HIV Testing and Patient Consent Issues

Any veteran who is at risk or who wishes to know his or her HIV status should be offered a test. Risk assessment should be routinely incorporated into health care discussions between patients and their providers regardless of the health care setting, such as primary care, mental health, acute care, etc. (June 2005)

No. VA regulations require pre- and post-test counseling, but do not identify specific requirements for counselors. The program office has emphasized that test a health care professional should provide counseling: that is, someone whose profession requires formal academic preparation, standards of practice, and a code of ethics. This would include physicians, nurses, social workers, and psychologists among others. (June 2005)

The purpose of pre-test counseling is to provide the information the patient needs about the risks and benefits of testing in order to make an informed choice. The usual elements of HIV pre- test counseling are now included in VA form, 10-0121, Pre-test Counseling and Consent for HIV Testing. This includes: information about the meaning of the HIV test results; information about how the test is done; information about the possible risks and benefits of the test; policies and guidelines regarding the confidentiality of the test results; information about how HIV is transmitted and how to prevent transmission to others; policies on disclosure of authorized disclosures; and VA's nondiscrimination in health care services for patients with HIV. Information may be tailored to meet the needs of individual patients who have varying levels of awareness and knowledge about HIV. (June 2005)

The VA form for Pre- Test Counseling and Consent for HIV Testing is form 10-0121 and is available online. Print copies have also been distributed to each VA Medical Center and are also available at the Publications Depot as well. This form was revised in November 2004, but it does not represent a change in VHA policy on the requirement for written informed consent or the elements for pre-test counseling. Instead, this form provides information about HIV testing designed to answer the patient's questions about testing, such as the HIV test procedures, the benefits and possible risks of the test, and the meaning of test results. This revised form also addresses the required elements of pre-test counseling for the provider who had not routinely provided HIV pre- test counseling in the past.

While giving the patient the consent form to read is an important part of the counseling process, pre-test counseling should provide an opportunity for an individualized discussion of the benefits and risks of HIV testing. The new HIV testing consent form provides the basic bullets of all the information needed for pre-test counseling as a prompt for providers who may not provide counseling on a regular basis and who may need some reminders on what to cover. A review of this basic information with the patient can be accomplished in a relatively brief amount of time. Such discussions are also important, as some patients may not freely offer that they have problems with reading or understanding all of the information on the form. Finally, pre-test counseling may provide an opportunity for the patient to address any additional concerns that they have about their history, the test itself, or the potential implications of the test results. (June 2005)

Certainly, it is good practice to provide the veteran with a copy of the consent and a copy should be scanned or entered into the medical record. However, there is no VA national policy requiring that the Lab receive a copy before proceeding with testing. While this has been a local requirement adopted by some facilities, this is not a requirement of any VA regulation. If the laboratory wishes to confirm that consent has been obtained, it would be preferable for the person obtaining consent to enter a progress note in the electronic medical record that the lab could then look up. (June 2005)

No. The VA regulations requiring written informed consent and pre- and post-test counseling apply to any laboratory test that is ordered for the purpose of establishing an initial diagnosis of HIV. This requirement is based on the purpose of the testing (one for diagnosis), not the type of HIV testing being ordered. This consent is not needed for a viral load test that is being done as part of routine care once the diagnosis of HIV has already been made in a patient. (June 2005)

Testing should be offered based on the patient's risk for HIV infection or desire to know his or her HIV status. Routinely requesting testing in the pre-operative setting may be interpreted as being a condition for receiving the appropriate surgical care, and is thus coercive and not ethical. Veterans may not be denied necessary medical care based on HIV status, and Standard Precautions to prevent exposure to blood-borne pathogens should always be employed regardless of the patient's HIV infection status. (June 2005)

If the patient is expected to regain decision-making capacity in a reasonable period of time, a discussion about HIV testing should be deferred. If the patient is not expected to regain decision-making capacity in a reasonable period, a surrogate may provide consent for HIV testing. The proper procedures for identifying a surrogate are contained in the Informed Consent Handbook (VHA Handbook 1004.1) This document also describes how to proceed when testing is medically indicated for the care of the patient and no surrogate is available. (June 2005)

Pre-test counseling should be documented with a progress note in the medical record. The progress note may refer to the informed consent document to describe the content of the counseling, but should be supplemented with any additional, relevant information necessary to describe unique situations or questions that may arise during an individual counseling session. If the iMedConsent process is used, a progress note will be generated automatically upon completion of the informed consent document. (June 2005)