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Routine HIV testing, or testing done as part of a health care visit regardless of risk, is standard of care. Florida's statutes have removed previous barriers such as need for written consent and pre-test counseling, in order to facilitate testing. Providers are encouraged to test all of their patients for HIV at least once. Providers are also asked to engage those who test negative but are at increased risk for HIV in enhanced prevention strategies including frequent testing for HIV and sexually transmitted infections, provision of condoms, and biomedical interventions including pre-exposure prophylaxis (PrEP).

In spite of ongoing prevention efforts and advances in treatment, HIV remains a significant public health concern throughout the United States (US) and in Florida, the state with the highest number of HIV diagnoses in 2017. The Centers for Disease Control and Prevention (CDC) estimate that, of the approximately 107,000 people living with HIV in Florida, 15.6% do not know they are infected. The CDC also estimates that people who were not aware of their infection transmitted 33% of all new HIV infections.

In July 2015 Florida law was changed to no longer require written informed consent for HIV testing in certain settings (section 381.004, Florida Statutes). Florida allows and encourages the implementation of opt-out HIV testing within these settings. This means that as long as an authorized healthcare facility gives a patient the opportunity to "opt-out" of testing, e.g. by displaying signage which asserts that the facility conducts routinized HIV testing for all of their patients, the facility can test any patient who does not explicitly state that they do not want to be tested for HIV. Florida legislation describes facilities that are authorized to implement the "opt-out" strategy as any; hospital; urgent care clinic; substance abuse treatment center; primary care clinic; community clinic; blood bank; mobile medical clinic; or correctional health care facility.

Decreasing requirements for documentation, including HIV testing as a normal part of health care is meant to facilitate routinized testing, decrease the stigma associated with HIV testing, and increase the number of individuals who are aware of their HIV status. These factors are crucial to reducing new HIV cases in Florida. However, three critical first steps must be made in order to achieve these goals; 1) increasing awareness among health care providers about the current Florida testing laws, 2) increasing awareness of the importance of routine HIV testing, and 3) Increasing awareness of enhanced prevention strategies, including PrEP, among individuals who are HIV negative and at risk for infection.

From a patient's perspective, early detection of HIV can lead to timely initiation of antiretroviral therapy and viral suppression. Persons who know they are living with HIV are also less likely to have unprotected sex. In addition, patients living with HIV have years and quality of life to gain if treatment is started early before symptoms develop. Overall, the costs of screening for HIV are minor in relation to the anticipated benefits for both providers and patients.

Routine HIV testing in health care settings and targeted testing in non-health care settings are part of the four key components to reduce HIV infections designated by the Florida Department of Health. Testing is also critical to two other key components: rapid engagement with initiation of antiretroviral medications for those who are diagnosed with HIV, and provision of PrEP for those who are HIV negative but have risk for infection. HIV testing is central to treatment, and to prevention.

HIV Testing Law Basics

Prevention counseling is no longer required before HIV testing in health care settings. Patients must be notified that HIV testing is planned and have the opportunity to opt-out of testing. This notification may occur in a number of ways including verbally or by the distribution of written materials. A facility may include a notification of HIV testing in general consent to medical treatment. If testing is declined, this decision should be documented and providers are encouraged to address the reasons for declining.

Why Conduct/Get Testing?

From a provider's perspective, the testing laws remove time spent acquiring written consent, conducting prevention counseling, and conducting HIV risk assessments. HIV can be reliably detected with rapid tests, which are inexpensive, and noninvasive. Testing can also be incorporated into routine blood work planned as part of a health care visit. Although not required, HIV counseling and risk assessment are billable actions during an office visit, and thus can be a source of revenue. Under the Affordable Care Act (ACA), Medicare, Medicaid, and private insurance are either required or incentivized to cover "A" and "B" grade services. HIV screening has an "A" rating from the U.S. Preventive Services Task Force and should be a covered service by Medicare, Medicaid, and ACA-qualified health plans. Although most HIV testing services will be covered, it is important to refer to each individual health plan to verify reimbursement coverage.

Who should be tested for HIV?

