Projected survival gains from revising state laws requiring written opt-in consent for HIV testing.

BACKGROUND: Although the Centers for Disease Control and Prevention recommends HIV testing in all settings unless patients refuse (opt-out consent), many state laws require written opt-in consent. OBJECTIVE: To quantify potential survival gains from passing state laws streamlining HIV testing consent. DESIGN: We retrieved surveillance data to estimate the current annual HIV diagnosis rate in states with laws requiring written opt-in consent (19.3%). Published data informed the effect of removing that requirement on diagnosis rate (48.5% increase). These parameters then served as input for a model-driven projection of survival based on consent method. Other inputs included undiagnosed HIV prevalence (0.101%); and annual HIV incidence (0.023%). PATIENTS: Hypothetical cohort of adults (>13 years) living in written opt-in states. MEASUREMENTS: Life years gained (LYG). RESULTS: In the base-case, of the 53,036,383 adult persons living in written opt-in states, 0.66% (350,040) will be infected with HIV. Due to earlier diagnosis, revised consent laws yield 1.5 LYG per HIV-infected person, corresponding to 537,399 LYG among this population. Sensitivity analyses demonstrate that diagnosis rate increases of 24.8-72.3% result in 304,765-724,195 LYG. Net survival gains vanish if the proportion of HIV-infected persons refusing all testing in response to revised laws exceeds 18.2%. CONCLUSIONS: The potential survival gains of increased testing are substantial, suggesting that state laws requiring opt-in HIV testing should be revised.

Less encouraging lessons from the front lines: barriers to implementation of an emergency department-based HIV screening program.

OBJECTIVE: We describe barriers to, and discuss recommendations for, implementing a limited emergency department (ED)-based HIV screening program. METHODS: A pilot program was designed to study the feasibility of integrating HIV screening into ED care among patients aged 18 to 64 years at an urban academic emergency department with an annual census of 50,000 patients. RESULTS: During the first 12 weeks of the pilot program, 395 patients were screened. Of those, 2 (0.5%; 95% confidence interval 0.06% to 1.8%) received a positive test result for HIV. Both were contacted by telephone, and one was seen for result notification, posttest counseling, and further care in the local health department. Of the patients who received a negative test result, 98% were contacted about their results. We encountered numerous barriers to implementation, which we categorized as departmental, public health, legal, institutional, test limitations, and infrastructure. CONCLUSION: Understanding potential barriers and making plans for dealing with them are critical to the successful implementation of an HIV screening program in the ED.

Ethical, financial, and legal considerations to implementing emergency department HIV screening: a report from the 2007 conference of the National Emergency Department HIV Testing Consortium.

OBJECTIVES: We seek to identify and analyze, from a group of participants experienced with HIV screening, the perceived challenges and solutions to the ethical, financial, and legal considerations of emergency department (ED)-based HIV screening. METHODS: We performed a qualitative analysis of the focus group discussions from the ethical, financial, and legal considerations portion of the inaugural National Emergency Department HIV Testing Consortium conference. Four groups composed of 20 to 25 consortium participants engaged in semistructured, facilitated focus group discussions. The focus group discussions were audiotaped and transcribed. A primary reader identified major themes and subthemes and representative quotes from the transcripts and summarized the discussions. Secondary and tertiary readers reviewed the themes, subthemes, and summaries for accuracy. RESULTS: The focus group discussions centered on the following themes. Ethical considerations included appropriateness of HIV screening in the ED and ethics of key elements of the 2006 Centers for Disease Control and Prevention HIV testing recommendations. Financial considerations included models of payment and support, role of health care insurance, financial ethics and downstream financial burdens, and advocacy approaches. Legal considerations included the adequacy of obtaining consent, partner notification, disclosure of HIV results, difficulties in addressing special populations, failure of not performing universal screening, failure to notify a person of being tested, failure to notify someone of their test results, liability of inaccurate tests, and failure to link to care. CONCLUSION: This qualitative analysis provides a broadly useful foundation to the ethical, financial, and legal considerations of implementing HIV screening programs in EDs throughout the United States.

Consistency of state statutes with the Centers for Disease Control and Prevention HIV testing recommendations for health care settings.

