Making HIV Testing A Standard of Preventive Care to Boost Equity

July 26, 2023 - Maranda Ward, EdD, MPH, wants every primary care provider asking all of their patients about HIV screening as a standard of preventive care. After all, that’s the best way to keep patients from slipping through the cracks and going without diagnosis or care, the assistant professor and director of equity in the Department of Clinical Research at George Washington University said.

HIV testing is like many other kinds of preventive screening. Using a blood sample, HIV tests can detect whether an individual is positive for the virus and gives patients and their providers the chance to begin treatment quickly. HIV treatments primarily work to lower an individual’s viral load and have proven extremely effective at letting patients lead normal lives.

But those good outcomes only come to fruition when an individual can get an HIV diagnosis and get connected to care, something that doesn’t always happen, according to June 2023 KFF data.

Overall, 21 percent of adults with diagnosed HIV go without access to care, KFF reported. Compared to their counterparts who can access HIV care, these folks are more likely to report issues interacting with the healthcare system and multiple care access barriers.

Particularly, folks with diagnosed HIV were more likely to lack insurance coverage, lack a usual source of care, face financial issues, have trouble with behavioral health and substance use, and struggle to get to the doctor’s office.

These issues arise because certain groups disproportionately bear the burden of social determinants of health than others, Ward explained.

And when an individual experiences housing insecurity, they probably aren’t thinking about getting an HIV test or, if they have already tested positive for HIV, taking their antiretroviral (ARV). They’re thinking about when they’ll eat next or sleep that night, Ward explained, leaving those unmet social needs to get in the way of their care access.

Because of structural racism and inequity, certain populations are more likely to face SDOH barriers than others.

Indeed, the KFF numbers showed that people who are Black are more likely to have an HIV diagnosis but go without care. Black people are more likely to face SDOH that block their access to care, Ward said, but the problem runs deeper than that.

“They're interacting with a medical community and healthcare landscape that is discriminatory,” she said.

In April 2022, a quarter of adults told The Commonwealth Fund that they’d experienced discrimination in healthcare. Of those who described experiences of racism, 27 percent said they did not get the care they needed because of it.

“Some people are not able to take advantage of all the medical breakthroughs and how wonderful HIV treatment and therapeutics are these days because of bias and discrimination,” Ward said.

For some patients, it’s that they have experienced so much discrimination that they do not trust their healthcare providers and choose not to access care. For others, it might be that a provider does not recommend a certain service or clinical trial because of preconceived notions about the patient.

For example, a clinician may assume a patient with complex social needs would not want to or be able to manage an ARV regimen or keep up with PrEP, the drug certain populations take to prevent HIV infection. But Ward pointed out that acting on those biases perpetuates health inequities. Instead, clinicians need to use strong patient-provider communication skills to outline the benefits of certain treatments and services to all patients in order to promote equity.

According to Ward, it’s going to require a multidisciplinary effort to get traditionally underserved patients into the clinic. It will take housing and transportation and other social services departments to work together to ameliorate some of those issues and ensure social determinants of health do not continue to be care access barriers.

But in terms of HIV testing and treatment access inside the clinic, Ward indicated that healthcare has some levers it can push by way of clinical guidelines. If every provider is beholden to asking every patient—regardless of their demographics—about HIV screening, Ward said the prevention and then treatment aspect could be much more attainable.

Right now, clinical standards recommend that primary care providers ask every patient between the ages of 13 and 64 to get an HIV test at least once.

“That's simply not enough,” Ward asserted. “If I get somebody asking me once at age 17, I'm not good for the rest of my life.”

Through her work with George Washington University, Ward and her colleagues are looking to change those clinical guidelines.

“We're making the policy case to update the CDC clinical guidelines on HIV screening,” she said. “We're saying that A, this needs to be annual, and B, it needs to be routinized, meaning this is the standard of care.”

Such an approach isn’t just effective for catching patients at different points in their lives (the 13-year-old might not be a high risk for HIV, but they may be when they’re 20) but also for eliminating bias from the equation.

For example, Ward mentioned that some providers exclude married patients from HIV testing guidance, even though marriage itself doesn’t protect anyone from HIV.

Moreover, it destigmatizes the conversation when providers do advise HIV testing. Ward said that much of the communication around HIV testing lacks any kind of sex positivity, so when providers suggest patients get a test, the patient may feel discriminated against.

“Ultimately, in the clinical visit, there should be a set of questions that are nonjudgmental and sex-positive,” Ward said. “This is for everyone, not just all those you perceive at risk so that we can eliminate stigma.”

Ensuring providers discuss HIV testing as a standard of care is integral to building patient trust, Ward added. Providers can begin discussing testing with patients by telling them that everyone gets advised to get screened. They might consider also telling patients when they are allowed to opt out of guidance, Ward said.

“I'm all for doing an HIV test, but when we talk about patient rights, it's not just informed consent,” she explained. “It's also informed refusal.”

Giving patients that level of autonomy, plus making sure they know when they are being tested for HIV, ensures they are centered in their own care.

It also lays the groundwork for providers to discuss the topic with empathy, Ward added.

HIV testing is sometimes packaged with many overall STI screenings and blood tests. But if a patient doesn’t know this is happening and doesn’t expect to see HIV on the test results, it could be catastrophic, especially if the results are positive, Ward said. In addition to adding HIV screening to clinical guidelines, providers should be beholden to being transparent with patients.

Ward said the current public health campaign is mostly looking at HIV and is paired with COVID-19 vaccination advisories. Looking ahead, it would be beneficial to examine how PrEP (pre-exposure prophylaxis) and PEP (post-exposure prophylaxis) fit into the conversation.

The two drugs are instrumental in preventing HIV, but many primary care providers leave them to infectious disease experts. However, Ward said the discussion of PrEP and PEP belongs in primary care. After all, that’s where preventive care efforts mostly happen.

Of course, all of these public health efforts need to account for patients’ basic needs. While it is essential for healthcare providers to advise patients about certain preventive measures, like HIV screening, patients can’t get there if they experience food or housing insecurity or literally can’t get a ride to the clinic.

As healthcare policymakers consider the ways in which they can protect public health inside the clinic, they need to work with other policymakers to ensure there is a wraparound approach that helps patients achieve that health and equity.