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The Reality of Risk

There is one thing in which each of us is an expert: ourselves. But when it comes to perception of HIV risk, we only think we know ourselves, said Jeremy Brown, M.D., assistant professor of Emergency Medicine at The George Washington University School of Medicine and Health Sciences.

As director of the Department of Emergency Medicine’s HIV screening program — one of only about 40 emergency departments in the country to offer routine HIV screening tests — Brown and his team have surveyed thousands of emergency room patients on their views of regular screening. Among the approximately 30 percent of patients who declined the test, Brown found that the top reason for refusal — “by far and away”— was the belief that they were not at risk.   

Frighteningly, that’s where the patients were wrong.  After testing the de-identified blood samples of those who declined testing, the researchers found that these patients’ rates of HIV infection were not only higher — but three times higher — than the baseline rate of about one percent.

“When someone says ‘I’m not at risk,’ something else is going on,” said Brown. “They [likely] don’t understand what their risks are. We need to reach out to everyone, even — and perhaps especially — to the patients who say ‘I’m not at risk.’”

The results of Brown’s study were presented during an event for first and second year GW medical students called, “Offering the Test: How Students Can Improve Routine HIV Testing in DC.” Sponsored by the GW School of Medicine and Health Sciences; the DC Department of Health (DOH); and the Global Business Coalition (GBC) on HIV/AIDS, TB, and Malaria, the program educated medical students about the scope of the HIV/AIDS epidemic in the District of Columbia, the purpose of routine HIV testing, and the rationale for implementing routine testing in high risk settings.

“This disease cuts across socioeconomic status, it cuts across gender lines, it cuts across race lines, it certainly cuts across geographic lines,” said Pierre Vigilance, M.D., M.P.H., director of the DOH. “At the same time, there are lots of people who don’t think they are at risk.”

Since 2006, the DC DOH has implemented a policy of routine opt-out HIV testing in medical settings, meaning that all people between 14 and 84 years old should be regularly tested for HIV, with the option to refuse. The “Offer the Test Campaign” aligns with current CDC guidelines and represents an important shift from telling patients to “ask for the test” to also urging physicians to “offer the test.”

“In the first phase of this campaign…we placed the onus on the patient, on the individual who was supposed to be coming to us for care,” said Vigilance. “But we find that there are a number of people who don’t have a medical home. How do you ask for the test if you don’t have a place to get care?”

“We are not asking practitioners to delve into the sexual history of their patients,” added Michael Kharfen, Communications and Community Outreach bureau chief at the DC DOH HIV, Hepatitis, STD, and TB Administration. “We just want HIV testing included in the same way that you are testing for diabetes, blood sugar, cholesterol, or hypertension. It’s the same standard as when you are testing for a common disease.”

And HIV is a common disease. Every ward in Washington, D.C., for instance, has an HIV prevalence of at least one percent; while the city as a whole rate is three percent—at least. According to Vigilance, the district’s epidemic rate is likely more a reflection of the city’s aggressive screening programs, rather than of the population itself.

The speakers urged the students to continue driving the movement forward through their participation in GW’s Clinical Apprenticeship Program, which gives students a chance to practice their clinical skills through a one-on-one partnership withMedical Center or community-based physicians.  “We ask that you read up on HIV in DC and then have a serious conversation with your physician. Talk about and encourage [HIV] testing for all patients,” said John Newsome, Vice President of the U.S. HIV/AIDS Initiative at the GBC. “You can help dispel some of those myths that testing is cumbersome and costly.”

“GW is a place that has really been changing the course of the epidemic,” concluded Kharfen. “The researchers are doing studies, the emergency department is leading the nation, [and] you all as students are doing it right here — because nowhere else in the nation is this happening.”