In September 2006, the Centers for Disease Control and Prevention (CDC) released the "Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-care Settings" to improve screening and diagnosis. The CDC now recommends that all patients in all health care settings be offered opt-out HIV screening without separate written consent and prevention counseling. State law on HIV testing is widely assumed to be a barrier to implementing the recommendations. To help policymakers and providers better understand their own legal context and to correct possible misunderstandings about statutory compatibility, a state-by-state review (including Washington, DC) of all statutes pertaining to HIV testing was performed and the consistency of these laws with the new recommendations was systematically assessed. Criteria were developed for classifying state statutory frameworks as consistent, neutral, or inconsistent with the new recommendations, and the implications for implementation of the CDC recommendations in these various legal contexts were examined. The statutory frameworks of 34 states and Washington, DC, were found to be either consistent with or neutral to the new CDC recommendations, which would enable full implementation. Statutory frameworks of 16 states were inconsistent with the new CDC recommendations, which would preclude implementation of 1 or more of the novel provisions without legislative change. In the 2 years since release of the recommendations, 9 states have passed new legislation to move from being inconsistent to consistent with the guidelines. State statutory laws are evolving toward greater compliance with the CDC recommendations. Policymakers, provider groups, consumer advocates, and other stakeholders should ensure that HIV screening practices comply with existing state law and work to amend inconsistent laws if they are interested in implementing the CDC recommendations.

Routine HIV testing in health care settings: the deterrent factors to maximal implementation in sub-Saharan Africa.

The sub-Saharan region of Africa is the most severely affected HIV/AIDS region in the world. The population of this region accounts for 67% of all people living with HIV/AIDS and 72% of all AIDS-related deaths. As international collaboration makes access to HIV treatment more widely available in this region the need to increase the population's awareness of its serostatus becomes greater. The incorporation of provider-initiated HIV testing and counseling (routine HIV testing model) as part of a routine medical care would not only increase the population's serostatus awareness but also lead to a better understanding of HIV prevention and treatment and ultimately, increased utilization of available HIV/AIDS prevention programs on a much larger scale. This mini-review summarizes some important regional, sociocultural, economic, legal, and ethical issues that may be deterrent factors to maximal implementation and integration of provider initiated HIV testing and counseling as part of routine medical care in the sub-Saharan African region.

Zambian court issues groundbreaking decision concerning HIV testing without informed consent.

HIV testing is a critical component in the response to HIV. Human rights law requires that it include informed consent, pre- and post-test counselling, and guaranteed confidentiality of test results. In this article, based on her presentation at AIDS 2010, Priti Patel discusses a precedent-setting case in Zambia in which two former members of the Zambian Air Force were subjected to HIV testing without their consent.

Characteristics of HIV seroprevalence of visitors to public health centers under the national HIV surveillance system in Korea: cross sectional study.

BACKGROUND: In Korea, the cumulative number of HIV-infected individuals was smaller than those of other countries. Mandatory HIV tests, dominating method until 1990's, have been gradually changed to voluntary HIV tests. We investigated HIV seroprevalence status and its characteristics of visitors to Public Health Centers (PHCs), which conducted both mandatory test and voluntary test under the national HIV/STI surveillance program. METHODS: We used HIV-testing data from 246 PHCs in 2005 through the Health Care Information System. The number of test taker was calculated using the code distinguished by the residential identification number. The subjects were classified into four groups by reason for testing; General group, HIV infection suspected group (HIV ISG), HIV test recommended group (HIV TRG), and sexually transmitted infection (STI) risk group. RESULTS: People living with HIV/AIDS were 149 (124 male and 25 female) among 280,456 individuals tested at PHCs. HIV seroprevalence was 5.3 per 10,000 individuals. Overall, the male revealed significantly higher seroprevalence than the female (adjusted Odds Ratio (adj. OR): 6.2; CI 3.8-10.2). Individuals aged 30-39 years (adj. OR: 2.6; CI 1.7-4.0), and 40-49 years (adj. OR: 3.8; CI 2.4-6.0) had higher seroprevalence than 20-29 years. Seroprevalence of HIV ISG (voluntary test takers and cases referred by doctors) was significantly higher than those of others. Foreigners showed higher seroprevalence than native Koreans (adj. OR: 3.8; CI 2.2-6.4). HIV ISG (adj. OR: 4.9; CI 3.2-7.5), and HIV TRG (adj. OR: 2.6; CI 1.3-5.4) had higher seroprevalence than General group. CONCLUSION: A question on the efficiency of current mandatory test is raised because the seroprevalence of mandatory test takers was low. However, HIV ISG included voluntary test takers was high in our result. Therefore, we suggest that Korea needs to develop a method encouraging more people to take voluntary tests at PHCs, also to expand the anonymous testing centers and Voluntary Counselling and Testing Program (VCT) for general population to easily access to HIV testing.

