Recommendations for HIV Testing Services for Inpatients and Outpatients in Acute-Care Hospital Settings

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Summary

These recommendations update previous recommendations regarding human immunodeficiency virus (HIV) counseling and testing of patients in acute-care hospital settings (1). The revision was prompted by additional information regarding both the rates at which patients admitted to some acute-care hospitals have unrecognized HIV infection and the potential medical and public health benefits of recognizing HIV infection in persons who have not developed acquired immunodeficiency syndrome.

BACKGROUND

Since previous CDC recommendations regarding human immunodeficiency virus (HIV) counseling and testing of patients in acute-care hospitals were published in 1987, studies have described HIV seroprevalence rates ranging from 0.3% to 6.0% among various patient populations (2-7). In anonymous unlinked serologic surveys conducted by CDC, 0.2%-8.9% of persons receiving care in emergency departments and 0.1%-7.8% of persons admitted to acute-care hospitals were HIV antibody positive (8-10). In two studies in which data were obtained regarding previous HIV testing or diagnosis, 63% and 65% of the HIV seropositive patients were unaware of their HIV infection before hospital admission (2,5).

In the period 1989-1990, CDC conducted anonymous unlinked serologic surveys to evaluate 13 hospital-specific variables as surrogate markers for hospital-specific HIV seroprevalence (11). The diagnosis rate for acquired immunodeficiency syndrome (AIDS) ({annual number of individual AIDS patients diagnosed and reported to the health department/annual number of discharges} x 1,000) was the only hospital-specific characteristic associated with hospital-specific seroprevalence.

Based on the 1989-1990 surveys, an estimated 225,000 HIV-infected patients were cared for in the 5,558 acute-care U.S. hospitals in 1990; 163,000 of these HIV-infected patients were estimated to have a primary diagnosis other than HIV/AIDS. Of these 163,000 patients, 125,000 (77%) were admitted to the 593 (11%) hospitals with an AIDS diagnosis rate of greater than or equal to 1.0 per 1,000 discharges; 110,000 (88%) of the 125,000 patients were ages 15-54 years (Table 1). Thus, HIV testing of patients in this age range at these hospitals would potentially identify 68% of infected persons hospitalized in the United States for conditions other than HIV/AIDS.

Knowledge of their HIV infection status allows infected persons and their infected partners to seek treatment with antiretroviral agents, prophylaxis against Pneumocystis carinii pneumonia, tuberculosis skin testing and tuberculosis prophylaxis (if appropriate), and other types of therapy and vaccines that may delay or prevent the opportunistic infections associated with HIV infection (12-15). Such measures have been shown to delay the onset of AIDS in infected persons and to prolong the lives of persons with AIDS (16,17). In addition, counseling and testing may help some persons change high-risk sexual and drug-use behaviors and thereby prevent HIV transmission to others (18-22).

HIV counseling and testing programs are not a substitute for universal precautions or other infection-control techniques (23). Limited information does not support the belief that knowledge of a patient's HIV status decreases the risk of infection for health-care workers through closer adherence to universal precautions (24,25). HIV testing also must not be relied upon as a means of infection control in the hospital because a) test results may not be available in emergency settings, b) HIV tests will not detect a newly infected person who has not yet seroconverted, and c) other bloodborne pathogens (e.g., hepatitis B) may be present.

RECOMMENDATIONS

Voluntary and confidential HIV counseling and testing of patients in acute-care hospitals are useful for a) assisting in differential diagnosis of medical conditions, b) initiating early medical management of HIV infection, and c) informing infected persons or persons at risk for infection about behaviors that can prevent HIV transmission.

To promote the appropriate use of HIV counseling and testing services, CDC recommends that acute-care facilities adopt the following guidelines *:

• Hospitals and associated clinics should encourage

health-care providers to routinely ask patients about their risks for HIV infection and offer HIV counseling and voluntary testing services to patients at risk (1). Patients should give informed consent for testing in accordance with local laws.

• Hospitals and associated clinics should develop policies

regarding provision of routine HIV counseling and voluntary testing services. Other health-care institutions such as drug treatment centers, mental health facilities, and private medical practitioners are also encouraged to consider offering these services. The decision to offer these services routinely may be based on the HIV seroprevalence in the patient population. This rate may be determined most directly by a representative sample of unlinked anonymous specimens. ** Alternatively, hospitals and other health-care providers may elect to use an indirect marker of HIV seroprevalence, such as the AIDS diagnosis rate (defined above).

