3. Promoting HIV Testing in Diverse Populations
Provider-Related Barriers
Korthuis and colleagues performed an Internet-based survey of 446 general
internists regarding their HIV screening behaviors, beliefs, and perceived barriers to routine HIV screening in outpatient primary care practices. [Korthuis 2011] Participants reported a high awareness of the revised CDC guidelines (88%), but the investigators reported that:
- Only 52% had increased HIV testing
- 61% offered HIV screening regardless of risk
- A median 2% (range 0 to 67%) of their patients were tested in the past month.
Internists practicing in perceived higher-risk communities reported greater HIV screening. One important finding was that the participants described consent requirements as a barrier to screening, particularly for VA providers and those practicing in states with HIV consent statutes inconsistent with CDC guidelines. The investigators reported these additional perceived barriers to adopting routine HIV testing (in descending order):
- Other priorities at time of visit
- Lack of time
- Patient reluctance/refusal
- Informed consent requirements
- Pretest counseling requirements
- Rapid HIV testing not available in clinic
- Testing low-risk established patients
- Language barrier
- Lack of high-risk behaviors
- Patient discomfort about discussing HIV testing
- Lack of reimbursement
Other provider-related concerns involve provider-patient relations. Bowles and colleagues reported the findings of a study that sought to determine the reasons some people had for declining to undergo rapid HIV testing during encounters at community-based organizations in 7 US cities, many of whose clients were members of populations at high risk for HIV infection. [Bowles 2008] The investigators cited several characteristics of the facilities’ clients that shed light on the barriers to increasing routine HIV testing that occur in practitioner-patients encounters:
- Patients’ lack of unawareness of their communities’ viral load
- Patients beliefs that they were at risk for HIV transmission due to their beliefs concerning sexual orientation—eg, the patient is not gay, is in a monogamous relationship, believes that he or she is too old or too young, is not an IDU)
- Married/partnered women who believe that their husbands or partners are also monogamous and therefore do not consider themselves at risk
- Patients’ fears of learning their HIV status at that particular time
- Reporting that they had recently taken an HIV test
- Worries about the confidentiality of name-based reporting
- Clients’ concerns that merely discussing HIV may put them at risk (similar to reluctance in earlier years to talk about cancer)
These attitudes among patients known to belong to population groups at risk for HIV infection illustrate the vital need for practitioners not only to understand the concerns of the members of the communities that they serve but also to develop the skills and organization-wide tools to address those concerns sensitively and effectively.
