摘要：Objectives. We measured HIV testing and seropositivity among veterans in Veterans Affairs (VA) care for calendar years 2009 through 2011 and analyzed 2011 results by patient demographics. Methods. We performed a repeated-measures cross-sectional study using standardized electronic data extraction from the VA electronic health records for all veterans with at least 1 outpatient visit during 2009 through 2011. We analyzed testing rates and seropositivity by demographic characteristics for 2011. Results. Of veterans with an outpatient visit, 20.0% had an HIV test in 2011, compared with 9.2% in 2009. Documented HIV testing rates were highest in women and Blacks. Of confirmed positive test results, 67.0% were in outpatients older than 50 years. Seropositivity was highest among men aged 30 to 49 years, women aged 50 to 69 years, and Black outpatients of both genders. Implementation of an electronic clinical reminder was associated with higher testing rates. Conclusions. The significant effect of an electronic clinical reminder suggests that such decision support tools can substantially increase testing rates. The frequency of positive test results in older individuals suggests the need for additional work to define optimum approaches to HIV testing in this population. Although the US Department of Veterans Affairs (VA) diagnosed and treated many of the first AIDS cases in the United States, 1 HIV testing in the VA has been tightly restricted since 1988 to maximize patient autonomy and to ensure confidentially and privacy for veterans seeking testing and care for HIV. In addition to barriers and obstacles to HIV testing seen in the general US population, 2 until recently, federal law and regulations specifically barred widespread HIV testing in the VA, required that informed consent for such testing be obtained in writing, and mandated that scripted pre- and posttest counseling be performed. 3 The VA is the largest direct provider of civilian health care in the United States, with more than 6 million veterans receiving outpatient care in 2011, and it is the largest provider of HIV care in the nation, with more than 24 000 veterans receiving HIV care in 2011. Veterans enrolled in VA care with a confirmed diagnosis of HIV receive high-quality, comprehensive care as reflected by measurement of performance on HIV care quality standards set by the National Quality Forum. 4 In 2009, 91% of veterans in VA care with known HIV infection who met validated clinical criteria for receipt of highly active antiretroviral therapy received such treatment, with 93% of HIV-positive veterans receiving regular CD4 count screenings and viral load testing. Of course, the full benefits of high-quality VA care for HIV infection can only be delivered to HIV-infected veterans after they have been diagnosed. Before the lifting of specific legal restrictions on HIV testing in the VA, the majority of VA patients were diagnosed with AIDS at the time of their HIV diagnosis. 5 At the same time, blinded seroprevalence studies showed that 0.1% to 2.8% of veterans in VA care were undiagnosed. 6 In August 2009, following the repeal of legal and regulatory restrictions on HIV testing in the VA, the VA aligned its HIV testing policies with the 2006 recommendations of the US Centers for Disease Control and Prevention (CDC) 7 to offer voluntary HIV testing as part of routine medical care at least once and annually for those with ongoing risk factors. The CDC also recommended opt-out HIV testing, with verbal, rather than written, informed consent. Federal law prohibits veterans to be tested without consent. Therefore, the VA modified its informed consent policies to allow opt-in HIV testing after verbal consent is documented in the VA’s electronic health record (EHR), with written informational material provided to patients before testing. These policy changes addressed well-described barriers to HIV testing and simplified the HIV testing process, allowing the VA to broaden access to HIV testing. 3,8–11 The VA’s goal in broadening routine HIV testing is to identify all veterans in VA care who are HIV positive and provide timely linkage to high-quality comprehensive care. Since 2009, the VA has monitored HIV testing rates among veterans in VA care annually to evaluate the impact of the policy changes we have described as well as operational interventions designed to promote increased HIV testing. 12 These interventions include social marketing campaigns, clinical reminders in the VA EHR to prompt providers to offer routine HIV testing, and quality improvement project funding at individual VA medical facilities to promote routine HIV testing in a variety of clinical settings. 13 Before implementing a routine HIV testing policy for all veterans in VA care, fewer than 10% of outpatient veterans had ever been tested for HIV in the VA, whereas in the first full year following the policy changes there was a 140% increase in the number of HIV tests performed. 12 We have reported the HIV testing data for the VA from calendar years 2009, 2010, and 2011 and presented demographic analyses of testing data collected in calendar year 2011.
