Who Is Most Likely to Opt Out of HIV and HCV Testing?

Credit: Unsplash / National Cancer Institute

About one-third of individuals eligible for HIV and hepatitis C virus (HCV) testing at a outpatient clinic in South Carolina declined such tests, according to findings from a new study that highlights key demographics of those who are less inclined to learn their HIV or HCV status.

The retrospective study of medical record data showed that non-Hispanic Black patients were the least likely to decline testing among all race and ethnicity groups, while sex disparities persisted among individuals based on race.

“To our knowledge, this is the first US-based study to describe the demographic and clinical characteristics of individuals who decline ‘opt-out’ HIV/HCV testing in an outpatient internal medicine clinic setting,” investigators wrote.

The US Centers for Disease Control and Prevention (CDC) recommends universal hepatitis C screening for all adults at least 18 years of age and all pregnant people during each pregnancy, additionally recommending HIV testing at least once as part of routine health care for people between the ages of 13 and 64.

Clinicians believe a focused effort to implement “opt-out" HIV/HCV testing—in which individuals are tested unless they decline—could facilitate increased testing, earlier diagnoses, and improved health outcomes.

Investigators sought to describe the demographic and clinical characteristics of people who declined “opt-out” HIV or HCV testing at a single internal medicine outpatient clinic, more specifically looking at the interaction between race and sex based on the high burden of HIV and HCV infections among Black males. To do so, they conducted a retrospective, medical record review of adult patients evaluated from May 1 to July 31, 2019, excluding those who did not meet age-based screening criteria (HIV: 18–65 years; HCV: 18–74 years), had a prior HIV/HCV diagnosis, were tested for HIV/HCV within the preceding 12 months, and whose “opt-out” decision was not documented. The final analyses included 706 individuals for HIV and 818 for HCV.

Of the 706 eligible individuals included in the HIV “opt-out” testing analysis, 216 (31 percent) declined testing. Among those who declined, the mean age was 48.7 years old, 43 percent were male, and 70p percent were non-Hispanic Black. Compared with individuals 30 to 39 years of age, investigators pointed out individuals 40 to 49 years of age were twice as likely to decline HIV testing.

Additionally, non-Hispanic Black individuals were less likely to decline testing compared to individuals of other races or Hispanic ethnicity, although investigators did not detect an interactive effect of race/ethnicity and sex on declining HIV testing. However, they observed an overall sex difference indicating males were more likely to decline HIV testing than females, a difference that was significant among Black individuals but not among individuals of other races or Hispanic ethnicity.

Of the 818 eligible individuals included in the HCV “opt-out” testing analysis, 246 (30 percent) declined HCV testing. Among those who declined, the mean age was 51.5 years, 43 percent were male, and 73 percent were non-Hispanic Black. Unlike the HIV testing model, race/ethnicity was not a significant predictor of declining HCV testing. However, similar to the HIV testing model, the race/ethnicity by sex interaction was not significant.

Investigators again observed an overall sex difference indicating males were more likely to decline HCV testing than females, a difference that was significant among non-Hispanic Black individuals, but not among individuals of other races or Hispanic ethnicity.

Although eligible participants had the option to decline HIV and HCV testing independently, investigators noted most who opted out did so for both tests. Of the 216 individuals who declined HIV testing, 18 (8 percent) accepted HCV testing while declining HIV testing. Of the 246 individuals who declined HCV testing, 9 (4 percent) accepted HIV testing and declined HCV testing.

Investigators outlined multiple limitations to these findings, including the exclusion of almost half of the patients eligible for HIV/HCV testing from the final analyses due to missing “opt-out” decision documentation as well as the lack of data collected on specific risk factors such as gender, sexual orientation, recreational drug use, or sexual activity.

“Healthcare providers and practice managers should be aware that, despite ‘opt-out’ HIV/HCV testing being the standard of care, approximately one-third of eligible individuals may decline testing,” investigators concluded. “The demographic characteristics of individuals who decline may overlap with those of individuals who are traditionally unaware of their status and are at increased risk of HIV or HCV infections. Establishing protocols that identify and understand the characteristics and needs of people who decline HIV/HCV testing is pivotal to the development of effective interventions that increase testing uptake for these treatable diseases.”

This article was originally published on sister site HCPLive.