behaviors, beliefs, and perceived barriers to routine HIV screening in outpatient internal medicine practices. Internists' awareness of revised CDC guidelines was high (88%), but only 52% had increased HIV testing, 61% offered HIV screening regardless of risk, and a median 2% (range 0-67%) of their patients were tested in the past month. Internists practicing in perceived higher risk communities reported greater HIV screening. Consent requirements were a barrier to screening, particularly for VA providers and those practicing in states with HIV consent statutes inconsistent with CDC guidelines. Interventions that promote HIV screening regardless of risk and streamlined consent requirements will likely increase adoption of routine HIV screening in general medicine practices.AIDS education and prevention: official publication of the International Society for AIDS Education 06/2011; 23(3 Suppl):70-83. · 1.51 Impact Factor
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ABSTRACT: Objective: This retrospective study analyzed the testing rates of individuals enrolled in the Hepatitis C Clinical Case Registry for the Veterans Health Administration (VHA) in order to determine Human Immunodeficiency Virus (HIV) co-testing rates for veterans with hepatitis C (HCV). Design: A chart review of 247,006 veterans enrolled in the National HCV Clinical Case Registry was examined retrospectively. Regression analysis identified factors that increased the probability of being tested for HIV. Methods: Simple odds ratios and a complex regression were applied to this dataset to calculate testing incidence and prevalence of HIV. Results: Only approximately one third of veterans with HCV were tested for HIV and, of these, 13.2% were positive. Sixty eight percent of veterans with HCV were not co-tested for HIV and within this group there may be a significant number of unidentified cases of HIV. Veterans with severe mental illness, substance use disorders and marijuana abuse/dependence treatment were more likely to be tested for HIV. Antiviral therapy for HCV had no impact on likelihood of co-testing prior to treatment initiation. Conclusions: Most veterans with HCV are not co-tested for HIV despite common risk factors for HIV and HCV infection. Mandatory testing for HIV, at least among veterans with HCV, as well as identification and removal of barriers to HIV testing within the VHA would serve to facilitate disease management for veterans in the future.The Open Infectious Diseases Journal 03/2011; 511(13):13-18.
VALDISERRI ET AL.
HIV TESTING IN U.S. VETERANS HOSPITALS
FREQUENCY OF HIV SCREENING
IN THE VETERANS HEALTH
IMPLICATIONS FOR EARLY
DIAGNOSIS OF HIV INFECTION
Ronald O. Valdiserri, Fred Rodriguez, and Mark Holodniy
We evaluated the frequency of HIV testing across the Department of Veterans
Affairs(VA), the largest providerof HIV care in the United States. An electronic
survey was used to determine the volume and location of HIV screening, confir-
matory testing, rapid testing and laboratory consent policies in VA medical cen-
VA laboratories reported that 112,033 HIV screening tests were performed
(81% outpatients vs. 19% inpatients, p < .0001). Overall HIV prevalence was
1.49% (1.62% in inpatients vs. 1.46% in outpatients, p = N.S., range =
0.2-3.8%). Rapid testing was available in 67% of facilities, 60% of which took
place in the clinical laboratory. Sixty-four percent of labs required a copy of the
informed consent in order to perform testing. We estimate that fewer than 10%
ing the survey period. Substantial opportunities for increasing routine HIV
testing exist in this population.
Early diagnosis of HIV infection remains a challenge in the United States. The U.S.
infections diagnosed in 2004 in the 33 states with confidential name–based HIV re-
nosed. Given that the median time from HIV infection to the development of AIDS in
untreated individuals can be as long as a decade (Hessol et al., 1994), these so–called
late testers were infected for years prior to diagnosis. During that long interval, these
undiagnosed persons weren’t able to take advantage of lifesaving treatments; nor is it
likely that they would have taken precautions to prevent the spread of an unknown
HIV infection to their partners (Valdiserri, 2007).
AIDS Education and Prevention, 20(3), 258–264, 2008
© 2008 The Guilford Press
Ronald O. Valdiserri is with the Department of Veterans Affairs, Public Health Strategic Health Care
fairs Medical Center and Department of Pathology, Louisiana State University School of Medicine, New
Orleans. Mark Holodniy is with the Department of Veterans Affairs, Public Health Strategic Health Care
Group, Washington, DC, and the Division of Infectious Diseases and Geographic Medicine, Stanford Uni-
versity, Stanford, CA.