• Hospitals with an HIV seroprevalence rate of at least 1%

or an AIDS diagnosis rate greater than or equal to 1.0 per 1,000 discharges should strongly consider adopting a policy of offering HIV counseling and testing routinely to patients ages 15-54 years.

• HIV counseling and testing procedures in the acute-care

setting should be structured to facilitate confidential, voluntary patient participation and should include a) pretest information on the testing policies of the institution or physician and b) basic information about the medical implications of the test, the patient's option to receive more information, and the documentation of informed consent.

• HIV counseling and testing should be offered in

nonemergency settings in which patients are able to make an informed and voluntary decision regarding HIV testing. HIV counseling and testing for purposes other than immediate medical care should be deferred until a later time for persons who are too severely ill to understand the pretest information or give informed consent.

• Test results should be provided to the patient in a

confidential manner and forwarded to state health departments in accordance with local law. Post-test counseling for infected patients and those at increased risk should be performed by trained health-care providers in accordance with existing CDC recommendations (1).

• Persons who decline HIV testing or who consent to testing

and are HIV antibody positive must not be denied needed medical care or provided suboptimal care. HIV-infected persons should receive medical evaluation for HIV infection and specific therapies and prevention services as needed. If therapeutic and prevention services are not available, the acute-care facility or provider should establish an effective referral system to ensure that these services will be provided.

• Facilities offering HIV testing and counseling should take

necessary steps to protect the confidentiality of test results. The ability of facilities to assure confidentiality of patients' test information and the public's confidence in that ability are crucial to efforts to increase the number of persons being counseled and tested for HIV infection. Moreover, to assure broad participation in counseling and testing programs, the public must be assured that persons found to be HIV positive will not be subject to discrimination (1).

• HIV testing programs must not be used as a substitute for

universal precautions and other infection-control techniques.

THE ROLE OF HEALTH DEPARTMENTS

State and local health departments are a source for at least three forms of assistance for implementing these recommendations. First, state and local health departments can provide data to assist hospitals to determine their AIDS diagnosis rate. Second, state and local health departments can provide technical assistance and training for hospital staff responsible for HIV-related counseling and testing services in acute-care settings. Third, health departments can help hospitals by providing partner notification services for HIV-infected patients, as well as additional prevention services for uninfected patients who are at high risk for HIV infection. Effective and ongoing collaboration between acute-care providers and health departments will improve both prevention and treatment services for persons infected with HIV or at risk for HIV infection.

References

1. CDC. Public health service guidelines for counseling and antibody testing to prevent HIV infection and AIDS. MMWR 1987;36:509-15.

2. Gordin FM, Gibert C, Hawley HP, Willoughby A. Prevalence of human immunodeficiency virus and hepatitis B virus in unselected hospital admissions: implications for mandatory testing and universal precautions. J Infect Dis 1990;161:14-7.

3. Risi GF, Gaumer RH, Weeks S, Leete JK, Sanders CV. Human immunodeficiency virus: risk of exposure among health care workers at a southern urban hospital. South Med J 1989;82:1079-82.

4. Lindsay MK, Peterson HB, Feng TI, Slade BA, Willis S, Klein L. Routine antepartum human immunodeficiency virus infection screening in an inner city population. Obstet Gynecol 1989;74:289-94.

5. Kelen GD, DiGiovanna T, Bisson L, et al. Human immunodeficiency virus infection in emergency department patients. JAMA 1989;262:516-22.

6. Soderstrom CA, Furth PA, Glasser D, Dunning RW, Groseclose SL, Cowley RA. HIV infection rates in a trauma center treating predominantly rural blunt trauma victims. J Trauma 1989;29:1526-30.

7. Lewandowski C, Ognjan A, Rivers E, Pohlod D, Belian B, Saravolatz LD. HIV-1 and HTLV-I seroprevalence in critically ill resuscitated emergency department patients (abstract Th.A.P. 9). V International Conference on AIDS, Montreal, Canada, 1989.

8. Marcus R, Bell D, Culver D, et al. Contact with blood of patients infected with HIV among emergency care providers (ECPS) (abstract). VI International Conference on AIDS, San Francisco, CA, June 17-22,1990;1:276.

9. St. Louis ME, Olivo N, Critchley S, et al. Methods of surveillance for HIV infection at U.S. sentinel hospitals. Public Health Rep 1990;105:140-6.

