Featured news from NHIVNA
HIV-related news from NAM
Opt-out approach can boost HIV testing rates
Roger Pebody, 2016-02-04 07:10:00
A large randomised study in an emergency department in San
Francisco clearly shows that an ‘opt-out’ approach to seeking consent for HIV
testing can increase the number of people who take the test.
The proportion tested ranged from 38% to 66%, depending on
the wording used by staff offering HIV testing, Juan Carlos Montoy and
colleagues reported in The BMJ last
week. While the conclusions are not a surprise, this topic has not previously
been evaluated in randomised studies (which provide the most reliable form of
Over a two year period 4800 patients at the emergency
department of the San Francisco General Hospital were approached by
non-clinical research staff and told: “We’re offering routine HIV tests to all
of our patients. It’s a rapid test with results available in one to two
Consent was sought in one three ways, depending on which group
the patient had been randomly allocated to:
- “You can let me, your
nurse, or your doctor know if you'd like a test today.” HIV testing was
sought by 38.0% of patients in this ‘opt-in’ group.
- “Would you like a test today?” HIV testing
was sought by 51.3% of patients when this ‘active choice’ approach was taken.
- “You will be tested
unless you decline.” In the ‘opt-out’ group, 65.9% of patients took a
Similar patterns of test uptake were seen in different
demographic groups and regardless of whether an individual reported sexual risk
Small changes in wording therefore significantly affected
patient’s behaviour – and the clinicians’ perception of their preferences. The
authors note the subtle difference between ‘opt-in’ and ‘active choice’
although the two may often be conflated in everyday practice.
In the study there were large variations in acceptance rates
according to which member of staff had approached the patient – even though the
interaction was meant to be heavily scripted. In usual clinical practice, these variations
are likely to be even greater.
The researchers note the wide variation in the proportion
accepting a test in previous studies done in emergency departments. “The
details of the testing regimen—including how the test is offered, by whom, to
whom, and in what setting—can be crucial to how likely patients are to agree to
be tested,” they say. The suggest that in routine practice, policies to offer
testing in an ‘opt-out’ manner may be delivered by some staff members in ways
which are not truly ‘opt-out’.
In an editorial, Jason Haukoos and Sarah Rowan comment: “To
our knowledge, the study by Montoy and colleagues represents one of the largest
trials to evaluate consent for HIV testing among emergency department patients,
and the only one to do it in a randomized fashion but with particular focus on
the efficacy of the various consent options… To maximize test acceptance and
subsequent new HIV diagnoses, we must use evidence to drive decisions about the
best way to conduct testing procedures.”