TEST: a public health and law enforcement collaboration to increase HIV/AIDS prevention in Westchester County, New York.

Test to Eliminate Sexual Transmission is an innovative collaboration among a county public health department, a county district attorney, and local courts intended to extend rapid testing to individuals who are at high risk of HIV transmission. The process of engaging partners for the collaboration is discussed, as is the design of the program itself. The outcome of the first year of operation is reviewed in terms of client and court participation and in terms of the ability of the program to reach a high-risk population that has previously proven to be elusive to public health.

Elimination of requirement for prior signature consent and pre-and post-test counseling for HIV testing. Final rule.

This document adopts, without change, the proposed rule published in the Federal Register on December 29, 2008, updating informed consent requirements related to testing for the Human Immunodeficiency Virus (HIV) for Veterans receiving health care from the Department of Veterans Affairs (VA). This final rule is in accordance with related provisions of the Veteran's Mental Health and Other Care Improvements Act of 2008. The final rule eliminates the regulatory requirement for written informed consent for HIV testing and specific pre- and post-test counseling of Veteran patients. VA will implement this rule through internal policy guidance specifying these requirements and how they apply to HIV testing.

Testing for HIV-1 infection in a public developmental center.

The discovery of human immunodeficiency virus type 1 (HIV) infection in an individual who recently moved from a developmental center prompted the center to offer HIV testing to current and former residents. The guardians of 199 (93 percent) of the Center's current residents consented to testing. The remaining 14 current residents (seven percent) were not tested because informed consent for testing was not received. Consent for testing of 41 former residents was also obtained. All people who underwent testing were seronegative. Whether former residents who were not included in the present analysis received testing from other sources is not known.

Uganda: Proposed bill would criminalize HIV transmission, force partners to reveal HIV-positive status.

The Uganda government has introduced in Parliament an omnibus AIDS bill which aims to criminalize the "intentional or willful" transmission of HIV, introduce "routine" HIV testing for pregnant women, and require disclosure of one's HIV-positive status to one's spouse or partner. The bill also contains measures to protect the rights of people living with HIV/AIDS, including guaranteeing access to treatment and providing protection against discrimination.

Macedonia: detention of sex workers sparks protest.

HIV/AIDS and human rights organizations have vigorously protested the detention, compulsory medical testing and criminal prosecution of alleged sex workers in Skopje, Macedonia in November 2008.

HIV/AIDS, reproductive and sexual health, and the law.

The law is a frequently overlooked tool for addressing the complex practical and ethical issues that arise from the HIV/AIDS pandemic. The law intersects with reproductive and sexual health issues and HIV/AIDS in many ways. Well-written and rigorously applied laws could benefit persons living with (or at risk of contracting) HIV/AIDS, particularly concerning their reproductive and sexual health. Access to reproductive health services should be a legal right, and discrimination based on HIV status, which undermines access, should be prohibited. Laws against sexual violence and exploitation, which perpetuate the spread of HIV and its negative effects, should be enforced. Finally, a human rights framework should inform the drafting of laws to more effectively protect health.

Uptake of an HIV voluntary counseling and testing program for pregnant women in Georgia.