Address correspondence to Ronald O. Valdiserri, M D , M.P.H., Department of Veterans Affairs—Public
Health SHG (13B), 810 Vermont Ave., NW, Washington, DC 20420; E-mail: R.Valdiserri@va.gov
Nationally,theCDCestimatesthat oftheapproximately 1millionpersonsinthe
United States who are infected with HIV, some 252,000–312,000, are unaware of
their infection (Glynn & Rhodes, 2005). A number of factors have been associated
perceptions that requirements for HIV consent and counseling are too time consum-
ing (CDC, 2003; Jenkins, Gardner, Thrun, Cohn, & Berman, 2006; Klein, Hurley,
Merrill, & Quesenberry, 2003).
As the largest integrated health care system in the United States (Oliver, 2007),
the Veterans Health Administration (VHA) is the biggest provider of HIV care in the
United States. In fiscal year 2006, VHA provided care to nearly 23,000 HIV–infected
veterans Veterans With HIV-AIDS, in VA Care, 2007). Although widely recognized
as an efficient and high–performing health care system (Asch et al., 2004; Jha, Perlin,
Kizer, & Dudley, 2003), late diagnosis of HIV infection has also been identified
only 36% of 13,991 veterans at risk for HIV had been tested for the virus (12). More
telling still, Gandhi, Skanderson, Gordon, Concato, and Justice (2006) and his col-
leagues reported that among 3760 HAART–naïve patients newly presenting for HIV
care at VA medical centers during 1998–2002, 55% had immunologic AIDS at the
time of presentation. And Holodniy and his colleagues (2007) opined that “delayed
identification of HIV infection” was responsible for a “substantial number” of
HIV–infected veterans starting antiretroviral treatment below recommended CD4+
cell count thresholds.
Within the U.S. Department of Veterans Affairs, the Public Health Strategic
Health Care Group (PHSHG) is responsible for promoting population health and
clinical preventive services, including early HIV diagnosis and referral into care, for
over 5 million veterans who receive care in VA health facilities. As part of an ongoing
effort to encourage early diagnosis of HIV infection, a national survey of VA clinical
laboratories was undertaken in early 2007, to determine the frequency of HIV diag-
nostic testing during a 1-year period across the entire VA system.
A brief electronic survey was jointly developed by PHSHG and the Pathology and
Laboratory Medicine Service (P&LMS), Office of Patient Services, at the VHA. The
purpose of the survey was to collect baseline information on the volume and location
of HIV screening, HIV confirmatory testing, rapid HIV testing—including point of
semination, the survey was pilot-tested among a group of four VA clinical laboratory
directors and revised based on their feedback. Following standard operating proce-
sistant chief medical officers at each of the 21 VA regional jurisdictions (known as
be forwarded to all clinical laboratory directors. Follow–up e-mail reminders were
sent to nonresponsive laboratories during the month of February 2007.
HIV TESTING IN U.S. VETERANS HOSPITALS259
Completed surveys were received from 135 VA laboratories. At present, the VA does
a single entity. Therefore, the denominator of all clinical laboratories across the VA
dled prior to reporting. Although we cannot provide an exact response rate, we esti-
The 135 laboratories that responded reported providing 112,033 HIV screening
tests between October 1, 2005, and September 30, 2006 (fiscal year 2006). The total
number of HIV screening tests was significantly greater in outpatients (81%) com-
pared with inpatients (19%) (p < .0001, two-tailed t test), reflecting patient distribu-
tion (Table 1). The total positive tests (n = 1,669) were also significantly greater in
outpatients (80%) compared with inpatients (20%) (p < .003). The overall rate of
confirmed HIV seropositive tests was 1.49%, with inpatients having a slightly higher
alyzed by VISN, combined inpatient and outpatient prevalence ranged from 0.2% to
3.8%, inpatient prevalence ranged from 0.3% to 4.37% and outpatient prevalence
ranged from 0.2% to 3.98% (see Table 1). In general, prevalence rates by VISN
reflected the number of HIV-infected veterans in care in that VISN.
