Minnesota health care providers urge universal screening for HIV

In an effort to reduce AIDS deaths and prevent new infections, Minnesota's largest health care providers are rewriting the rules on who should get screened for HIV.

Instead of limiting testing to high-risk groups such as gay and bisexual men or intravenous drug users, the new rules call for everyone aged 18 through 64 to get tested at least once.

HealthPartners and the Mayo Clinic have already begun testing a broader group of patients, and other clinic groups are expected to join in coming months, after several influential blue-ribbon medical panels recommended new guidelines.

"We need a new strategy since it is extraordinarily difficult to identify who is high-risk," said Dr. John Wilkinson, a family practice doctor at the Mayo Clinic in Rochester. "There is a lot of HIV everywhere, relatively speaking, and it is going undetected."

Nationally, more than 1.2 million Americans are HIV-positive, including an estimated 168,000 who do not know that they are infected, according to the Centers for Disease Control and Prevention in Atlanta.

About 320 new infections are discovered in Minnesota every year, and about one-third, on average, are found in "late testers" — those who develop AIDS within one year of the HIV diagnosis.

Prevention experts hope that catching these cases earlier will forestall the progression to AIDS through highly-effective drug treatments and help stop the spread of new cases.

"We strongly support universal HIV testing and for everyone to know their status," said Matt Toburen, public policy director with the Minnesota AIDS Project. "This is good news that clinics in Minnesota are starting to get serious about making that happen."

Hennepin County Medical Center, which has clinics spread throughout the county, is one organization that will be implementing universal HIV screening.

"If you have an opportunity to diagnose someone with HIV earlier, treatment is wildly successful when people are engaged with their care," said Dr. Nicholas Vogenthaler, an infectious disease physician at HCMC in Minneapolis.

Vogenthaler said studies find that many people who are diagnosed with HIV often had several interactions with the health care system — but had not been tested.

"These were missed opportunities for HIV testing and missed opportunities for bringing these folks into the appropriate health care setting," he said.

Sensitive questions

The key to making the program work is the electronic health record, which will give a doctor a prompt during a health care visit with a patient who shows no history of taking the HIV test.

But doctors and nurses also need to prepare themselves for what can be a difficult conversation with patients about the HIV test.

"Even asking the question, we are all sensitive to the social and emotional context of the screening," said Dr. Beth Averbeck, associate medical director for primary care at HealthPartners clinics. "People may not expect it at a visit."

HealthPartners, with 28 clinics that see about 400,000 patients a year, reprogrammed its electronic health records in March.

At Mayo, which has implemented widespread screening at some of its locations, Wilkinson said the goal is to make conversations about HIV testing as routine as other preventive care

"We say this is something we normally do, we screen everybody," he said.

Wilkinson said each patient visit is unique and the HIV conversation might not happen at the first opportunity given other pressing needs of the visit.

But a study at the Metro Health System, a publicly funded academic teaching hospital in Cleveland, showed that HIV testing rates improved dramatically in two years.

Using prompts in the electronic health record, HIV testing rates for patients at the system's clinics increased from 25 percent in 2010 to 56 percent in 2012 for men, while the rate for women increased from 40.5 percent to 66 percent. Women typically have higher testing rates because most pregnant women routinely receive an HIV test.

Although the rate of positive HIV tests remained stable at 0.2 percent of those tested, the number of new cases increased because more people were tested, according to the study, published in the Journal Aids & Clinical Research in 2012.

Less secrecy

Under the Affordable Care Act, the HIV test is considered an essential preventive service, on par with mammograms, immunizations and colon cancer screening, which means that most health insurers must pay for it.

The U.S. Centers for Disease Control recommended universal HIV screening in 2006, but the goal received a boost in 2013 after the U.S. Preventive Services Task Force, a federal panel of prevention experts, urged the same.

Locally, the Institute for Clinical Systems Improvement, a collaboration among the state's health care providers and insurers, adopted the task force guideline as a best practice.

That could lead to more organizations adopting the practice. Allina Health, which has 56 primary care clinics, said it will review the guideline.

If HIV screening becomes mainstream, it will mark the biggest use of the test since it was first developed more than 30 years ago.

At that time, some mainstream providers advised their patients to get an HIV test anonymously at STD clinics like Hennepin County's well-known Red Door Clinic in Minneapolis. There was suspicion that putting an HIV test into a patient's medical record — whether the result was positive or negative — could cause difficulties obtaining health insurance in the future.

Since then, the Affordable Care Act prohibited insurance companies from denying coverage based on pre-existing conditions. Even so, 20 percent of new HIV cases reported to the Minnesota Department of Health over the past five years originated from HIV testing sites like Red Door.