Communicating HIV Test Results: Who? What? How?

The objective behind HIV screening in health care settings is to maximize the number of persons who are aware of their HIV infection and so receive appropriate care and prevention services in the timeliest way possible. The extremely sensitive and personal nature of an HIV test result, whether positive or negative, and the public health implications of a positive result are the basis on which the CDC offers guidelines and recommendations for both HIV testing and for communicating test results. Here, a top-line Q&A and links to additional resources.

Who is in the best position to convey the results of an HIV test result to the patient?
The ordering clinician is the best one to inform the patient of the result. Providing the results of an HIV test, however, involves more than simply telling the patient that he or she is or is not infected.  In the case of a negative test result, the CDC recommends education and counseling; in the case of a positive test, conveying the result involves providing emotional support in addition to structured guidance on the next level of care.¹ 

What to do when the HIV test result is negative? 
A negative test offers an opportunity to counsel a patient about high-risk behaviors and how to reduce personal risk. When results of initial testing are negative, you will need to help the patient understand the concept of possible seroconversion and the need to repeat the HIV test in 3 to 6 months after the presumed exposure to HIV.² In most newly infected people, detectable antibodies develop within 2 to 8 weeks of exposure (the average is 25 days).² However, antibodies to the virus may not be detectable for up to 6 months in a small subset of the population. It is important to communicate the extreme importance of follow-up testing. Patients who are known to the screening clinician to be at high risk for infection should be aware of the need for ongoing periodic re-testing.¹

Most important, patients given a negative HIV test result should be given prevention counseling, including where to obtain additional information about the disease and community resources that may be available to them.¹ Referral to outside sources is recommended if these services are not available within the ordering physician’s setting.¹

What to do when the HIV test result is positive?
The reporting of a positive HIV test result to an infected patient is more complex and requires linkage to clinical and counseling services. The clinician must ensure confidentiality and acknowledge the patient’s concerns. Initial counseling by the primary care provider should include how to prevent transmission of HIV to the patient’s partner and guidance on getting the partner tested. The screening physician should also provide initial education on current HIV therapies.¹ Prompt referral should be made to a specialty HIV clinic; recommendations for infectious disease specialists and psychologists or other mental health professionals also are recommended.¹

The primary care provider should encourage the patient to seek support from family members and friends to help manage the anxiety surrounding a positive diagnosis.

When working with pregnant women, the HIV test result should also be documented in the medical record of her infant. If the mother's HIV test result is positive, maternal health care clinicians should notify the pediatric care providers of the impending birth of an HIV-exposed infant to anticipate any complications (after obtaining consent from the mother).¹

For patients with limited English proficiency, do not use family or friends as interpreters to disclose test results; even among relatives or other loved ones there is a risk of stigma and discrimination.¹ The Privacy Rule under the Health Insurance Portability and Accountability Act of 1996 prohibits use or disclosure of a patient's health information, including HIV status, without the patient's permission.¹What about use of rapid oral HIV testing?
Rapid oral HIV tests can be obtained when results are needed immediately. The results can be delivered at the same clinic visit, so use of these tests can help reduce the number of persons who do not receive results (ie, do not follow up).³ Patients must understand, however, that a negative result indicates the absence of antibody formation to the HIV virus and does not necessarily rule out acquired infection⁴; a follow-up screening should be scheduled. A positive result on a rapid HIV test is considered preliminary and requires confirmation (serum HIV ELISA and Western blot) before the diagnosis of HIV infection is established.⁴ The CDC recommends that patients be counseled on the provisionary status of rapid testing results and urged to take precautions to avoid potential transmission of the virus.⁴

If the patient presents with suspected acute HIV syndrome and the serum HIV ELISA is negative, then an RNA test (HIV viral load) can be obtained. The viral load can be detected within 9 to 11 days of exposure.² 

How should results of HIV testing be communicated: On the phone or in a "face-to-face” visit?
The CDC provides clear direction on how test results should be delivered.¹ The best practice is to convey an HIV test result face-to-face. In some areas, however, results both positive and negative are already conveyed by phone.³ If a one-on-one visit causes undue burden, for example, test results can be discussed by phone. The same counseling, education, and support needs to be offered in this conversation as in a face-to face-visit.⁴ The CDC states, “Positive test results should always be communicated by personal contact and should never be delivered by mail.”³ The CDC also recommends that positive results be communicated “. . . confidentially through personal contact by a clinician, nurse, mid-level practitioner, counselor, or other skilled staff.”¹

State laws govern the policies on HIV reporting, so each provider should be aware of guidelines and requirements in his or her own state.⁵ Documentation needs to include test results, counseling that was provided, assessment of the patient's emotional and mental status, and referrals and follow-ups scheduled. If results are provided by phone, be sure to document the details of the conversation and to explain why you conducted the discussion via phone instead of in person.

References
1. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. 2006;55(RR14):1-17. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm. Accessed May 7, 2013.

2. HIV/AIDS Resource Center. 2012. HIV testing.  http://hivaidsresource.org/hiv-testing. Accessed May 1, 2013.

3. Centers for Disease Control and Prevention. Questions and answers for professional partners: revised recommendations for HIV testing of adults, adolescents, and pregnant women in healthcare settings. 2009. http://www.cdc.gov/hiv/topics/testing/resources/qa/qa_professional.htm. Accessed May 2, 2013.

4. Centers for Disease Control and Prevention. HIV counseling with rapid tests. http://www.cdc.gov/hiv/pubs/rt-counseling.htm. 
Accessed May 7, 2013.

5. National HIV/AIDS Clinicians' Consultation Center. 2012. State HIV testing laws: 2012 compendium of state HIV testing laws. University of California, San Francisco.
http://www.nccc.ucsf.edu/consultation_library/state_hiv_testing_laws/. Accessed May 2, 2013.