Routine Opt-Out HIV Testing Routine Opt-Out HIV Testing Texas STD ClinicsTexas STD Clinics

1996-20051996-2005

James H. Lee, Senior Public Health AdvisorHIV/STD Program

Texas Department of State Health Services

Targeted Opt-In Testing Targeted Opt-In Testing Prior to 1996Prior to 1996

Clients with high risk behaviors (e.g. Clients with high risk behaviors (e.g. MSM, IDU, genital ulcer disease) MSM, IDU, genital ulcer disease)

Clients requesting an HIV testClients requesting an HIV test Separate consent form requiredSeparate consent form required

Routine Opt-Out Testing Routine Opt-Out Testing Phased Implementation Phased Implementation

1996-19971996-1997 All clients tested Unless:All clients tested Unless: Client was known to be HIV-positiveClient was known to be HIV-positive Had been recently tested (last 30 - 90 Had been recently tested (last 30 - 90

days)days) Client declined testClient declined test

General consent for all STD servicesGeneral consent for all STD services

Background - ReasonsBackground - Reasons

Seroprevalence studies: ~50% of HIV-positive Seroprevalence studies: ~50% of HIV-positive clients were not tested in some STD clinicsclients were not tested in some STD clinics

Only 50% of clients accepted opt-in HIV testingOnly 50% of clients accepted opt-in HIV testing Routine opt-out testing is effective and has been Routine opt-out testing is effective and has been

the norm for other STD screening historicallythe norm for other STD screening historically Early detection of HIV can help communities, STD Early detection of HIV can help communities, STD

clinicians and especially clients (Early clinicians and especially clients (Early Intervention)Intervention)

Background: Focus Background: Focus GroupsGroups

Pre-test counseling identified as a Pre-test counseling identified as a deterrent to HIV testingdeterrent to HIV testing

Many clients thought they were tested Many clients thought they were tested routinely and assumed they were HIV routinely and assumed they were HIV negative after their STD clinic visitnegative after their STD clinic visit

Focus group participants strongly Focus group participants strongly recommended making routine HIV recommended making routine HIV testing part of STD screeningtesting part of STD screening

Texas Informed Consent Texas Informed Consent LawLaw

Sec. 81.105. Informed Consent.Sec. 81.105. Informed Consent.

(a) Except as otherwise provided by (a) Except as otherwise provided by law, a person may not perform a law, a person may not perform a test designed to identify HIV test designed to identify HIV antibody without first obtaining the antibody without first obtaining the informed consent of the person to informed consent of the person to be testedbe tested..

Texas General Consent Texas General Consent LawLaw

Sec. 81.106. General Consent.Sec. 81.106. General Consent.

(a) A person who has signed a general (a) A person who has signed a general consent form for the performance of consent form for the performance of medical tests is not required to also sign medical tests is not required to also sign a specific consent form relating to a specific consent form relating to medical tests to determine HIV infection medical tests to determine HIV infection that will be performed on the person that will be performed on the person during the time in which the general during the time in which the general consent form is in effect.consent form is in effect.

Evaluation ObjectiveEvaluation Objective

Evaluate major changes in the Evaluate major changes in the implementation of routine, opt-out HIV implementation of routine, opt-out HIV testing in STD clinics:testing in STD clinics:

Change in eligibility, from “targeted” to Change in eligibility, from “targeted” to “routine”“routine”

Change in consent, from Change in consent, from – ““opt-in” (separate consent solicited) toopt-in” (separate consent solicited) to– ““opt-out” (HIV test included as one of regular opt-out” (HIV test included as one of regular

screening tests, unless it is refused.) screening tests, unless it is refused.)

