CDC: Time for an 'opt-out' approach to HIV testing
CDC: Time for an 'opt-out' approach to HIV testing
Counseling, testing now separate interventions
The Centers for Disease Control and Prevention offers the following answers to some frequently asked questions about its new guidelines of HIV testing:
• What is opt-out HIV screening and why is CDC recommending it in health care settings? Opt-out screening means performing an HIV test after notifying the patient that 1) the test will be performed; and 2) the patient may elect to decline or defer testing. Opt-in screening means testing is offered, and the patient is required to actively give permission for testing. Areas that have opt-out testing policies for pregnant women and for recipients of sexually transmitted disease (STD) services have higher HIV testing rates than those that use opt-in policies (where the patient is given the opportunity to choose the HIV test) or those that require specific counseling for testing. Patients prefer when testing is routine and offered to everyone rather than being singled out for testing because they are perceived to be "at-risk." For these reasons, CDC believes an opt-out approach provides the best opportunity for more people to know their HIV status.
• Is CDC de-emphasizing counseling or just separating it from testing? In health care settings, CDC recommends that counseling and testing be treated as two separate interventions, and emphasizes counseling for persons who are HIV-infected. Prevention counseling remains important for all persons who are sexually active, but it does not need to be linked with HIV testing in health care settings. Notifying a patient that HIV screening will be performed might result in acknowledgement of risk behaviors and offers an opportunity to discuss HIV infection and how it can be prevented. Patients found to have risk behaviors [e.g., heterosexuals or men who have sex with men (MSM) who have multiple sex partners, persons who have received a recent diagnosis of an STD, persons who exchange sex for money or drugs, or persons who engage in substance abuse] and those who want assistance with changing behaviors should be provided with or referred to HIV risk-reduction services (e.g., drug treatment, STD treatment, and/or prevention counseling).
• Why is CDC recommending that separate, written informed consent for HIV testing should not be required? The need for separate, written informed consent for HIV testing generated considerable debate among various constituents during development of these recommendations. Opinions on this issue have been especially polarized. Proponents support maintaining the existing paradigm of separate, written informed consent and pretest counseling for HIV testing. Opponents, with similar conviction, assert that requiring separate, written consent, and pre-test counseling for all patients is a major impediment that makes HIV screening impractical in health care settings.
Further investigation revealed that certain states require written informed consent for all HIV testing; others specifically exempt health care providers from this requirement, and several explicitly state that no separate consent for an HIV test is necessary when a general consent for care is in effect.
Additionally, a recent survey by the Kaiser Family Foundation found that 65% of U.S. adults felt that no separate procedures, such as signed permission from the patient, should be necessary for HIV testing. CDC considers it essential to protect both patient autonomy and to reduce potential barriers that hinder HIV screening. To help strike a balance, CDC emphasizes in the summary statement and throughout the recommendations that the revised recommendations are intended for HIV testing in health care settings where other diagnostic and screening tests are conducted routinely, that patients must be informed of the test, and that testing must be voluntary and free from coercion. In health care settings, CDC recommends that informed consent for HIV testing can be incorporated into the consent for treatment, recognizing that each jurisdiction must carefully consider the legal meaning of informed consent in light of the public health considerations addressed by the recommendations.
(Editor's note: The complete CDC recommendations for HIV testing are on-line at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm.)