From 2002 to 2005 the Elizabeth Glaser Pediatric AIDS Foundation prevention of mother-to-child transmission of HIV project operated in Georgia and was managed by the Maternal and Child Care Union. The project covered Tbilisi, the capital, and included 34 clinics that provide women's healthcare. Out of 35,385 pregnant women starting prenatal care in clinics involved in the project, 91% (32,262) had received HIV counseling and, among those counseled, 94% (30,330) were tested for HIV antibodies; 14 pregnant women (<0.001%) were found to be HIV-infected.

Nonconsented human immunodeficiency virus testing among critically ill patients: intensivists' practices and the influence of state laws.

BACKGROUND: Human immunodeficiency virus (HIV) testing can improve care for many critically ill patients, but state laws and institutional policies may impede such testing when patients cannot provide consent. METHODS: We electronically surveyed all US academic intensivists in 2006 to determine how state laws influence intensivists' decisions to perform nonconsented HIV testing and to assess intensivists' reliance on surrogate markers of HIV infection when unable to obtain HIV tests. We used multivariate logistic regression, clustered by state, to identify factors associated with intensivists' decisions to pursue nonconsented HIV testing. RESULTS: Of 1,026 responding intensivists, 765 (74.6%) had encountered decisionally incapacitated patients for whom HIV testing was wanted. Of these intensivists, 168 pursued testing without consent and 476 first obtained surrogate consent to testing. Intensivists who believed nonconsented HIV testing was ethical (odds ratio, 3.8; 95% confidence interval, 2.2-6.5) and those who believed their states allowed nonconsented testing when medically necessary (odds ratio, 2.3; 95% confidence interval, 1.6-3.4) were more likely to pursue nonconsented HIV tests; actual state laws were unrelated to testing practices. Of the intensivists, 72.7% had ordered tests for perceived surrogate markers of HIV infection in lieu of HIV tests; more than 90% believed these tests were sufficiently valid to base clinical decisions on. CONCLUSIONS: Most US intensivists have encountered decisionally incapacitated patients for whom HIV testing may improve care. Intensivists' decisions to pursue nonconsented testing are associated with their personal ethics and often erroneous perceptions of state laws, but not with the laws themselves. Uniform standards enabling nonconsented HIV testing may minimize inappropriate influences on intensivists' decisions and reduce intensivists' reliance on perceived surrogate markers of immunodeficiency.

[Informed consent for HIV diagnostic tests: what to do in case of minors]. / Il consenso informato per l'effettuazione del test per la diagnosi di infezione da HIV: come comportarsi in caso di minori.

AIDS is a clinical picture related to Human Immunodeficiency Virus (HIV) infection. In the last 20 years this infection has spread progressively, with approximately 2.4 million children under 15 years old now infected. The HIV antibody test is generally used to reveal the infection. In most European countries the test is voluntary; in Italy, implementation of the test is now regulated by Law 135/90. Art. 5 of the law states that the test is voluntary while informed consent is obligatory. However, nothing is stated concerning the child's consent. By contrast, other Italian laws (e.g., Law 194/78, Law 194/96 and DPR 309/90) establish that the physician should only accept the wishes of minors after first appraising the maturity of the child and his/her age. Physicians must inform the minor about testing risks, about the meaning of its result, and about the most important aspects of sexual education.. They may then decide to inform the parents if they feel that the child would be unable to take future decisions in the event of a positive HIV antibody test.

Mexico: general recommendations issued against mandatory HIV testing and discharge from armed forces.

In September and October 2008, Mexico's National Human Rights Commission (NHRC) issued three separate Recommendations addressing the practice of mandatory HIV testing and discharging HIV-positive personnel from Mexico's armed forces.

Legislation contagion: building resistance.

The HIV/AIDS Policy & Law Review recently carried a feature article recounting the spread of problematic new HIV laws in west and central Africa. It outlined less-than-model approaches in the AWARE-HIV/AIDS "model" law and described how its provisions had been replicated in many national HIV laws. At the time of writing that article, eight national HIV laws had been passed in the region. Since that date, the rush to legislate HIV in west and central Africa in ways that do not accord with human rights law or policy has continued unabated.

Manitoba legislation would authorize testing for HIV without informed consent.

Manitoba's Health Minister has introduced legislation that would authorize the forced testing of people for HIV and other infections in some situations of possible occupational and non-occupational exposure to blood or other bodily fluids.