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© 2008 American Public Health Association
DOI: 10.2105/AJPH.2008.142596
LETTER |
The authors are with the San Francisco Department of Public Health, San Francisco, California, and the University of California, San Francisco.
Correspondence: Requests for reprints should be sent to Moupali Das-Douglas, MD, MPH, Director of Research, HIV Prevention Section, AIDS Office, San Francisco Department of Public Health, 25 Van Ness, Suite 500, San Francisco, CA 94102 (e-mail: moupali.das-douglas{at}ucsf.edu).
Goldman et al. posit without empirical evidence that written informed consent is not a barrier to routine HIV testing.1 Our experience in San Francisco, California, suggests otherwise.
In May 2006, the San Francisco Department of Public Health Medical Care System, which includes an acute care hospital, a long-term care facility, and more than 15 primary health care centers, eliminated the requirement for a separate written informed consent form for HIV testing.2 Before May 2006, clinicians were required to complete a separate HIV-test laboratory requisition form and obtain written documentation of patient informed consent to order an HIV test. Incomplete forms were rejected by the laboratory. Beginning in mid-May 2006, patient consent forms were removed from medical settings, and HIV antibody testing was added to the routine laboratory requisition form. Clinicians were required to obtain informed consent and to document in the medical chart that the patient consented, but a patient signature was not required, consistent with California state law.
These administrative changes resulted in an increase in the monthly rate of HIV testing (from 13.5 HIV tests per 1000 patient visits in June 2006 to 17.9 HIV tests per 1000 patient-visits in December 2006).3 The mean number of positive tests per month increased from 20.6 (95% confidence interval [CI] = 17.3, 23.8) before the change in policy to 30.6 (95% CI = 25.7, 35.5) after the change in policy (P = .006).2 No tests were rejected because of incomplete documentation after the policy change.2 The trend of increased HIV testing after the policy change has continued. No adverse consequences of this policy change have been reported.
In San Francisco, as in the United States as a whole, we continue to have unacceptable numbers of undiagnosed HIV infections. We also continue to miss opportunities to diagnose individuals early: approximately 40% of those newly diagnosed with HIV are diagnosed with AIDS within 12 months of their positive test.3,4 Facilitating awareness of HIV serostatus is vital for both treatment and prevention; testing is a necessary step toward linking to care,5 and receipt of an HIV-positive test is associated with dramatic reductions in HIV risk behavior.6
We strongly support efforts to increase HIV serostatus awareness and believe that ethical and professional testing can be done without requiring written documentation of informed consent. Our results demonstrate the public health benefits of such an approach.
Footnotes
Contributors
M. Das-Douglas originated the response and led the writing. N. M. Zetola, J. D. Klausner, and G. N. Colfax provided meaningful editorial input.
Accepted for publication May 6, 2008.
References
1. Goldman J, Kinnear S, Chung J, Rothman DJ. New York City’s initiatives on diabetes and HIV/AIDS: implications for patient care, public health, and medical professionalism. Am J Public Health.2008;98:807–813.
2. Zetola NM, Klausner JD, Haller B, Nassos P, Katz MH. Association between rates of HIV testing and elimination of written consents in San Francisco. JAMA.2007; 297:1061–1062.
3. HIV/AIDS Surveillance Report, 2006. Atlanta, GA: Centers for Disease Control and Prevention; 2008.
4. Schwarcz S, Hsu L, Dilley JW, Loeb L, Nelson K, Boyd S. Late diagnosis of HIV infection: trends, prevalence, and characteristics of persons whose HIV diagnosis occurred within 12 months of developing AIDS. J Acquir Immune Defic Syndr.2006;43:491–494.[CrossRef][Web of Science][Medline]
5. Frieden TR, Das-Douglas M, Kellerman SE, Henning KJ. Applying public health principles to the HIV epidemic. N Engl J Med.2005;353:2397–2402.
6. Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr.2005;39:446–453.[CrossRef][Web of Science][Medline]
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