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Human immunodeficiency virus (HIV) testing is the gateway to antiretroviral treatment and behavior prevention; however, due to several real-world challenges and barriers, HIV testing in healthcare settings often falls short of desired uptake (1-2). Yunnan Province is a high HIV prevalence area in China (3). To further expand HIV testing services and help more HIV-infected individuals learn their status, a policy was implemented in January 2020 offering free opt-out HIV screening tests to all patients receiving bloodwork testing in hospitals. This study retrospectively analyzed the impact of this policy by incorporating HIV screening into routine services in hospitals in Xishuangbanna Prefecture, Yunnan Province, where the estimated HIV prevalence was 0.26% in 2019 (Unpublished data from Yunnan Provincial CDC). Results showed that following the implementation of routine HIV screening in Xishuangbanna Prefecture, the number of HIV screenings and positive results increased 2.08-fold and 1.88-fold, respectively, and the positive rate of HIV screening in primary-level hospitals increased significantly from 0.12% to 0.14%. To our knowledge, this is the first study in China to provide practice-based evidence of the effectiveness of implementing routine HIV testing in healthcare settings.
After implementing a policy of routine HIV screening in hospitals, patients were informed of a free opt-out HIV screening test provided in bloodwork testing. Prominently posted signs in the blood collection area stated that HIV testing was provided at no cost for all patients who received bloodwork testing and that those who did not wish to have HIV testing could refuse. This ensured that patients were fully informed about routine HIV testing in hospitals and that physicians did not require additional consultation or informed consent.
In this study, HIV testing data from all 43 public hospitals in Xishuangbanna, including 2 tertiary hospitals, 4 secondary hospitals, and 37 primary hospitals, were collected through an official survey organized by the health administration in Xishuangbanna from January 2019 to December 2020, with January to December in 2019 and 2020 as the reference and implementation periods, respectively. SPSS (version 22.0, IBM Corp., Armonk, NY.) was used for data analysis. The positive rate of HIV screening was compared using the Pearson chi-square test, and P<0.05 was considered statistically significant.
A total of 1,078,845 HIV screening tests were recorded from January 2019 to December 2020. During the 2020 implementation period, HIV screening and positive results increased 2.08-fold (728,331/350,514) and 1.88-fold (1,413/752), respectively, compared to the 2019 reference period. However, the overall positive rate of HIV screening decreased slightly but significantly from 0.21% to 0.19% (P=0.026) (Table 1).
Visit types Reference period Implementation period P value§ Screening
NPositive
NPositive rate
% (95% CI)P value* Screening
NPositive
NPositive rate
% (95% CI)P value† Total 350,514 752 0.21 (0.20–0.23) 728,331 1,413 0.19 (0.18-0.20) 0.026 Hospital tiers <0.001 <0.001 Tertiary 84,815 314 0.37 (0.33–0.41) 153,960 488 0.32 (0.29–0.35) 0.031 Secondary 72,704 214 0.29 (0.25–0.33) 91,214 260 0.29 (0.26–0.33) 0.728 Primary 192,995 224 0.12 (0.11–0.14) 483,157 665 0.14 (0.13–0.15) 0.027 Abbreviation: HIV=human immunodeficiency virus; CI=confidence interval.
* P value of Chi-square test compares the positive rate of HIV screening among different hospital tiers in the reference period (January to December 2019).
† P value of Chi-square test compares the positive rate of HIV screening among different hospital tiers in the implementation period (January to December 2020).
§ P value of Chi-square test compares the positive rate of HIV screening for the same hospital tiers between the reference and implementation periods.Table 1. Volumes and yields of routine HIV screening in 43 hospitals in Xishuangbanna Prefecture, Yunnan Province, January 2019 to December 2020.
