The impact of HIV reporting on HIV pretest counseling

When HIV infection becomes legally reportable in British Columbia on 1 May 2003, there will be important implications for health care providers and patients. For this initiative to be successful and do no harm, the pattern of practice for BC will need to change.

For pretest counseling, new issues will need to be added to the standard pretest discussion.

New issues 
HIV will now be reported
Patients need to understand that a positive HIV test will now be reported to local and provincial health authorities and that public health will contact the health care provider and sometimes the positive patient for follow-up. Ideally, patients should know this before deciding to undergo the test, perhaps through posters or pamphlets in the waiting room, but this will also need to be discussed with all patients individually during pretest counseling. Informed consent is then obtained before the blood is drawn.

Nominal or non-nominal testing
Patients need to be informed that they have the option of nominal or non-nominal testing. On the test requisition, they may use their full name as it appears on their CareCard or they may use initials or pseudonyms. However, patients and providers should be able to recall these initials or pseudonyms later, and they must understand that follow-up and partner notification will occur even if the non-nominal option is chosen. If the test is positive, the subsequent report to public health will use the information that was used on the requisition.

Regardless of the reporting option chosen, confidentiality will be preserved.

Follow-up
Patients need to understand the specifics of follow-up and partner notification. This is discussed in the accompanying article “Public health follow-up of reported cases of HIV infection in BC."

Standard issues
Pretest counseling is an important opportunity to educate patients about HIV, to discuss their risk, and to inform them about prevention. This discussion should address the following:

• HIV/AIDS—an incurable viral infection, how HIV is transmitted, the asymptomatic and symptomatic stages, treatment, and prevention.

• HIV test—a test for antibodies, the timing of the test (positive 6 weeks after most infections but 6 months in rare cases), 2 weeks for the test result, and a positive test means HIV infection not AIDS.

• Follow-up—the importance of reducing risk (not sharing needles, using condoms, reducing the number of sexual partners, and, with a physician, discussing pregnancy) and returning for the result in person.[1]

Plan the result visit so that there is minimal delay between receiving the result and telling the patient. Whether physicians or public health staff are providing follow-up, the two groups must work closely together. The patient, the provider, and public health must also work together to minimize the risk of negative repercussions for patients and contacts and to promptly report incidents when they occur. These may include verbal or physical violence, breaks in confidentiality, loss of employment or housing, and despair or depression, even suicide.

It will be crucial to ensure that the patient is given the option of non-nominal testing. This option will be addressed as follows:

• Including a prominent “nominal/non-nominal” tick box at the top of the new HIV test requisition.

• Verifying during the first call-back by public health to the testing provider that the option was presented to and understood by the patient.

• If public health does the follow-up, asking the patient which option he or she chooses.

• Recording the testing/reporting option chosen on the report form.

• Including this question in the evaluation of HIV reportability.

At the provincial level, all patient data are protected on one secure computer with restricted access. Before data are transferred to Health Canada, all identifiers are removed.

The objectives of HIV reportability are important and laudable: better management of HIV positive patients, more complete and prompt notification of contacts, and a more complete picture of local HIV epidemiology. Realizing these objectives will improve HIV/AIDS control through enhanced care, support, and prevention. A primary care partnership involving the patient, the provider, and public health is the key ingredient for success.

—Michael L. Rekart, MD
—Linda J. Knowles, BScN

References

1. Nusbaum MRH, Hamilton CD. The proactive sexual health history. Am Fam Physician 2002;66:1705-1712. PubMed Abstract Full Text 

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Dr Rekart is the director of STD/AIDS Control, British Columbia Centre for Disease Control (BCCDC) and clinical professor of medicine at the University of British Columbia Centre for Disease Control. Ms Knowles is the clinic nursing administrator of STD/AIDS Control at the BCCDC.