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ICAAC 2009: People Who Decline Routine HIV Testing Are More Likely to Be Positive, Written Consent Requirement May Discourage Testing

People who "opted out" of routine HIV testing in a Washington, DC, emergency department were almost 3 times more likely to be infected than those who accepted voluntary testing, according to a poster presented at the 49th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC 2009) last month in San Francisco. Another study suggested that requiring written informed consent may cause more people to decline testing.

In 2006, the U.S. Centers for Disease Control and Prevention (CDC) instituted a policy recommending that HIV testing should be implemented as a routine aspect of medical care.

Researchers from George Washington University in Washington, DC, aimed to estimate the prevalence of HIV infection among people who decide not to get tested. The university hospital's emergency department provides rapid HIV testing for all patients unless they opt out; nearly 44% of individuals offered the test decline.

For this analysis, discarded blood samples from patients who opted out of testing were stripped of all identifying information and tested anyway, using the Ora-Quick rapid HIV assay. Samples that tested positive were sent to a lab for confirmation by a Western blot test.


  • 1.9% of individuals who declined routine HIV testing had a positive Ora-Quick test.
  • This was more than twice the 0.79% HIV positive rate in the group that accepted routine testing.
  • Just over 80% of individuals who tested HIV positive were African-American.
  • More than 40% were uninsured, one-third used Medicaid or local managed care organizations, and 25% had private insurance.
  • The most common chief complaint of test decliners was abdominal pain.
  • The most common reason for declining the test was that the individual thought they were not at risk for HIV.

"Although there are various reasons to opt out of HIV testing, the most common reason documented was that patients felt they were not at risk for HIV infection," the investigators stated. "It is critical for public health issues to determine whether the opt-out population is HIV negative or whether their personal risk is being underestimated. Interventions are needed to decrease the opt-out rate."

George Washington University, Washington, DC.

STD Clinic Clients

The CDC also recommends that all patients seeking treatment for other sexually transmitted diseases (STDs) should be tested for HIV. This study aimed to assess the rates and factor that determine HIV testing among patients with health insurance seeking STD treatment.

The researchers looked at administrative claims data from 6 U.S. health plans covering a total of 16 million members in 6 States. They included patients aged 14-64 who were diagnosed or screened for STDs (chancroid, chlamydia, gonorrhea, epididymitis, granuloma inguinale, herpes, human papilloma virus [HPV], syphilis, and trichomonas condyloma)or acute hepatitis B or C in 2006-2007. After excluding patients with known HIV/AIDS or with a CD4 cell count, the final cohort comprised 270,423 participants.


  • The overall HIV testing rate was 33%.
  • Women were significantly less likely to be tested than men.
  • Individuals aged 25-34 were significantly more likely to be tested than any other age group.
  • Patients with any chronic illness were less likely to be tested than those without.
  • People in states that require specific written informed consent for HIV tests were less likely to be tested than individuals in states that do not.

Based on these findings, the researchers stated, "CDC guidelines on HIV testing are far from being implemented."

"[O]nly one-third of patients who are screened, diagnosed, or treated for STDs received HIV testing," they continued. "HIV testing rates among members diagnosed with certain high risk conditions such as trichomonas and human papillomavirus were even lower."

"Ensuring better compliance of treating physicians to clinical guidelines on HIV testing is urgently needed, with particular attention to women and STDs that are commonly diagnosed in primary care settings such as HPV," they concluded. "Requiring specific written informed consent for HIV testing is associated with significantly less HIV testing, and is likely to result in delayed HIV diagnosis and treatment as well as poorer patient health outcomes."

Health Benchmarks, IMS Health, Woodland Hills, CA; Gilead Sciences, Foster City, CA; Brown University, Providence, RI.



M Czarnogorski, J Brown, V Lee, and others. Higher Prevalence of HIV Infection in Patients who Decline Routine HIV Testing than in Those Who Accept it in an Urban Emergency Department. 49th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC 2009). San Francisco. September 12-15, 2009. Abstract H-239.

JY Chen, Q Ma, F Everhard, and others. HIV Testing among Patients Seeking Treatment for Sexually Transmitted Diseases (STD). ICAAC 2009. Abstract L1-1651.