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Opt-Out HIV Testing in U.S. Tuberculosis Clinics: A Survey of Current Practice and Perceived Barriers Adrian Gardner MD, MPH Assistant Professor of Clinical Medicine, Infectious Diseases, Indiana University School of Medicine Assistant Professor of Clinical Medicine (Adjunct), Alpert School of Medicine at Brown University Visiting Lecturer, Moi University School of Medicine, Eldoret, Kenya Disclosures • No relevant conflicts of interest • Survey conducted and analyzed by Caitlin Naureckas as part of her senior undergraduate thesis work (Brown University) • Presented at the 16th Conference of The Union North American Region (2012) in San Antonio, TX • Manuscript is in progress Methods • Online Survey Monkey® survey designed to assess the extent of opt-out HIV testing as well as TB providers’ knowledge and perceptions of the current CDC guidelines • No comprehensive list of TB providers in US • Survey was sent to 2011 National TB Conference attendees, National TB Nurse Controllers, and the CDC’s TB-educate mailing list Results and Limitations • 158/2522 (6.3%) responded – Self-selected group (? bias) – Limited generalizability of conclusions Results: Demographic characteristics of respondents • Occupation – 91 (59.5%) nurses – 30 (19.6%) physicians – 19 (12.4%) public health practitioners – 13 (8.5%) other • Geography – 39 states were represented • Experience – 104 (66%) reported >5 years in TB care Results: How important is HIV Testing? How important do you think it is to test for HIV in: 180 160 Unimportant 140 Of little importance Neither important nor unimportant Important 120 100 80 60 40 20 Very Important 0 Patients with active Patients with LTBI Patients with Patients suspected TB disease contact to a patient to have active TB with active TB disease disease Results: Current Practice In your clinic, are patients with the following diagnoses routinely tested for HIV? Yes, always 180 Yes, almost always Yes, sometimes 160 140 120 Yes, rarely 100 No, never 80 60 40 20 0 Active TB disease Latent TB infection Contact to a patient Patient suspected to with active TB disease have active TB disease 141 (92.2%) reported pts with TB disease were “always”/ “almost always” HIV tested 65 (42.5%) for LTBI patients 58 (36.7%) for all patients seen in TB clinic Results: Barriers Which of the following would be/are barriers to incorporation of routine, opt-out HIV testing for ALL TB patients in your clinic? Please select Yes/No for each answer. Burden of obtaining consent ✓✓ Patient refusal of test Patient discomfort with finger stick or… Disruptive of patient flow No lab space available Yes Not enough available space No Administrative burden Requires too much provider time Patient failure to return for results Staff unwilling ✓ Testing Staff not qualified No easily accessible HIV referral site ✓ Not Testing ✓ Prevalence too low to justify Too many false positives ✓ Cost 0 50 100 150 200 Results: Informed Consent for Testing • 59 (38.6%) respondents reported their state required written consent for HIV testing – 12 of those (7.8% of total respondents) are from states that actually required written consent at the time of survey distribution • One (0.7%) respondent from a state with laws requiring written consent stated it was not compulsory • 7 (4.6%) reported they did not know whether written consent was required Results: Perceived Feasibility Do you think routine, opt-out testing would be feasible and acceptable in your setting? Yes No 39.90% 16.50% 43.70% Already routinely test all patients for HIV Conclusions • Significant work must be done to promote the integration of opt-out HIV testing into routine care of all patients affected by TB—by either infection or disease • Fewer than half of respondents’ care settings have an optout HIV testing policy for LTBI patients, indicating a true missed opportunity • Although providers tend to report acceptance of the need for universal testing of TB affected patients, they cite a long list of barriers, some of which are no longer valid (i.e. HIV consent procedures by state) – This represents a teachable moment as well a potential funding partnership for TB care Contact Information • Caitlin Naureckas MD (2016) – [email protected] • Adrian Gardner MD, MPH – [email protected] • E. Jane Carter MD – [email protected]