August 5, 2008
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I'm Dr. Urbina and I work at St. Vincent's Catholic Medical Center. We have a poster here on integrating HIV testing into inpatient hospital settings in New York State.1
We know that in New York State, in order to offer HIV testing, patients have to sign a separate written informed consent. Historically, testing has been done by designated testers and counselors so that doctors really haven't felt that it was in their purview to offer HIV testing. I was really surprised that at St. Vincent's, at the epicenter of HIV infection where we have a surrounding prevalence of 3% to 4%, that doctors in training were not offering their patients HIV testing.2
Antonio E. Urbina, M.D.
Yes. It's because -- and that's a bit strongly worded -- there may be an institutional bias in that -- [background speaker: It's not too strongly worded!] organizations that take care of disenfranchised persons really should have a systematic approach to offering them HIV testing or you're excluding them from life-saving treatment. Hospitals really should be including and making sure that, operationally, they offer HIV testing to their patients that walk through there. Otherwise, that segment of the population that is excluded because they don't have access to health care because they don't have private insurance are going to be systematically excluded from being offered HIV testing.
[background speaker: That's institutional racism!]
With that background, what we did is that we trained 99 medical house staffs to incorporate HIV testing into their routine admissions procedures at our 350-bed inpatient hospital in New York City.
House staff at the hospital, typically have a history and physical form , in order to write their notes. With a $10,000 grant, we got the New York City Department of Health, , to actually print for us the informed consent forms, part A and B, and to imbed them or collate them into our history and physical forms. So that when the house staff reached for them, everything was right there.
Additionally, we set it up operationally so that the process of offering HIV testing would run very smoothly for them. They can just order it in their lab orders, so a CBC [complete blood count], LFTs [liver function tests] and HIV test.
Then we did trainings with them. We did them at orientation. Then we did it for this 15-month period encouraging them to continue offering HIV testing to their patients. Also, we conducted some pre- and post-HIV testing implementation questionnaires to measure the house staff's attitudes and practice. Then we also looked at the number of HIV tests that were offered pre- and post- our implementation.
Our results are as follows: If you look at the number pre-implementation of our training, there were only 24 tests that were offered per month at St. Vincent's Hospital. We looked at the number of unique admissions, those that were non-HIV positive already, and then those that were offered HIV testing. Out of the 350 unique admissions, there were only 24 tests that were offered a month. Really, only 3% of those that could have been offered HIV testing were offered HIV testing. Despite that, we actually found a prevalence rate of 14%, so that's huge.
After our implementation we found that our tests that were offered jumped from 3% to 6%. Big deal -- that's a 100% increase -- but the test offers only went from 24 to 44 tests a month. Even though we increased the rates, really our absolute numbers didn't really increase, so there was some resistance to this training.
We kind of looked at our focus groups to look at why. These were some of the things that came out. If you looked at the providers, why did they not offer HIV testing? Sometimes a lot of them felt that the patient was not at risk because of their age or because of their relationship status, so they did their own risk profiling. They also felt that the patient would be discharged before their result could be returned.
Initially, the assay that was used was this Bayer automated assay, and it took a day to get their results. If the house staff thought that the patient would be discharged before the day, [they thought:]"Eh, I'm not going to do it."
Since then, it has changed. Now the lab does a Uni-Gold, so it's a rapid assay. The results are available that day.
They also didn't want patients to react negatively towards them. So, for example, if I offer you HIV testing, they're going to think that I'm offering it because I feel that they're at risk or they're in that demographic group. Again, they would do their own kind of risk assessments or they would kind of have this emotional baggage. They thought, "If I offer testing to you, you're going to get offended."
Really, the testing process required too much time. House staff are busy at hospitals, so anything else, that's the straw in the camel's back. They have a lot of competing interests. If a patient comes in and they're very difficult to manage or they have a heart attack and stuff like that, offering HIV testing is going to get dropped.
If you looked at some of the organizational barriers, really what we found is that having to have a separate written informed consent, as New York State law requires, [is a] big barrier. If it was just opt-out testing where it was rolled into just the general medical consent -- because a lot of the time these forms dropped out of the history of the physical. They couldn't find them or they got lost or the lab didn't receive them so they wouldn't run the test. Just having a secondary step that had to occur really discouraged, I think, a lot of our house staff from offering HIV testing.
There were some other issues as well. Some of the patient barriers were that having to give these pre-test counseling points caused patients a lot of anxieties. What we found was that certain ethnic groups refused testing more than others. For example, Muslims tended to refuse HIV testing more and persons of Chinese backgrounds also tended to refuse testing more, interestingly.
Again, some patients also felt profiled that they were asked to be tested, and offended. Then patients would report that they didn't have any risk factors. Then some patients that had high risk for HIV infection often declined testing.
What's our next step? I think we're very glad that we did this study because we increased awareness in our institution. We were able to make HIV testing operational within our institution. I think even if the New York State laws don't change, which they might, so we may go from opt-in to opt-out, you need buy-in from the institutions. I think our next step is to really talk to our chair of medicine, Dr. Dennis Greenbaum, and to speak with our attending [physicians] who are on the floors, because imagine that one of our house staff offers HIV testing and then he goes to his attending rounds and an attending says, "Why'd you do that?" That's just going to really break it all down.
