HIV SCREENING AND ACCESS TO CARE
Exploring Barriers and Facilitators to Expanded HIV Testing
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, DC.
www.nap.edu
THE NATIONAL ACADEMIES PRESS
500 Fifth Street, N.W.
Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by Contract No. HHSP23320042509XI between the National Academy of Sciences and the White House Office of National AIDS Policy. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
International Standard Book Number-13: 978-0-309-15661-5
International Standard Book Number-10: 0-309-15661-0
Additional copies of this report are available from the
National Academies Press,
500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.
Copyright 2010 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2010. HIV screening and access to care: Exploring barriers and facilitators to expanded HIV testing. Washington, DC: The National Academies Press.
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.
COMMITTEE ON HIV SCREENING AND ACCESS TO CARE
PAUL D. CLEARY (Chair), Dean,
Yale School of Public Health, New Haven
RONALD BAYER, Professor,
Department of Sociomedical Sciences, Joseph L. Mailman School of Public Health, Columbia University, New York
ERIC G. BING, Endowed Professor of Global Health and HIV,
Charles R. Drew University of Medicine and Science, Los Angeles
SCOTT BURRIS, Professor,
School of Law, Temple University, Philadelphia
J. KEVIN CARMICHAEL, Chief of Service,
Special Immunology Associates, El Rio Community Health Center, Tucson
SUSAN CU-UVIN, Professor of Obstetrics and Gynecology and Medicine,
Brown University, Providence
JENNIFER KATES, Director,
Global Health Policy and HIV, The Henry J. Kaiser Family Foundation, Washington, DC
ARLEEN A. LEIBOWITZ, Professor,
School of Public Affairs, University of California, Los Angeles
ALVARO MUÑOZ, Professor,
Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore
LIISA M. RANDALL, Manager,
HIV Prevention Programs, Michigan Department of Community Health, Lansing
BETH SCALCO, Chief of Staff,
Louisiana Office of Public Health, New Orleans
VICTOR J. SCHOENBACH, Associate Professor,
Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
MARTIN F. SHAPIRO, Professor,
Departments of Medicine and Health Services, University of California, Los Angeles
LIZA SOLOMON, Principal Associate,
Domestic Health Division, Abt Associates, Bethesda
ANTONIA M. VILLARRUEL, Associate Dean for Research,
School of Nursing, University of Michigan, Ann Arbor
Project Staff
MORGAN A. FORD, Study Director
RITA DENG, Associate Program Officer (April 2010–August 2010)
NORA HENNESSY, Associate Program Officer (October 2009–April 2010)
KAREN ANDERSON, Senior Program Officer
CHINA DICKERSON, Senior Program Assistant
MARIA HEWITT, Rapporteur
ROSE MARIE MARTINEZ, Director,
Board on Population Health and Public Health Practice
MARK GOODIN, Editor
Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
Adaora Adimora, School of Medicine, University of North Carolina, Chapel Hill
George Ayala, Global Forum on MSM and HIV
Thomas J. Coates, School of Medicine, University of California, Los Angeles
James G. Hodge, Jr., Sandra Day O’Connor College of Law, Arizona State University
William L. Holzemer, College of Nursing, Rutgers, The State University of New Jersey
Bruce Jennings, Center for Humans and Nature
Roger J. Lewis, School of Medicine, University of California, Los Angeles
David J. Malebranche, School of Medicine, Emory University
Celia J. Maxwell, Howard University Hospital
Randall Mayer, Iowa Department of Public Health
Stephen Raffanti, Vanderbilt University Medical Center
Ann Robbins, Texas Department of State Health Services
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Kristine M. Gebbie, School of Nursing, Hunter College of the City University of New York. Appointed by the National Research Council, she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
Tables, Figures, and Boxes
TABLES
1 |
Estimated Number and Percent of Undiagnosed HIV Cases, by Race/Ethnicity and Transmission Category, |
|||
2 |
Select State HIV Testing Laws, |
FIGURES
1 |
Percentage of people who reported being tested for HIV in past 12 months, by year, |
|||
2 |
Number of states implementing components of the CDC’s 2006 revised HIV testing recommendations, |
|||
3 |
Municipal HIV/AIDS test scale up campaigns, |
|||
4 |
ACTS pocket guide, |
|||
5 |
Implementation of opt-out testing in health care settings by 65 state, territorial, and local health departments after the Expanded Testing Initiative (as of February 2008), |
BOXES
Abbreviations and Acronyms
ADA Americans with Disabilities Act
ADAP AIDS Drug Assistance Program
AIDS acquired immune deficiency syndrome
ART antiretroviral therapy
CBO community-based organization
CDC Centers for Disease Control and Prevention
CHC community health clinics
CLIA Clinical Laboratory Improvement Amendments
CMS Centers for Medicare & Medicaid Services
ED emergency department
EOB explanation of benefits
ETI Expanded Testing Initiative
H1N1 Subtype of Influenza A in the 2009 pandemic
HAART highly active antiretroviral therapy
HEDIS Healthcare Effectiveness Data and Information Set
HIPAA Health Insurance Portability and Accountability Act
HIV human immunodeficiency virus
HMO Health Maintenance Organization
IDU injection drug user
IHS Indian Health Service
IOM Institute of Medicine
KFF Kaiser Family Foundation
MSM men who have sex with men
NASTAD National Alliance of State and Territorial AIDS Directors
NHAS National HIV/AIDS Strategy
ONAP White House Office of National AIDS Policy
PJP Pneumocystis jirovecii pneumonia
RNA ribonucleic acid
STD sexually transmitted disease
TB tuberculosis
USPSTF U.S. Preventive Services Task Force
Abstract
The HIV epidemic remains a major disease burden in the United States, with approximately 56,300 new infections occurring each year (CDC, 2008a). Knowledge of HIV status and receipt of timely care can help to prevent HIV transmission and improve clinical outcomes. Yet, of the 1.1 million people in the United States living with HIV/AIDS, approximately 21 percent are unaware that they are infected with the disease (Campsmith et al., 2010). The White House Office of National AIDS Policy (ONAP) has developed a National HIV/AIDS Strategy (NHAS) to reduce new HIV infections, increase access to care and improve health outcomes for individuals living with HIV, and reduce HIV-related health disparities in the United States (ONAP, 2010b). To help inform the implementation of the NHAS, an Institute of Medicine committee hosted a public workshop and gathered data to assess the extent to which federal and state laws and policies and private health insurance policies pose a barrier to expanded HIV testing. The committee identified barriers to HIV testing that included state legal requirements for HIV testing; discordant federal HIV testing recommendations; public and private health insurance policies; policies inhibiting use of rapid HIV tests; and policies and practices in corrections settings. In addition, the committee identified the need for more programs and policies to promote clinician education and training and reduce constraints on practice environments, as well as reduce HIV stigma and discrimination, as barriers to expanded HIV testing. The committee identified several strategies to increase HIV testing and identification of HIV-infected individuals as well.