HIV Testing in the US Department of Veterans Affairs, 2009-2010 FREE

The US Department of Veterans Affairs (VA) is the nation's largest single provider of human immunodeficiency virus (HIV) care. Veterans with HIV infection in VA care receive HIV care at all 152 VA Medical Centers (VAMCs) and throughout all 21 of the VA's Veterans Integrated Service Networks (VISNs). To date, nearly 64 000 Veterans have received HIV care in the VA, and in 2009, more than 24 000 Veterans with HIV were receiving care at the VA.¹

Congressional repeal of long-standing requirements barring widespread HIV testing and requiring written informed consent allowed for change in VA HIV testing policy. In August 2009, the VA aligned its HIV testing policies with the 2006 recommendations on HIV testing by the US Centers for Disease Control and Prevention² to offer voluntary HIV testing to all veterans, regardless of age, as part of routine health care at least once, and annually for those veterans with ongoing risk factors. These policy changes also allowed informed consent for such testing to be obtained verbally at VAMCs, regardless of individual state law.

In late 2009, as part of its operational mission, the VA's Office of Public Health (OPH) deployed a validated, standardized application to collect HIV testing information from the electronic health record (EHR) at all VAMCs for quality improvement purposes, representing the first time that VA has systematically collected and reported national HIV testing data. Using this application, we determined VA HIV testing rates for 2009 and 2010.

The application reported the number of all unique patients who had had an outpatient visit at a given VAMC, the number who had ever had an HIV test, the number who had an HIV test in that calendar year, and the number with positive test results in that year. Data were analyzed at the VAMC, VISN, and national level. This Research Letter presents national level data; data are reported without attempt to assess causality or quantify specific impact of the change in pertinent federal law and VA policy or evaluate quality improvement interventions directed at increasing HIV testing rates.

The Table provides a summary of the 2009 and 2010 data. In 2009, there were 5 713 265 veterans with at least 1 outpatient visit; 9.2% (524 267) had documentation of HIV testing ever being performed, and 2.5% (142 345) received an HIV test during that calendar year. Of those tested in 2009, 1.2% (1739) had a positive HIV test result. In 2010, 5 888 599 veterans had at least 1 outpatient visit; 13.5% (795 126) had ever been tested for HIV in their lifetime, and 5.8% (341 414) received an HIV test during that calendar year. Of the 341 414 veterans tested for HIV, 0.7% (2233) had a positive test result.

In this Research Letter, we provide the annual HIV testing rates and results for 2009 and 2010 in the VA. Overall, the VA saw an increase in HIV testing from 2009 to 2010, with a 47% increase in both the proportion of veterans ever tested for HIV (9.2% to 13.5%) and a 132% increase in proportion of veterans tested in the calendar year (2.5% to 5.8%).

The data presented in this Research Letter were systematically collected using a validated software application, creating reports via automated electronic extraction from the EHR. This is the first time the VA has performed and reported such an analysis, providing a baseline assessment for future data collection.

There are several limitations to this report. First, the data are only unique at the VAMC level; if a veteran received 1 HIV test at 1 VAMC and then received another one at a different VAMC during the same calendar year, that patient would be counted twice in merged data. We do not believe this is a major source of inaccuracy, especially since clinicians at each VAMC are able to view EHR data obtained at other VAMCs, including HIV testing results, and avoid unnecessary test duplication. In addition, to be included in this analysis, a veteran must have had 1 outpatient visit in the calendar year. It is possible that there are some veterans enrolled in VA care who may not have had an outpatient visit in 2009 and/or 2010 and would not be included in this analysis for 1 or both years.

In conclusion, the VA has increased its HIV testing from 2009 to 2010; however, there is still room for improvement. It is current VA policy that every veteran be offered HIV testing at least once in a lifetime, regardless of risk factors and age, and that all veterans identified as HIV positive be linked to high-quality comprehensive care in a timely manner. The VA's OPH will continue to collect annual HIV testing data and strive to improve HIV testing rates throughout the entire VA system.