Study Finds One-Third of Eligible Patients Decline “Opt-Out” HIV, HCV Testing

Jodian Pinkney, MD, MBBS

Credit: Jodian Pinkney on X

Findings from a recent study are providing clinicians with an overview of the demographic and clinical characteristics of individuals who decline “opt-out” human immunodeficiency virus (HIV) or hepatitis C virus (HCV) testing, underscoring the need for targeted interventions to increase testing uptake in these specific patient populations.¹

The study involved a retrospective, medical record review of adults seen at an internal medicine outpatient resident continuity clinic in South Carolina and found approximately one-third of eligible individuals declined HIV/HCV testing. Although non-Hispanic Black individuals were the least likely to decline testing among all race/ethnicity groups, notable sex disparities were observed among Black patients.¹

“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,” Jodian Pinkney, MD, MBBS, an infectious diseases physician at Massachusetts General Hospital, and colleagues wrote.¹

The US Centers for Disease Control and Prevention (CDC) recommends universal hepatitis C screening for all adults ≥ 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 64.2,3 Focused expansion of “opt-out" HIV/HCV testing in which individuals are tested unless they decline could facilitate increased testing, earlier diagnoses, and improved health outcomes.¹

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.¹

HIV

Of the 706 eligible individuals included in the HIV “opt-out” testing analysis, 216 (31 %) declined testing. Among those who declined, the mean age was 48.7 (±11.7) years, 43 % were male, and 70% were non-Hispanic Black. Compared with individuals 30–39 years of age, investigators pointed out individuals 40–49 years of age were twice as likely to decline HIV testing (adjusted odds ratio [aOR], 2.15; 95 % CI, 1.18 - 3.92; P = .012).¹

Additionally, non-Hispanic Black individuals were less likely to decline testing compared to individuals of other races or Hispanic ethnicity (aOR, 0.60; 95% CI, 0.36 - 0.99 among females; aOR, 0.59; 95% CI, 0.33 - 1.07; among males; P = .0456), although investigators did not detect an interactive effect of race/ethnicity and sex on declining HIV testing (interaction P = .98). 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 (aOR, 1.61; 95 % CI, 1.08 - 2.40) but not among individuals of other races or Hispanic ethnicity (aOR, 1.63; 95 % CI, 0.84 - 3.14).¹

HCV

Of the 818 eligible individuals included in the HCV “opt-out” testing analysis, 246 (30%) declined HCV testing. Among those who declined, the mean age was 51.5 (±13.4) years, 43% were male, and 73% 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 (P = .97).¹

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 (aOR, 1.50; 95% CI, 1.04 - 2.16), but not among individuals of other races or Hispanic ethnicity (aOR, 1.52; 95 % CI, 0.81 - 2.84).¹

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 %) accepted HCV testing while declining HIV testing. Of the 246 individuals who declined HCV testing, 9 (4 %) accepted HIV testing and declined HCV testing.¹

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.¹

“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.¹ “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.”

References

1. ^{Pinkney J, Tong Y, Hoeppner S, et al. Who declines “opt-out” HIV/HCV testing? Experience of an internal medicine resident continuity clinic serving a predominantly Black adult population in South Carolina. Journal of the National Medical Association. https://doi.org/10.1016/j.jnma.2024.07.009}
2. ^{US Centers for Disease Control and Prevention. Clinical Screening and Diagnosis for Hepatitis C. Hepatitis C. Accessed August 6, 2024. https://www.cdc.gov/hepatitis-c/hcp/diagnosis-testing/index.html}
3. ^{US Centers for Disease Control and Prevention. HIV Testing. HIV. May 16, 2024. Accessed August 6, 2024. https://www.cdc.gov/hiv/partners/testing/index.html}