Other Changes in Other Changes in ProceduresProcedures

Bilingual Signs and videotapes Bilingual Signs and videotapes developed to inform clientsdeveloped to inform clients

High risk individuals and those opting-High risk individuals and those opting-out referred to a Disease Intervention out referred to a Disease Intervention Specialist (DIS)Specialist (DIS)

During clinic visit, prevention counseling During clinic visit, prevention counseling offered to all clientsoffered to all clients

Evaluation OutcomesEvaluation Outcomes

Change in the number and percentage Change in the number and percentage of positive clients identifiedof positive clients identified

Change in demographics of positive Change in demographics of positive clientsclients

Change in the risk profile of positive Change in the risk profile of positive clientsclients

Compare partner services outcomesCompare partner services outcomes

MethodsMethods

6-month evaluation periods before and 6-month evaluation periods before and after implementing opt-out at 6 STD after implementing opt-out at 6 STD programs:programs:

Amarillo, Austin, Dallas, Fort Worth, Houston, Amarillo, Austin, Dallas, Fort Worth, Houston, LubbockLubbock

Each site recorded data on:Each site recorded data on:– Utilization of HIV testing, prevention Utilization of HIV testing, prevention

counselingcounseling– Number of new HIV infections identifiedNumber of new HIV infections identified– Partner elicitation, counseling, and HIV testingPartner elicitation, counseling, and HIV testing

DALLAS COUNTY HEALTH & HUMAN SERVICES

S. T. D. CLINIC (SEXUALLY TRANSMITTED DISEASE)

ALL PATIENTS SEEN IN THIS CLINIC WILL BE TESTED FOR:

GONORRHEA SYPHILIS

CHLAMYDIA HIV

I hereby voluntarily consent to medical and/or dental examinations, treatments and procedures including laboratory tests and x-rays which are deemed necessary in the opinion of my physician and health care providers selected by my physician.I understand that no guarantees or warranties have been made to me concerning the results of the examinations,treatments or procedures. My signature acknowledges that I have been given the opportunity to ask questions about this consent form.

HOUSTON DEPARTMENT OF HEALTH AND HUMAN SERVICES

GENERAL CONSENT FORM

ResultsResultsOpt-in Opt-outOpt-in Opt-outN (%) N (%) % ChangeN (%) N (%) % Change

STD VisitsSTD Visits 31,558 34,533 +931,558 34,533 +9 Eligible ClientsEligible Clients 19,184 (61) 23,686 (69) +2319,184 (61) 23,686 (69) +23 Pre-test CounselPre-test Counsel 15,038 (78) 11,466 (48) -2415,038 (78) 11,466 (48) -24 TestedTested 14,927 (78) 23,020 (97) +5414,927 (78) 23,020 (97) +54 Post-test CounselPost-test Counsel 6,014 (40) 4,406 (19) -27 6,014 (40) 4,406 (19) -27 HIV-positiveHIV-positive 168 (1.1) 268 (1.2) +59 168 (1.1) 268 (1.2) +59

Partner ServicesPartner Services

Opt-in Opt-outOpt-in Opt-out HIV+ Index PatientsHIV+ Index Patients 145 251145 251 Partners ElicitedPartners Elicited 139 (.96) 206 (.82)139 (.96) 206 (.82) Known HIV+Known HIV+ 19 (14%) 26 (13%) 19 (14%) 26 (13%) Unknown HIV StatusUnknown HIV Status 120 (86%) 180 (87%)120 (86%) 180 (87%) Partners LocatedPartners Located 96 (80%) 131 (73%) 96 (80%) 131 (73%) Partners TestedPartners Tested 85 (89%) 111 (85%) 85 (89%) 111 (85%) Partners HIV+Partners HIV+ 10 (12%) 30 (27%) 10 (12%) 30 (27%)

Evaluation SummaryEvaluation Summary

HIV testing increased 54% (attendance increased HIV testing increased 54% (attendance increased 9%)9%)

HIV-positive clients identified increased 60%HIV-positive clients identified increased 60% Number of HIV-positive clients successfully Number of HIV-positive clients successfully

referred to early intervention programs increased referred to early intervention programs increased 89%89%

