Saturday, January 9, 2016

#HIV: The Ethics of Opt-Out testing

*Note: Today the Strength In Numbers blog started a year ago today. Over 150 posts later and thousands of readers, Thank you from the bottom of my heart. There is more to come, even though we not all agree on some of the subject matter, you continue to support and that means the world.

XOXO - Ashton*

My concerns, specifically for adults and adolescents are borne from the fact that locally in the city of Houston and Harris County there is a movement to implement opt-out screening among the homeless population. This population is mainly within the confines of the city of Houston, where the homeless are typically SGL/LGBT youth, mentally ill adults and other groups. First, if one is homeless and encounters a health care provider via arrest and other methods they are not thinking about HIV screenings or may not even have the capacity to understand what opt in or out means. Conversely, one could argue that many in the homeless population do understand and would wonder why those in HIV testing & prevention would take their choice away. WHY would I want you to screen me and then ask me for consent after the fact?

While one could argue that HIV screenings should be a normal part of a health screening, the stigma of HIV and lack of education still persists. In a sense, it forces one to know their results without taking into consideration that yes it will get them into care, but still facing the prospect of homelessness. What I mean is that, IF I were homeless and SGL/LGBT, got screened, tested positive & got prescribed meds; where would I live? Where would I store my meds? The question of survival in many cases would override the need to stay compliant with medication. To be honest, there are a myriad of services available to those living with HIV and AIDS that have housing issues. Many of the community based organizations that exist in the Houston area are at the whim of funding and tend to run out of money depending on what time of year it is.

*For assistance in Houston you, check out the Bluebook -HOUSTON RESOURCE GUIDE: http://www.rwpchouston.org/Blue_Book/15-16/1516BBComplete.pdf*

Whatever the case, affordable housing and consistent access to shelter are extremely important if we are to go along with opt-out screenings the homeless population. Access to employment, a steady supply of food and other needs that contribute to the stabilization of one's health, it takes more than one pill before bedtime. The idea for opt - out came in 2006 the Centers for Disease Control (CDC) released the Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings which advises providers in healthcare settings to:
  • Adopt a policy of routine HIV testing for everyone between the ages of 13-64 and all pregnant women
  • Use opt-out screening for HIV—meaning that HIV tests will be done routinely unless a patient explicitly refuses to take an HIV test
  • Eliminate the requirements for pretest counseling, informed consent, and post-test counseling“Opt-out testing” does not mean that you MUST take an HIV test. In general, you have the right to refuse an HIV test. (Exceptions include blood and organ donors, military applicants and active duty personnel, Federal and state prison inmates under certain circumstances, newborns in some states, and immigrants.)"
Part of the rationale behind this recommendation according to The U.S. Preventive Services Task Force made a recommendation "that clinicians screen for HIV all adults and adolescents at increased risk for HIV, on the basis that when HIV is diagnosed early, appropriately timed interventions, particularly HAART, can lead to improved health outcomes, including slower clinical progression and reduced mortality (24). The Task Force also recommended screening all pregnant women, regardless of risk, but made no recommendation for or against routinely screening asymptomatic adults and adolescents with no identifiable risk factors for HIV. The Task Force concluded that such screening would detect additional patients with HIV, but the overall number would be limited, and the potential benefits did not clearly outweigh the burden on primary care practices or the potential harms of a general HIV screening program (24,83)..."


While the report made it clear under their "Consent and Pretest Information for Adults & Adolescents:

  • Screening should be voluntary and undertaken only with the patient's knowledge and understanding that HIV testing is planned.
  • Patients should be informed orally or in writing that HIV testing will be performed unless they decline (opt-out screening). Oral or written information should include an explanation of HIV infection and the meanings of positive and negative test results, and the patient should be offered an opportunity to ask questions and to decline testing. With such notification, consent for HIV screening should be incorporated into the patient's general informed consent for medical care on the same basis as are other screening or diagnostic tests; a separate consent form for HIV testing is not recommended.
  • Easily understood informational materials should be made available in the languages of the commonly encountered populations within the service area. The competence of interpreters and bilingual staff to provide language assistance to patients with limited English proficiency must be ensured.
  • If a patient declines an HIV test, this decision should be documented in the medical record."

& "HIV Screening for Pregnant Women and Their Infants

Universal Opt-Out Screening
  • All pregnant women in the United States should be screened for HIV infection.
  • Screening should occur after a woman is notified that HIV screening is recommended for all pregnant patients and that she will receive an HIV test as part of the routine panel of prenatal tests unless she declines (opt-out screening).
  • HIV testing must be voluntary and free from coercion. No woman should be tested without her knowledge.
  • Pregnant women should receive oral or written information that includes an explanation of HIV infection, a description of interventions that can reduce HIV transmission from mother to infant, and the meanings of positive and negative test results and should be offered an opportunity to ask questions and to decline testing.
  • No additional process or written documentation of informed consent beyond what is required for other routine prenatal tests should be required for HIV testing.
  • If a patient declines an HIV test, this decision should be documented in the medical record."
For more info: