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HIV antibody testing has been available since 1985. An estimated
one-fourth of the approximately 1 million persons in this
country who are living with HIV do not know they are infected
(CDC, 2006). That's approximately 250,000 persons who could
be spreading HIV to their partners unknowingly. This unwitting
spread of HIV infection is part of the reason why the Center
for Disease Control and Prevention (CDC) issued new guidelines
in September, 2006 regarding HIV testing. The Revised Recommendations
for HIV Testing of Adults, Adolescents, and Pregnant Women
in Healthcare Settings (CDC, 2006) aim to make HIV testing
a routine part of medical care in addition to expanding the
gains made in diagnosing HIV infection among pregnant women.
The goal is to make HIV testing may be a routine part of healthcare
with yearly testing integrated into physicals similar to other
tests used for screening such as cholesterol, Prosthetic Specific
Antigen (PSA), and stools for occult blood. As HIV screening
becomes a more routine aspect of medical care, more people
will know they are infected with HIV and hopefully will utilize
prevention measures.
Key differences in the revised Recommendations for
patients in all healthcare settings are (CDC, 2006e; Branson,
et al., 2006):
- HIV testing for patients, aged 13-64, in all healthcare
settings after the patient is notified that testing will
be performed unless the patient declines (opt-out screening).
- All patients initiating treatment for TB should be screened
routinely for HIV infection.
- All patients seeking treatment for STDs, including all
patients attending STD clinics, should be screened routinely
for HIV during each visit for a new complaint, regardless
of whether the patient is known or suspected to have specific
behavior risks for HIV infection.
- HIV testing of people at high risk for HIV infection at
least once a year.
- Screening should be incorporated into the general consent
for medical care; separate written consent is not recommended.
- Prevention counseling should not be required with HIV
diagnostic testing or as part of HIV screening programs
in healthcare settings.
Additional key differences in the Recommendations
for pregnant women in healthcare settings are (CDC, 2006):
- Including HIV screening in the routine panel of prenatal
screening tests for all pregnant women, unless the patient
declines (opt-out screening).
- Repeat screening in the third trimester in certain jurisdictions
with elevated rates of HIV infection among pregnant women.
The Recommendations emphasize the importance of voluntary
testing. Some may have concerns that eliminating the recommendation
for separate informed consent for an HIV test could result
in some patients being tested for HIV without their knowledge.
Others have asserted that requiring separate, written informed
consent is a barrier that makes HIV screening difficult to
conduct in healthcare settings, and that removing this requirement
would make widespread HIV screening feasible (CDC, 2006).
Concerns have also been expressed over the lack of HIV prevention
counseling in conjunction with HIV testing. The new recommendation
from the CDC continue to support prevention counseling as
an intervention to help people reduce their risks for HIV,
but recognize it can become a barrier to HIV testing in busy
healthcare settings. CDC still recommends that patients receive
information about HIV testing, HIV infection, and the meaning
of test results (CDC, 2006).
The Recommendations are intended for healthcare providers
in both the public and private sectors. These include healthcare
workers in hospital emergency departments, inpatient services
(including labor and delivery), correctional health care facilities,
clinics including substance abuse treatment, public health,
community, pediatric and adolescent, prenatal, and mental
health, and other primary care settings (CDC, 2006).
These Recommendations address HIV testing in healthcare
settings only. They do not change existing CDC recommendations
on HIV counseling, testing, and referral for persons at high
risk for HIV who receive testing in nonclinical settings such
as at community-based organizations (CDC, 2006).
More detailed information about the revised Recommendations
can be obtained at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm.
Informed Consent for HIV Testing
in the Commonwealth of Kentucky
Testing for HIV infection can be a valuable tool in protecting
the public health. However misunderstanding of the nature
of the test or fear of test results or denial of one's own
risk, keeps people from being tested.
In the Commonwealth of Kentucky, per KRS.214.625, a person
who has signed a general consent form for the performance
of medical procedures and tests is not required to also sign
a specific consent form relating to medical procedures or
tests to determine HIV infection or antibodies. The general
consent form must instruct the patient that, as part of the
medical procedures or tests, the patient may be tested for
HIV, hepatitis, or any other blood-borne infectious disease.
The physician who orders the test or the attending physician,
is responsible for informing the patient of the results of
the test if the test results are positive for human immunodeficiency
virus infection. If the tests are positive, the physician
shall also be responsible for either:
(a) Providing information and counseling to the patient
concerning his infection or diagnosis and the known medical
implications of such status or condition; or
(b) Referring the patient to another appropriate professional
or healthcare facility for the information and counseling.
In any emergency situation where informed consent of the
patient cannot reasonably be obtained before providing healthcare
services, there is no requirement that a healthcare provider
obtain a previous informed consent.
No person in Kentucky can perform a test designed to identify
HIV or its antigen or antibody, without first obtaining the
informed consent of the person upon whom the test is being
performed.
Kentucky law requires that each public health department
provides a program of counseling and testing for HIV on either
an anonymous or confidential basis.
The Cabinet for Health and Family Services established a
network of voluntary HIV testing programs in public health
departments in every county in the state. Each public health
department has the ability to provide counseling and testing
for HIV to each patient who receives services and to offer
the testing on a voluntary basis to each patient who requests
the test.
A confidential HIV test means the patient gives their
real name, and the results of a test are known only to themselves
and the healthcare provider or counselor who provides test
results, medical care or prevention services to that person.
In the event of a positive HIV test, those who have confidential
testing must be reported by name and other specific information
by law.
An anonymous HIV antibody test means that the person
who orders or performs the test does not maintain a record
of the name of the person they are testing. Only the statistical
information relating to a positive test for HIV is reported
to the cabinet.
See Appendix A for a listing of HIV services in the state
of Kentucky, including locations for HIV testing.
HIV Counseling with HIV Testing
HIV test counseling should be offered to all clients who
are at risk for HIV or who request counseling. At the same
time, the law states that persons who refuse counseling should
not be denied an HIV test (clients can refuse counseling);
and that the person conducting the HIV test does not have
to provide the counseling themselves. They can refer the client
to another person or agency for counseling.
Pre-test Counseling
HIV pre-test counseling should be based on the CDC's Revised
Guidelines for HIV Counseling, Testing and Referral Recommendations
(accessed at http://cdc.gov/hiv/topics/testing/guideline.htm);
and should:
- Assist the individual to set realistic behavior-change
goals and establish strategies for reducing their risk of
acquiring or transmitting HIV;
- Provide appropriate risk reduction skill-building opportunities
to support their behavior change goals; and
- Provide or refer for other appropriate prevention, support
or medical services.
Post-test Counseling
Everyone who tests negative should be offered an individual
counseling session at the time they receive their test results.
This counseling can be provided by the person providing the
results or can be a referral for the client to receive these
services at another agency. This post-test counseling should
accomplish the same goals as pre-test counseling: assist the
client to set behavior change goals, establish strategies
to achieve these goals, provide skills-building to support
achieving these goals, and provide appropriate referrals.
For those clients who test positive, counseling can't just
be offered. It must be provided or referred and in addition
to what is provided to those with negative results, must also
include:
- If confidentially tested, the information that HIV is
a reportable condition;
- Either the provision of partner notification support
or referral to public health for these services;
- Appropriate referrals for alcohol and drug and mental
health counseling, medical evaluation, TB screening, and
HIV prevention and other support services.