According to the tiers of hospitals, HIV screening tests increased 1.82-fold (153,960/84,815), 1.25-fold (91,214/72,704), and 2.50-fold (483,157/192,995) in tertiary, secondary, and primary hospitals, respectively. HIV-positive results increased 1.55-fold (488/314), 1.21-fold (260/214), and 2.97-fold (665/224) in the hospitals at tertiary, secondary, and primary levels, respectively. In both the reference period and implementation period, the positive rate of HIV screening showed statistical significance (χ22019=205.07, P<0.001; χ22020=238.55, P<0.001) in different tiers of hospitals. Following implementation of the policy, the positive rate of HIV screening in primary hospitals increased significantly from 0.12% to 0.14% (χ2=4.89, P=0.027). In contrast, the positive rate of HIV screening in tertiary hospitals decreased significantly from 0.37% to 0.32% (χ2=4.63, P=0.031) (Table 1).
When investigating the effect of routine HIV screening in specialized departments, we only used information from tertiary and secondary hospitals, as primary hospitals generally do not have many specialized departments. The positive rate of HIV screening varied among different departments (χ22019=297.32, P<0.001; χ22020=369.15, P<0.001) in both reference and implementation periods. The top four departments with high positive rates of HIV screening were the Dermatovenereal Department, Infectious Diseases Department, Rehabilitation Department, and Emergency Department. Following implementation of the policy, the positive rate of HIV screening in the Dermatovenereal Department decreased significantly from 1.57% to 0.90% (χ2=10.06, P=0.002) (Table 2).
Visit types Reference period Implementation period P value§ Screening
NPositive
NPositive rate
% (95% CI)P value* Screening
NPositive
NPositive rate
% (95% CI)P value† Total 157,519 528 0.34 (0.31–0.37) 245,174 748 0.31 (0.29–0.33) 0.097 Departments <0.001 <0.001 Internal medicine 35,270 128 0.36 (0.30–0.43) 48,318 148 0.31 (0.26–0.36) 0.159 Gynecology and obstetrics 31,377 42 0.13 (0.10–0.18) 40,184 60 0.15 (0.12–0.19) 0.587 Emergency 26,186 119 0.45 (0.38–0.54) 31,349 171 0.55 (0.47–0.64) 0.125 Medical examination 21,179 40 0.19 (0.14–0.26) 64,511 95 0.15 (0.12–0.18) 0.185 Surgery 19,320 52 0.27 (0.21–0.35) 29,250 104 0.36 (0.30–0.44) 0.100 Ophthalmology and otorhinolaryngology 5,944 18 0.30 (0.19–0.47) 6,086 17 0.28 (0.17–0.45) 0.811 Infectious diseases 5,115 54 1.06 (0.81–1.38) 2,070 32 1.55 (1.10–2.18) 0.084 Pediatric 4,536 9 0.20 (0.11–0.38) 3,633 8 0.22 (0.11–0.43) 0.830 Dermatovenereal 3,059 48 1.57 (1.19–2.08) 9,706 87 0.90 (0.73–1.11) 0.002 Traditional Chinese medicine 2,463 2 0.08 (0.02–0.29) 6,315 11 0.17 (0.09–0.31) 0.309 Rehabilitation 1,528 10 0.65 (0.35–1.19) 1,788 8 0.45 (0.23–0.88) 0.419 Other 1,542 6 0.39 (0.18–0.85) 1,964 7 0.36 (0.18–0.74) 0.874 Abbreviation: HIV=human immunodeficiency virus; CI=confidence interval.
* P value of Chi-square test compares the positive rate of HIV screening among different hospital tiers in the reference period (January to December 2019).
† P value of Chi-square test compares the positive rate of HIV screening among different hospital tiers in the implementation period (January to December 2020).
§ P value of Chi-square test compares the positive rate of HIV screening for the same hospital tiers between the reference and implementation periods.Table 2. Volumes and yields of routine HIV screening in 6 secondary/tertiary hospitals in Xishuangbanna Prefecture, Yunnan Province, January 2019 to December 2020.
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