Opt-out HIV testing feasible and acceptable

Michael Carter
Published: 01 June 2009

Opt-out HIV testing in a sexual health clinic is feasible and acceptable, Dutch investigators report in the May edition of Sexually Transmitted Infections, but the patients most likely to opt out tend to be those with the highest risk of HIV.

There is concern across Europe about the large number of HIV-positive individuals who are undiagnosed. In the Netherlands, it is estimated that as many as 80% of heterosexual HIV infections are undiagnosed, as are between 40 and 60% of infections in gay men. A significant proportion of HIV cases in the UK are also undiagnosed, a situation which a recent editorial in The Lancet called “appalling”.

Due to concerns about the large number of undiagnosed individuals in the Netherlands, the sexual health clinic in South Limburg implemented a policy of opt-out HIV testing in 2004. It was the first sexual health clinic in the Netherlands to adopt such a policy.

Services offered by the clinic are free. Limburg has a population of 630,000 and because of its geographical location also attracts patients from Belgium and Germany.

Investigators retrospectively analysed the effectiveness of HIV testing between 2003 and 2007 and examined the reasons why individuals refused a test.

In the period of the study there were just under 13,000 consultations at the clinic. The number of consultations increased annually from a little over 1900 in 2003 to almost 4000 in 2007. The majority of patients (53%) were women, with 38% being heterosexual men and 9% gay men. A third of patients were over the age of 30.

Following the introduction of the opt-out testing policy, there was a marked increase in the number and proportion of patients tested for HIV. In 2003, 84% of patients tested for HIV, and this had increased to 96% in 2007.

Increases in HIV testing were observed in all demographic groups. There was also a marked decline in the proportion of patients refusing an HIV test, and in the second half of 2007 only 3% of heterosexual men and women and 2% of gay men refused an HIV test.

A total of 45 individuals (0.4%) tested HIV-positive. After the introduction of opt-out testing, the number of patients diagnosed with HIV increased from four in 2003 to ten in 2007.

The investigators found that the risk factors for refusing an HIV test appeared to be suggestive of a greater risk of HIV. The likelihood of HIV testing for heterosexuals decreased as their number of sexual partners increased. Furthermore, refusal of a test by heterosexuals was also associated with having a sexually transmitted infection present at the time of the visit to the clinic, symptoms of an infection, or being contacted by a partner and advised to attend for a sexual health check-up. For gay men, refusal of an HIV test was associated with age over 30 years, current symptoms of a sexually transmitted infection, and partner recommendation to attend the clinic.

Individuals refusing an HIV test were asked why, and the answer was recorded on their notes. A third of heteroseuxals and 11% of gay men said that this was because they thought they were in the 'window period'. A little over a fifth of heterosexuals and 28% of gay men perceived themselves to be at low risk of HIV, and 15% of heterosexuals and 18% of gay men reported a previous HIV test. Few heterosexual patients said they refused an HIV test because they feared the result, but this answer was given by 11% of gay men who declined an HIV test.

“We assessed a marked increase in the absolute and relative number of HIV tests at our STI clinic”, write the investigators.

They stress that for opt-out HIV testing to be effective it must be linked to HIV treatment and care services.

“Result of this study showed that standard testing on HIV in a STI clinic is feasible and effective in increasing awareness of one’s HIV status”, conclude the investigators. They add, “implementation of opting-out in a STI clinic can lead to more traced HIV infections and more people receiving timely anti-HIV treatment. It should be an essential part of STI screening…and should be considered in other healthcare settings for specific risk groups as well.”


Dukers-Muijrers NHTM et al. Effectiveness of an opting-out strategy for HIV testing: evaluation of 4 years of standard HIV testing in a STI clinic. Sex Transm Infect 85: 225-30, 2009.

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