- HIV Management Returning to Primary Care Providers
A 32-year old uninsured woman, living in a rural town in the Deep South, presents to the emergency room at a local hospital with complaints of cough and fever. She is diagnosed with pneumonia and given a prescription for an antibiotic. It takes a few days to raise the money for the prescription but she eventually fills it and improves with treatment. Over the next several months, she goes to three different free-care clinics for vaginal yeast infections. One year after the initial episode of pneumonia, she returns to the same hospital with gradually increasing shortness of breath, a non-productive cough, and a low-grade fever. Her chest x-ray reveals a bilateral interstitial pattern and her PaO2 [partial pressure of oxygen in arterial blood] is 52. She is admitted to the hospital and clinically worsens over the next 24 hours, requiring intubation. Bronchos-copy reveals the patient has Pneumocystis jiroveci pneumonia and the patient is found to be HIV-infected. Her CD4 lymphocyte count is 34 cells/hpf.
This scenario is intended to represent the fact that patients with undiagnosed HIV infection frequently access the health care system several times before they are tested for HIV, resulting in late diagnosis and an AIDS classification (CD4 count .200). It is estimated that over 1,200,000 people in the United States are living with HIV infection; despite extensive efforts for primary prevention, the CDC estimates there are 56,300 new infections annually.1 The efficacy of HIV treatment has dramatically improved since the mid-1990s, with the introduction of highly active antiretroviral therapy (HAART) resulting in a decrease in the incidence of AIDS-related deaths. Consequently, a steady number of new infections coupled with a decrease in mortality rates results in an increase in the total number of people living with HIV each year.
In 2006, the CDC released its Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm). In this document, the CDC encourages the routinization of HIV screening/testing for everyone in the U.S. between the ages of 13 to 64 years. When patients initially enter a health care system, they should be asked as part [End Page 1127] of the initial intake if they have ever been tested for HIV and if they are aware of their results. If the response is negative, a brief risk assessment should be performed and an HIV test should be ordered again at that time if appropriate. The patient is then able to opt out of the test if they do not wish to have it, and this should be documented in the chart (including the reason given for refusal). Written consent is still required in some states, depending on state laws. The initial testing choice is a routine screening test not based on reported risky behavior; repeat testing should be offered as part of a differential diagnosis or based upon a risk assessment of behaviors that put the patient at increased risk for HIV.
Routine HIV screening is a practice now being put into place across medical settings such as emergency rooms, inpatient hospitals, primary care and subspecialty clinics, dental practices, substance abuse treatment centers, and mental health facilities. Opt-out testing is often routinely added to admission and pre-operative screening requirements. To reach the CDC goal that every person should know his or her HIV status, all health care team members must be involved in HIV screening. A well-informed health care team increases the opportunities for a patient to understand the importance of routine HIV testing and positively affects the decision to test.2
In July 2010, President Obama's Office of National AIDS Policy (ONAP) released, for the first time, a National HIV/AIDS Strategy (NHAS) for the United States. This document identified three key components to controlling HIV in America: reduce HIV incidence; increase access to care and optimize health outcomes; and reduce HIV-related health care disparities and stigma. The Strategy identifies...