Confidentiality of HIV Testing
According to KRS 214.625, anyone who has knowledge of a test
result, or the identity of the person upon whom the test was
performed is prohibited from disclosing this information except
to the following:
- The subject of the test or the subject's legally authorized
representative;
- Any person designated in a legally effective release of
the test results executed prior to or after the test by
the subject of the test or the subject's legally authorized
representative;
- A physician, nurse, or other healthcare personnel who
has a legitimate need to know the test result in order to
provide for his protection and to provide for the patient's
health and welfare;
- Healthcare providers consulting between themselves or
with healthcare facilities to determine diagnosis and treatment;
- The Cabinet, in accordance with rules for reporting and
controlling the spread of disease, as otherwise provided
by state law;
- A health facility or healthcare provider which procures,
processes, distributes, or uses: a) human body part from
a deceased person, with respect to medical information regarding
that person; or b) Semen provided prior to July 13, 1990,
for the purpose of artificial insemination;
- Health facility staff committees, for the purposes of
conducting program monitoring, program evaluation, or service
reviews;
- . Authorized medical or epidemiological researchers who
shall not further disclose any identifying characteristics
or information;
- A parent, foster parent, or legal guardian of a minor;
a crime victim; or a person specified in KRS 438.250;
- A person allowed access by a court order.
Disclosure must be accompanied by a statement in writing
which includes the following or substantially similar language:
"This information has been disclosed to you from records whose
confidentiality is protected by state law. State law prohibits
you from making any further disclosure of such information
without the specific written consent". People who perform
HIV counseling and testing in public health departments or
health districts must sign strict confidentiality agreements.
These agreements regulate the personal information that may
be revealed in counseling and testing sessions, and test results.
HIV test results are kept in locked files, with only a few
appropriate staff members having access to them.
All medical records are confidential and must be maintained
in a manner that protects that confidentiality. Confidentiality
of medical information means that information that can be
related to the specific patient may not be disclosed to ANYONE
except under specific circumstances as above.
Reporting of Positive HIV Test Results
Reporting of HIV and AIDS cases assists local and state officials
in tracking the epidemic. It also allows for effective planning
and intervention to be provided in the effort to reduce the
transmission of HIV to other people. According to 902 KAR
2:020 which addresses disease surveillance, in Kentucky, physicians
and medical laboratories must report positive test results
for HIV infection from:
- ELISA;
- Western Blot;
- PCR;
- HIV antigen;
- HIV culture;
- CD4+ assay including absolute CD4+ cell counts and CD4+%;
- HIV detectable Viral load assay; and
- A positive serologic test result for HIV infection.
Physicians and medical laboratories must also report a diagnosis
of AIDS that meets the definitions of AIDS established by
the CDC, revised in 2008, discussed previously.
How, When and Where to Report
Reports of an HIV infection or an AIDS diagnosis must be
reported within five business days, whenever possible
utilizing the Adult HIV/AIDS Confidential Case Report
form or the Pediatric HIV/AIDS Confidential Case Report
form.
Reports of an HIV infection or AIDS diagnosis must be submitted
to the HIVAIDS Surveillance Program of the Louisville-Metro
Health Department for any resident of the following counties:
- Jefferson,
- Henry,
- Oldham,
- Bullitt, Shelby,
- Spencer, and
- Trimble.
Report for residents of the remaining Kentucky counties must
be submitted to the HIV/AIDS Surveillance Program of the Kentucky
Department for Public Health, or as directed by the HIV/AIDS
project coordinator.
Reports for persons with HIV infection, but not a diagnosis
of AIDS, must include the following information:
- The patient's full name;
- Date of birth, using the format MMDDYY;
- Gender;
- Race;
- Risk factor, as identified by CDC;
- County of residence;
- Name of facility submitting report;
- Date and type of HIV test performed;
- Results of CD4+ cell counts and CD4+%;
- Results of viral load testing;
- PCR, HIV culture, HIV antigen, if performed;
- Results of TB testing, if available; and
- HIV status of the person's partner, spouse or children.
Reports of AIDS cases shall include the information above
as well as:
- The patient's complete address;
- Opportunistic infections diagnosed; and
- Date of onset of illness.
Reports of AIDS must be made whether or not the patient has
been previously reported as having HIV infection. If the patient
has not been previously reported as having HIV infection,
the AIDS report also serve as the report of HIV infection.
Spousal Notification/Partner Notification
Federal Public Law 104-146 (1996) requires that states take
action to require that a "good faith effort" be made to notify
all spouses of HIV-infected persons. A "spouse" is defined
as anyone who is or has been the marriage partner of
an HIV-infected individual within 10 years prior to the HIV
diagnosis.