The short answer is everyone. The CDC recommends that everyone between the ages of 13 and 64 is tested for HIV at least once in their lifetime. This recommendation is similar to screening guidelines for other treatable conditions. However, the frequency of testing should increase with a level of risk. For those at higher or ongoing risk for HIV, testing should be repeated at least annually. More frequent testing may be indicated for some individuals at highest risk.

Patients who have increased or ongoing risk for HIV include:

• Those who identify as a man who has sex with men
• Sexual partners of people living with HIV
• Those starting a new sexual relationship
• Those with recent sexually transmitted infections
• Those with multiple sexual partners
• Those who report inconsistent condom use

It is important to remember that although there is no cure, HIV is a manageable infection. Current medicines are extremely effective and help people live longer healthier lives.

What is PrEP and Where is it Available?

PrEP, when people who do not have HIV but who are at substantial risk of infection take medication to prevent HIV, can be highly effective. PrEP, in combination with HIV testing, testing for sexually transmitted infections, and provision of condoms, should be discussed with all people who are at increased risk for HIV infection after receipt of a negative test. Currently, there is only one FDA-approved medication for PrEP: the single tablet combination of two antiretroviral medications (tenofovir and emtricitabine) with the brand name Truvada. Provision of PrEP requires baseline testing for HIV, sexually transmitted infections, viral hepatitis, and monitoring of serum creatinine. PrEP can be provided through a number of venues including primary care, sexually transmitted infection clinics, family planning clinics, and other venues.

Who should take PrEP?

CDC guidelines suggest that PrEP be discussed with people without HIV who are at increased risk of infection from sex or injection drug use. Federal guidelines recommend that PrEP is considered for people who are HIV-negative and who are:

• Men who have sex with men
• Sexual partners of people living with HIV
• Exchanging sex for drugs money or other items
• Engaging in sex with multiple sexual partners
• Using condoms inconsistently
• Injection drug users
  

Please see below a list of resources which further explain/assist with the implementation of HIV testing, PrEP programs, linkage to HIV care, and HIV prevention in general.

Our program is designed to increase information and provide resources to Florida providers regarding HIV prevention. For more information regarding our services and for testing & PrEP resources for your practice, please contact us at 305-243-2584 or Sab321@med.miami.edu.

Resources:

Florida Department of Health's resource for HIV testing and prevention. https://www.testmiami.org/. Accessed December 14, 2018

Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. September 2006;55(RR-14);1-17. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm. Accessed December 14, 2018. ?

U.S. Preventive Services Task Force. Screening for HIV- Current Recommendations. https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/. Accessed December 14, 2018. ?

University of South Florida. A Provider's Guide to Reimbursement and sustainability for HIV Testing in Florida healthcare facilities.2015 http://usfcenter.org/prevention/wp-content/uploads/2015/10/HIVTestingSustainabilityGuide.pdf. Accessed December 14, 2018. ?

World Health Organization. Dr Gottfried Hirnschall. Striving for zero discrimination in health care. March 2016. http://www.who.int/mediacentre/commentaries/zero-discrimination-day/en/. Accessed December 14, 2018.

2-1-1 Big Bend. Florida HIV/AIDS Hotline. http://www.211bigbend.org/flhivaidshotline. Accessed December 8, 2018.

Health Resources and Services Administration. Get HIV Care and Treatment. https://hab.hrsa.gov/get-care/get-hiv-care. Reviewed October 2016. Accessed December 8, 2018..

Florida Department of Health. AIDS Prevention. http://www.floridahealth.gov/%5C/diseases-and-conditions/aids/prevention/index.html. Accessed December 8, 2018.

Florida Department of Health. PrEP Plan of Action Toolkit. http://escambia.floridahealth.gov/programs-and-services/clinical-and-nutrition-services/community-clinical-health/hiv-aids/_documents/prep-toolkitfinal-03-29-16.pdf Updated March 2016. Accessed December 8, 2018.

Florida Department of Health. Testing and Counseling. http://www.floridahealth.gov/diseases-and-conditions/aids/prevention/testing-counseling.html. Accessed December 8, 2018.

Health Resources and Services Administration. Test and Treat: A New Paradigm for Slowing the Spread of HIV.https://hab.hrsa.gov/sites/default/files/hab/Publications/careactionnewsletter/hab_test_and_treat_january_careaction_pdf.pdf. Accessed December 9, 2018.