Jeffrey T. Kirchner, D.O., AAHIVS
A 25-year-old female visits her family physician for a general checkup and asks about contraceptive options. "I'm in a new relationship," she says, "and I'm not certain what my best choice is."
Based on her medical history, her physician discusses the various options and adds, "I also recommend that we test you for HIV. Screening for HIV is now recommended for everyone at least once, as a routine part of medical care, so I encourage all of my patients to get tested."
"I don't think I'm at risk for HIV," she replies, "but if you think it's a good idea, let's do it."
The physician includes a fourth-generation HIV antigen/antibody test and sexually transmitted infection screening as part of her exam. The woman makes an appointment to return in two weeks to review the test results. The physician expects to release a negative HIV result for the patient via the patient portal but is surprised when the test result comes back positive. This is the first HIV-positive test result the physician has received for any patient.
How to Deliver News of a Positive Test Result
The CDC recommends that physicians have definitive mechanisms in place to inform patients of their HIV test results(www.cdc.gov). This should be done confidentially and, if at all possible, in person by the ordering clinician. This is consistent with CDC guidance, and in many states, it is what the law requires.
The physician should convey the information clearly in a direct, neutral tone and should immediately reassure the patient about the benefits of medical care and treatment. Steady advances in HIV treatment, particularly the use of combination antiretroviral therapy, have transformed HIV infection into a manageable chronic condition. Current medications, when taken consistently and correctly, are highly effective in suppressing the virus, reducing HIV viral load to very low or undetectable levels, allowing for immune system recovery and clinical stability for most patients.
Patients newly diagnosed with HIV infection should be linked to care for full evaluation, follow-up and management, with prompt initiation of antiretroviral treatment, as soon as possible after diagnosis. Depending on their clinical experience and expertise in providing HIV specialty care, including decisions related to antiviral therapy, primary care physicians may plan to refer a patient who tests positive to an HIV specialist. If so, they should reassure the patient that they will collaborate closely with the specialist and will remain involved in their comprehensive care over the long term.
In either case, physicians should have an established process for linking patients who are diagnosed with HIV infection to the next level of structured care. They can find assistance from sources such as the American Academy of HIV Medicine;(providers.aahivm.org) the HIV Medicine Association;(www.hivma.org) the University of California, San Francisco, Clinician Consultation Center;(nccc.ucsf.edu) state departments of health and human services; and local AIDS education and training centers.
Patients' reactions to a positive test result vary and, not surprisingly, may be quite strong. The physician should be flexible and supportive of the patient's needs, and should have information readily available to provide quick, easy access to emotional and practical support resources.
While ensuring that patients clearly understand the meaning of test results, physicians may need to keep their initial counseling brief to allow for absorption of key information related to prevention of HIV transmission to others, partner notification and testing, and immediate next steps in care. This may require providing educational resources -- including information on HIV infection and its medical management -- and scheduling a follow-up visit in a few days.
To fully participate in their care and protect their health, newly diagnosed patients need to accept their diagnosis and understand what it means to be HIV-positive. Physicians should ensure they understand the basic aspects of HIV disease and the benefits of earlier antiretroviral treatment, and they should talk with patients about programs that can help, as well as about the next level of care.
Utilizing Partner Services
When delivering a positive HIV test result to a patient, physicians should explain that it is standard procedure for the health care professional or laboratory to report positive test results to the state or local health department and that a trained counselor from the health department may contact the patient.
Through the CDC's free, confidential partner services program,(effectiveinterventions.cdc.gov) health department staff will work to help identify and locate patients' sexual contacts or drug injection partners to inform them of their risk of HIV exposure, removing the burden of disclosure from patients. Physician should stress that the program is voluntary and private, and that it does not reveal patients' identities or share any medical or personal information. Alternatively, partner services staff can give guidance to patients who want to notify partners personally. In either case, staff will ensure that partners have access to testing, counseling and appropriate referrals.
Educating patients about the partner services program can open a discussion about how to reduce risky transmission behaviors and how the program helps to increase HIV testing and prevent the spread of HIV infection.
Among people in the United States living with HIV infection, about 13 percent are unaware of their infection(www.cdc.gov) and these people contribute disproportionately to HIV transmission.(www.ncbi.nlm.nih.gov) A systematic review found that 20 percent of partners who were notified and tested by CDC's partner services were positive for HIV but previously undiagnosed.(www.ncbi.nlm.nih.gov)
HIV Screening Benefits in Primary Care Settings
We now know that risk-based HIV screening misses many people who are infected with the virus. Consequently, the CDC, the U.S. Preventive Services Task Force (USPSTF), and the AAFP all recommend routine HIV screening in primary care settings, with slight differences in the age at which screening should begin. The AAFP recommends that clinicians screen adolescents and adults ages 18-65, the USPSTF(www.ncbi.nlm.nih.gov) recommends routine screening for patients aged 15-65, and the CDC sets its screening recommendation parameters at 13-64 years.
Although the large majority of patients screened for HIV in clinical practice will have a negative test result, the prevalence of HIV infection is significant enough throughout the United States that screening should be done regardless of practice setting. Early diagnosis links patients who have HIV infection to lifesaving antiretroviral treatment, reduces morbidity and mortality, and lowers the risk of transmission to others.
Family physician Jeffrey T. Kirchner, D.O., AAHIVS, is medical director for Lancaster General Health Physicians Comprehensive Care in Lancaster, Pa., and provides HIV/AIDS medical care.