10. St. Louis ME, Rauch KJ, Petersen LR, et al. Seroprevalence rates of human immunodeficiency virus infection at sentinel hospitals in the United States. N Engl J Med 1990;323:213-8.

11. Janssen RS, St. Louis ME, Satten GA, et al. HIV infection among patients in U.S. acute-care hospitals: strategies for the counseling and testing of hospital patients. N Engl J Med 1992;327:445-52.

12. Hardy AM. AIDS knowledge and attitudes for January-March 1991:provisional data from the National Health Interview Survey. Adv Data; No. 216, August 21, 1992.

13. Volberding PA, Lagakos SW, Koch MA, et al. Zidovudine in asymptomatic human immunodeficiency virus infection. N Engl J Med 1990;322:941-9.

14. CDC. Guidelines for prophylaxis against Pneumocystis carinii pneumonia for persons infected with human immunodeficiency virus disease. MMWR 1989;38(suppl. S-5).

15. CDC. Screening for tuberculosis and tuberculous infection in high-risk populations and the use of preventive therapy for tuberculous infection in the United States. Recommendations of the Advisory Committee for Elimination of Tuberculosis. MMWR 1990;39(No. RR-8).

16. CDC. Pneumococcal polysaccharide vaccine. MMWR 1989;38:64-8,73-

18. Rosenberg PS, Gail MH, Schrager LK, et al. National AIDS incidence trends and the extent of zidovudine therapy in selected demographic and transmission groups. J Acquir Immune Defic Syndr 1991;4:392-401.

19. CDC. Estimates of HIV prevalence and projected AIDS cases: summary of a workshop, October 31-November 1, 1989. MMWR 1990;39:110-2, 117-9.

20. DesJarlais DC, Friedman SR. The psychology of preventing AIDS among intravenous drug users: a social learning conceptualization. Am Psychol 1988;43:865-70.

21. Godfried JP, Van Griensven MS, Ernest MM, et al. Impact of HIV antibody testing on changes in sexual behavior among homosexual men in the Netherlands. Am J Public Health 1988;78:1575-7.

22. McCusker J, Stoddard AM, Mayer KH, Zapka JG, Morrisson C, Saltzman MS. Effect of HIV antibody test knowledge on subsequent sex behaviors in a cohort of homosexually active men. Am J Public Health 1988;78:462-7.

23. Higgins DL, Galavotti C, O'Reilly KR, Schnell DJ, Moore M, Rugg DL, Johnson R. Evidence for the effects of HIV antibody counseling and testing on risk behaviors. JAMA 1991;266:2419-29.

24. CDC. Recommendations for the prevention of HIV transmission in health-care settings. MMWR 1987;36(suppl. 2S).

25. Tokars J, Bell D, Culver D, Marcus R, Mendelson M, Sloan E, et al. Percutaneous injuries during surgical procedures. JAMA 1992;267:2899-904.

26. Gerberding JL, Littell C, Tarkington A, Brown A, Schechter WP. Risk of exposure of surgical personnel to patients' blood during surgery at San Francisco General Hospital. N Engl J Med 1990;322:1788-93.

• These guidelines are based in part on comments received by CDC at a meeting of consultants in Atlanta, Georgia, April 5 6, 1990. The consultants represented the American College of Emergency Physicians, American College of Obstetrics and Gynecology, American College of Orthopedic Surgery, American Hospital Association, American Medical Association, American Physicians for Human Rights, Association of State and Territorial Health Officers, Association of State and Territorial Public Health Laboratory Directors, Council of State and Territorial Epidemiologists, National Association of County Health Officers, National Association of Public Hospitals, National Institutes of Health, National Medical Association, Occupational Safety and Health Administration, and other technical experts. These Public Health Service recommendations may not reflect the views of all individual consultants or the organizations they represented.

** To determine directly the rate of infection for a patient population, hospitals may consider conducting anonymous unlinked serologic surveys (i.e., testing of serum or plasma samples that were collected for other purposes and have had personal identifiers removed before testing). For guidelines regarding the conduct of blinded HIV serosurveys in hospitals, contact: Seroepidemiology Branch, Division of HIV/AIDS, Mailstop E-46, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, 30333.

SUGGESTED CITATION: Centers for Disease Control and Prevention. Recommendations for HIV testing services and outpatients in acute-care hospital settings; and Technical guidance on HIV counseling. MMWR 1993;42(No. RR- 2):{inclusive page numbers}.

CIO Responsible for this publication: National Center for Infectious Diseases

Division of HIV/AIDS

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