Number of new HIV-positive partners increased Number of new HIV-positive partners increased 200%200%

Demographics did not changeDemographics did not change Risk profile did not changeRisk profile did not change Uninfected STD clients receiving prevention Uninfected STD clients receiving prevention

counseling decreasedcounseling decreased

Evaluation ConclusionsEvaluation Conclusions

Opt-out HIV testing in STD Clinics is an Opt-out HIV testing in STD Clinics is an effective strategy for identifying HIV- effective strategy for identifying HIV- positive individuals and linking them positive individuals and linking them into early intervention servicesinto early intervention services

Partner notification is an effective Partner notification is an effective strategy for identifying HIV-positive strategy for identifying HIV-positive individualsindividuals

STD Clients Eligible for HIV STD Clients Eligible for HIV TestTest

STD clients are eligible for HIV testSTD clients are eligible for HIV test unless: unless: Client is known to be HIV-positiveClient is known to be HIV-positive Has been recently tested (last 30 - 90 Has been recently tested (last 30 - 90

days) based on the clinic’s syphilis days) based on the clinic’s syphilis testing proceduretesting procedure

Eligible STD Clients Eligible STD Clients Percent Tested for HIVPercent Tested for HIV

86%

88%

88%

90%

90% 93%

92%

95%

94%

96%

94%

92%

95%

95%

95%

95%

96%

93%

0%10%20%30%40%50%60%70%80%90%

100%

Semi-annual Period

STD Clients HIV Tested (Goal 95%)

Eligible STD Clients Eligible STD Clients Percent PositivePercent Positive

1.0%

1.0%

0.8%

0.8%

0.8% 0.

9%

0.8% 0.

9%

0.7%

0.7%

0.9%

0.8%

0.8%

0.7% 0.

8%

0.8% 0.

9%

0.8%

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

1.6%

1.8%

2.0%

Semi-annual Period

Eligible STD Clients Eligible STD Clients Percent Prevention Percent Prevention

CounseledCounseled54

%

56%

52%

44%

46% 50

%

47%

44%

55%

44%

42%

41% 46

% 49% 52

%

49%

51%

39%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Semi-annual Period

Conclusions: 1997-2005Conclusions: 1997-2005

HIV testing rates remain high (average, 92%) HIV testing rates remain high (average, 92%) The proportion of clients who test HIV-The proportion of clients who test HIV-

positive remains stable (average, 0.8%) positive remains stable (average, 0.8%) Approximately half of persons tested with Approximately half of persons tested with

opt-out consent (average, 48%) accept opt-out consent (average, 48%) accept prevention counseling prevention counseling

This compares favorably to the percentage of This compares favorably to the percentage of STD clients who accepted participation in the STD clients who accepted participation in the Project RESPECT study of prevention Project RESPECT study of prevention counseling (43%) counseling (43%)

AcknowledgementsAcknowledgements

Bernard Branson, CDCBernard Branson, CDC Don Hutcheson, Dallas County HIV/STD Don Hutcheson, Dallas County HIV/STD

ProgramProgram Barry Mitchell, DSHSBarry Mitchell, DSHS Beverly Nolt, DSHS (now CDC)Beverly Nolt, DSHS (now CDC) John Paffel, Houston HIV/STD ProgramJohn Paffel, Houston HIV/STD Program Ann Robbins, DSHSAnn Robbins, DSHS Michelle C. Thomas, DSHSMichelle C. Thomas, DSHS

Contact InformationContact Information

Jim LeeJim Lee512-533-3109512-533-3109

Jim.Lee@dshs.state.tx.usJim.Lee@dshs.state.tx.us

Program Operations Procedures and Program Operations Procedures and Standards (POPS)Standards (POPS)

Chapter 4 HIV Testing in STD ClinicsChapter 4 HIV Testing in STD Clinicshttp://www.tdh.state.tx.us/hivstd/guidelines/http://www.tdh.state.tx.us/hivstd/guidelines/

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