Forty–three percent (58/135) of laboratories reported performing HIV screening
tests in–house, 32% (43/135) at another VA laboratory, 21% (28/135) at a commer-
cial laboratory and 4% (6/135) “other.” Fewer HIV confirmatory tests were per-
formed “in house” (8%, or 11/135), with the majority of confirmatory tests being
performed by commercial laboratories (51%, or 69/135) or another VA laboratory
(33% or 45/135); 7% (10/135) reported that confirmatory HIV tests were performed
by “other” laboratories.
dicated that they had rapid HIV testing available within their facilities. In response to
a follow–up question, most rapid HIV testing in the VA system appears to be taking
place within the laboratory, rather than as point–of-care testing; over 60% of all
were emergency departments (11% of locations cited) and employee health clinics
(11% of locations cited). Primary care clinics, mental health clinics, substance abuse
clinics, and other outpatient locales were less frequently cited.
Finally, respondents were asked, “Does your laboratory require a copy of the
consent form prior to HIV testing?” Sixty–four percent of the respondents (87/135)
indicated that the laboratory required a copy of the HIV testing consent form—or
some other tangible proof that consent had been obtained—prior to testing.
In September 2005 the Under Secretary for Health at the Department of Veterans Af-
ers, stressing “the importance of offering every veteran under the care of the
Department of Veterans Affairs the opportunity to have a voluntary test for human
immunodeficiency virus.” However, the same communication reminded providers
written informed consent and documented pretest and posttest counseling
(Department of Veterans Affairs, 2005).
260VALDISERRI ET AL.
TABLE 1. HIV Screening Across the Veterans Health Administration: Diagnostic Yield
by Inpatient/Outpatient Status and Veterans Integrated Service Networks (VISNs), FY 2006
aNumber of unique veterans seen within each VISN.bFor FY2005: Based on lab tests/ICD–9 codes, followed by manual confirmation.
ans, substantial evidence exists that HIV testing is underutilized throughout the VA
system (Owens et al., 2007). Although the VHA has a well–documented track record
of high-quality medical care, strongly associated with proactive clinical performance
measurement (Asch et al., 2004), routine HIV testing is not a specified performance
measure in the VA system. Gifford and colleagues (2006) identified nearly 271,000
veteran patients at increased risk for HIV infection (based on documented diagnoses
of hepatitis B, hepatitis C, sexually transmitted infection, or substance abuse) of
whom only 21% had been tested for HIV. Among nearly 12,000 veteran patients
from the Pacific Northwest who were infected with hepatitis C virus, only a third
(35%) had been tested for HIV (Huckans, Blackwell, Harms, Indest, & Hauser,
of provider prioritization of HIV testing and the time needed for pre and post–test
counseling” (Goetz et al.,2006). At present, a 1988 federal law (section 124 of Public
Law 100–322) requires written informed consent for HIV testing, documented in the
veteran’s medical record (Department of Veterans Affairs Information, 2006). Many
VA providers have stated that the requirement to obtain written informed consent is
an impediment, given the multiple time demands on primary care providers (personal
communications). Heightened awareness of the federal requirement for written in-
formed consent among veteran patients can be seen in the widespread laboratory
umentation, before the laboratory will actually test the specimen (64% of surveyed
Because of the current lack of a uniform reporting structure for VA clinical labo-
ratories at a national level, it is not possible to calculate exact rates of HIV testing
FY 2006 the VA recorded 5,537,839 unique outpatients and 368,585 unique inpa-
period, clinical laboratories reported performing 91,189 HIV screening tests on out-
a number of caveats (e.g., not every laboratory responded to survey, the current lab
survey tallied tests and not unique patients who had been tested, reported lab figures
include duplicate tests, survey did not determine or account for previously tested vet-
erans, etc.), one can reasonably assert that fewer than 5% of VA outpatients
(91,189/5,367,774 = .0170) and fewer than 10 percent of VA inpatients
(20,844/368,585 = .056) were tested for HIV in fiscal year 2006.
The overall seroprevalence of HIV infection in VA of those tested in this survey
was 1.49% (VISN range = 0.2-3.8%). This prevalence rate is consistent with data
from a recent blinded HIV seroprevalence study in six VA medical centers where the
tionranging from0.1%to2.8%among outpatients andfrom0%to1.7%among in-
patients (Owens et al., 2007). In that study, HIV infection was significantly more
Current CDC recommendations suggest that routine universal HIV screening should
be performed if the known seroprevalence in the population is > 0.1% (CDC, 2006).
Given the HIV seroprevalence found in this and other VA studies, the VA would
benefit from a universal HIV testing policy.
262VALDISERRI ET AL.