Understanding Opt-Out HIV Testing

Getting tested for HIV is a powerful step towards taking control of one’s sexual health. Opt-out HIV testing, sometimes referred to as universal screening, is defined as conducting HIV testing after notifying patients that the test will be conducted and that they may decline or defer testing.  According to the Centers for Disease Control and Prevention (CDC), opt-out testing is an evidence-based approach that has been shown to remove the stigma associated with HIV testing, foster earlier diagnosis and treatment, reduce transmission risk, and is cost-effective.  

How to Use Your Electronic Health Record to Implement Opt-Out HIV Testing In Your Health Center

Implementing Opt-Out HIV testing in health care settings can be achieved by leveraging your electronic health record (EHR). Examples include:

• Developing an algorithm or care guidelines to prompt HIV screening for all medical patients between the ages of 18 and 65 who have never been screened for or diagnosed with HIV.  To align with the HIV screening electronic clinical quality measure reported in the UDS, health centers should consider expanding this to between 15 and 65. 
• Including HIV tests in pre-built order sets in the EHR for annual wellness visits for adults, new patient testing, routine physicals, etc.
• Incorporating HIV testing into preventive care templates or workflows so that providers can easily identify that HIV screening is needed when the patient’s chart is opened and include a box or drop-down for indicating a patient’s opt-out status. Note: Some EHRs allow a field to input reasons for opting out. Examples include:
  • Did not ask the patient
  • Patient is HIV positive
  • Can't verbally consent
  • Patient declines blood draw
  • Patient doesn't feel at risk
  • Patient declines for other reason
• Implementing an algorithm in which persons who had a complete blood count (CBC) ordered would have an HIV Ag/Ab test auto-ordered if they were 13–64 years of age, did not have HIV on their problem list, and did not have an HIV Ag/Ab test in their EHR within the past 12 months.  As previously stated, to align with quality measure reporting in the UDS, health centers may consider implementing this for patients aged 15 through 65.  
• Developing a reminder system to identify patients with unknown HIV status using data from the EHR and offer them an HIV screening at their next visit.
• Using your EHR to identify patients with hepatitis C in need of HIV screening.
• Using a web-based management tool such as the Generic Disease Management System (GDMS), which uses clinical data in the EHR to determine what preventive services or chronic disease management tasks are needed, calculate when they are due alerts the provider. 

Discussing Opt-Out HIV Testing With a Patient

Implementing opt-out HIV testing in the EHR is only half the challenge. Some health care providers are unsure of how to navigate discussing opt-out HIV testing with their patients. Here are some strategies for discussing opt-out HIV testing with a patient:

1. Inform the patient, either verbally or through written/electronic material (e.g., patient brochure), that an HIV test will be included in the standard preventive screening tests and that they may decline the test (opt-out screening). Consider using your organization’s materials as a teaching tool for providing clarity on opt-out testing for patients. Explain the HIV testing process to the patient using the materials or verbally discuss the HIV testing protocol. Be sure to clarify any myths about HIV or HIV testing should they arise. 

One important note is that CDC cautions against requiring any non-critical steps before HIV testing, including requiring prevention counseling before testing. Prevention counseling is defined as an interactive process of assessing the risk of infection, recognizing specific behaviors that increase this risk, and developing a plan to reduce risk.  While important, this should be separate from informing the patient of routine testing and should not be required before HIV testing.

2. Utilize scripts to discuss opt-out HIV testing with the patient. Examples of what you can say include:

• “You will be tested for HIV today unless you tell me not to. You can decline the test.”
• “In my practice, I recommend HIV testing for many of my patients, so I am planning to test you for HIV unless you decline to be tested.” 
• “Here is some information about HIV infection and the test.”
  • Provide [..] patient fact sheet or other material that includes: 
  • A brief explanation of HIV infection 
  • Meaning of HIV test results 
  • Reporting requirements
  • Treatment options and HIV-related services for people who test positive
  • Note: The clinician can also explain this information verbally. 
• “[..] With your consent, I [would like to] order an HIV test.”
•  “You have the right to decide not to be tested, and if so, you won’t be denied other health services as a result.” 
• “Do you have any questions about HIV or HIV testing?” 
  • Provider allows sufficient time for the patient to ask questions or decline testing.
  • The provider verifies that the patient understands that the test will be performed and that their acceptance is voluntary.
• “HIV testing is a routine part of health care, but you have the right to object or decline an HIV test.”