Again, buy-in from the institution so that it really becomes really routinized. But I think most importantly that it becomes part of a physician's culture that he do this and that it's part of his responsibility as a physician so that when he finishes his training, he's going to offer HIV testing wherever he may land.
It's surprising to me -- I don't work for a hospital or anything -- to hear how difficult it is to implement the CDC recommendations.
And you work for the hospital. It's not like you're an outsider coming in.
Yet there's still -- it seems it's a very stigmatized disease still among the health care practitioners who don't take care of HIV patients.
Right, yes. Even with having a lot of easy access, it was still very difficult to operationalize it and to really get buy-in from our house staff. Not to say that they're not well-intentioned and ethical. It's just that I think for so long HIV testing has not been part of their education and training and it really should be. Because, really, doctors should be given back that authority to take care of their patients effectively. Part of that is offering HIV testing.
I think there will be a shift in terms of medical education, but I really think that we have to push forward with it.
It's also surprising to me because, from a historical point of view in terms of St. Vincent's, I remember St. Vincent's back in the early 1990s. It was really the epicenter of the HIV epidemic in New York City. There were AIDS floors. It was just packed with people living with HIV, dying of HIV, and I would have thought that most of the personnel working there were sensitized to the situation in some way and that even the administration would be very HIV conscious and everyone who got a job there would have HIV training.
Right. Well, you know something, I don't think it's very uncommon that most hospitals don't have a system for offering their hospitalized patients HIV testing. I think that they just didn't feel that it should or could be done there, that it may be more of an outpatient issue. I think they just have to shift their focus to realize that in our current health care system, that not a lot of people have access to a primary care physician and it's those populations that are most vulnerable, so that we really do have to pick it up.
I think for St. Vincent's, they were so involved with treatment and with advocacy and those issues that I think this is something that just kind of was below the radar. But again, I think we do have buy-in, we just really have to amp it up a little bit and really make it part of the culture of the institution.
You say that 44 HIV tests a month is low. Is there a number that you had in mind?
Yes, of course, 100%! I would really like to see it as close to 100% of those that have not been offered HIV testing or do not know their status, have not been tested recently, that everyone be offered HIV testing.
Another matter is people who refuse testing. I think that's another very interesting kind of phenomenon. We didn't really look at it in this poster, but I think that would be an interesting next step too, to look at patients who refused testing and find out why. I especially find it very interesting, that those who are at high risk often refuse testing. I think that whole psychological issue of fear and denial really plays huge in patients, but I think that's where we really have to intervene. I think we can crack that nut and get those people to consent to test.
Do you think that we're close to a time in the future when an HIV test could be like a red blood cell count test? It's just to see if you have an illness. It doesn't say anything about what you did or your life, it's just "Do you have this illness?" Like what we do with pregnant women and what is done with every single baby born in New York State. It's a law. Every single baby is tested for HIV and no one is asked. Most people don't even know that their baby is tested.
That's why I feel there's a huge disconnect in New York, because you're absolutely right. In terms of pregnancy and that baby bill that was passed by Nettie Mayerson. You know, strong advocacy and acceptance of that testing, yet in terms of the basic routine offering of HIV testing, there seems to be some type of resistance to that. I'm not really clear where that comes from, but I'm hopeful that that will change as well.
Your work is probably one of the things that could help change it. Are many hospitals in New York doing the same kind of intervention-- each hospital, I guess, has to strenuously do the same exact thing, right?
Yes, they do, because every institution is a little different, so you find that you really do have to individualize it to your institution -- such as what type of HIV test your institution uses is going to factor into your algorithm and how you set this up.
But it can be done. Again, I think buy-in from the top is always helpful, from the chair, and then from the attendings and stuff like that. But I think it can be done if there's a will. The thing is is that with opt-in it's much more expensive than, I think, if it was opt-out. With opt-out, you would just have to set it up once. You just have to roll in HIV testing into the general medical consent, which patients have to sign anyway. Then you basically just have to educate your house staff. But if that HIV test would just be rolled in and not given only if patients verbally said, "No, I don't want it." I think it would make it much, much easier, because it would take the onus off of the provider and put it on the patient, which I don't think is so bad.
One last thing. Were you surprised to see how providers reacted? Had you imagined that there was still so much stigma about HIV, and that physicians would worry about embarrassing patients?
You know something, I was not surprised. I think that house staff, especially new house staff, are a little impressionable. I think, like with a lot of us, they don't want to offend or to have a mishap. But, again, I think that has to change. We really have to make it that HIV testing is really life-saving and life-changing, and that you really -- in the best interest of the patient -- [need] to offer it and, it's okay to be a little aggressive and to make it a little harder for the patient to say no.
Again, I think it's just part of education and really educating our house staff. It is really an important test and that patients really should be encouraged to say yes.
Also, that surprising people could be HIV positive.
Exactly. Look at Hilda Spitzer, right? We'll call that the Hilda Spitzer effect.
[background speaker: Silda!]
Silda! [the wife of former New York Governor Eliot Spitzer, who resigned amidst a scandal surrounding his use of sex workers -- with whom he allegedly did not like to use a condom]
Silda Spitzer, right! But who would have thought she would have been at risk for HIV? Not to say that she is or isn't, but who would have thought about offering her an HIV test? There are others like her.
A great way to end. Thank you very much.
No comments have been made.
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