Notification means that spousal information will be
discussed with individuals prior to their HIV test. If the
test result is positive, the individual will be given the
choice to notify his/her spouse(s), to allow the health care
provider to notify the spouse(s) or refer to the local health
jurisdiction for assistance in notifying the spouse(s). More
information on spousal notification can be found in the Testing
and Counseling Section, covered earlier in this course. Partner
notification is a voluntary, confidential service provided
to HIV-positive people and their sex and/or injection equipment-sharing
partners.
Partner notification is provided using a variety of
strategies to make sure exposed partners, including spouses,
are notified of their exposure to HIV and receive appropriate
counseling in a way that respects the confidentiality of the
source patient.
People who have newly tested HIV-positive should also receive
help notifying partners, including spouses. Providers must
confirm those partners have been notified and/or seek agreement
to refer the name of the individual to the local health officer
for assistance in notifying partners.
Partner notification is a critical tool to inform partners
of their exposure so that they can test for HIV. If uninfected,
they can take steps to ensure that they do not become infected.
If infected, they can take steps to take care of their health
and ensure that they do not pass the virus on to others.
Disability and Discrimination
People with AIDS and HIV are also protected by federal law
under the Americans with Disability Act (1990) and Section
504 of the Federal Rehabilitation Act of 1973, as amended.
Persons with HIV infection and/or AIDS who feel discriminated
against on the basis of their disease may file a complaint
with the Office for Civil Rights (OCR) of the U.S. Department
of Health and Human Services. OCR will investigate anonymous
reports. HIV infection and AIDS are medical conditions that
are considered disabilities under the federal Americans with
Disability Act (ADA).
The law means that it is illegal to discriminate against
someone who has AIDS or is HIV infected. It is also illegal
to discriminate against someone who is 'believed' to have
AIDS or HIV infection, even though that person is not, in
fact, infected. The areas covered in the law are:
- Employment;
- Rental, purchase or sale of apartment, house or real estate;
- Places of public accommodation (restaurants, theaters,
etc.);
- Healthcare, legal services, home repairs, and other personal
services available to the general public;
- Applying for a loan or credit card, or other credit transactions;
- Certain insurance transactions.
Employers may not discriminate against persons with HIV infections
or AIDS in:
- Employment
- Recruitment
- Hiring
- Transfers
- Layoffs
- Terminations
- Rate of pay
- Job assignments
- Leaves of absence, sick leave, any other leave or fringe
benefits available by virtue of employment
Employers are required to provide and maintain a working
environment free of discrimination. They must assure that
no harassment, intimidation or personnel distinction is made
in terms and conditions of employment. If a worksite situation
develops that poses the threat of discrimination, employees
must be given education and supervision to end harassment,
the use of slurs and/or intimidation.
Employers are responsible for providing reasonable worksite
accommodations which will enable a qualified, disabled employee
or job applicant to perform the essential tasks of a particular
job. Reasonable accommodation means relatively inexpensive
and minimal modifications, such as:
- Providing special equipment
- Altering the work environment
- Allowing flex-time
- Providing frequent rest breaks
- Allowing the person to work at home (telecommute)
- Restructuring the job
When a person goes for a job interview or is hired, the employer:
- Cannot ask questions directed at the perception or presence
of HIV infection or AIDS, unless based on a "bona fide"
occupational qualification, which at this time, according
to CDC does not exist.
- Cannot require a blood test to determine HIV infection,
unless HIV status limits the ability to perform the work,
i.e. overseas assignment in country that requires HIV certification.
- Cannot require a physical exam directed to identify HIV
infection, except for exams necessary to evaluate the need
for, or nature of, reasonable accommodation or specific
job-related conditions.
- Cannot ask questions about lifestyle, living arrangements,
or sexual orientation.
Exceptions to this are applicants for the U.S. Military,
the Peace Corps, the Job Corps, and persons applying for U.S.
citizenship.
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