3. Accept the patient’s refusal. If, after informing the patient, they opt-out of receiving an HIV test, affirm the patient of their decision not to be tested at that visit, and assure them that the option is available if they change their mind. 

Documenting a Patient’s Refusal

You may have heard the adage “if it’s not documented, it didn’t happen.” Documenting the patient’s refusal can provide the documentation that the patient was offered an HIV test and serve as a prompt for checking in with a patient later about their decision to be tested for HIV.  Work with your IT department to determine the best strategy for capturing this information in your EHR. Some examples include: 

• Creating a new data field or modifying an existing one that includes drop-down boxes or checklists in the EHR to ensure all parts are done.
• Using brief standardized statements such as “Patient declined HIV testing” or “Patient would like an HIV test at the next visit or a later date” in the progress note or visit summary.

Conclusion

Implementing opt-out HIV testing where all patients are informed and then screened unless they choose to opt-out is an evidence-based approach to routine HIV screening recommended by the CDC. Using this approach has many benefits and can be supported by EHR, and health IT systems with the algorithms and order sets outlined. Implementing these ideas in the EHR in your health center can increase HIV screening rates. Nevertheless, the success of the opt-out HIV testing relies on strong patient communication and education, which in turn relies on provider confidence and buy-in. As such, health centers should engage providers and care teams throughout the process of opt-out HIV testing implementation to ensure seamless adoption both in patient communication and in EHR workflows. 

Additional References

• Opt-Out Screening | Screening for HIV | Clinicians | HIV | CDC. www.cdc.gov. Published March 4, 2020. Accessed October 19, 2020. https://www.cdc.gov/hiv/clinicians/screening/opt-out.html
• Cunningham CO, Doran B, DeLuca J, Dyksterhouse R, Asgary R, Sacajiu G. Routine Opt-Out HIV Testing in an Urban Community Health Center. AIDS Patient Care and STDs. 2009;23(8):619–623. doi:10.1089/apc.2009.0005
• Expect the Test.; 2018. Accessed October 19, 2020. https://www.health.ny.gov/publications/9822.pdf
• Sample Script for Clinicians Regarding Verbal Consent for HIV Testing. Published May 2010. https://www.dhs.wisconsin.gov/hiv/provider-sample-consent-script.pdf
• HIV Testing, Reporting and Confidentiality in New York State 2017-18 Update: Fact Sheet and Frequently Asked Questions. Published June 2018. https://www.health.ny.gov/diseases/aids/providers/testing/docs/testing_fact_sheet.pdf
• Marcelin JR, Tan EM, Marcelin A, et al. Assessment and improvement of HIV screening rates in a Midwest primary care practice using an electronic clinical decision support system: a quality improvement study. BMC Medical Informatics and Decision Making. 2016;16(1). doi:10.1186/s12911-016-0320-5
• Sha BE, Kniuksta R, Exner K, et al. Evolution of an Electronic Health Record Based–Human Immunodeficiency Virus (HIV) Screening Program in an Urban Emergency Department for Diagnosing Acute and Chronic HIV Infection. The Journal of Emergency Medicine. 2019;57(5):732–739. doi:10.1016/j.jemermed.2019.08.008
• Opt-Out| Pregnant Women, Infants, and Children. www.cdc.gov. Published 2019. https://www.cdc.gov/hiv/group/gender/pregnantwomen/opt-out.html
• Ruffner AH, Ancona RM, Hamilton C, et al. Identifying ED patients with previous abnormal HIV or hepatitis C test results who may require additional services. American Journal of Emergency Medicine. 2020;38(9):1831-1833. doi:10.1016/j.ajem.2020.05.020