Background
Opt-out HIV testing is a novel concept in Australia. In the opt-out approach, health care providers (HCPs) routinely test patients for HIV unless they explicitly decline or defer. Opt-out HIV testing is only performed with the patients’ consent, but pre-test counselling is abbreviated [
1]. This approach to HIV testing uses the behavioural economics concept of default bias, which is the propensity to choose inaction over action [
2,
3] Australian national testing guidelines do not currently recommend opt-out HIV testing for the general population. HIV testing in Australia is “opt-in”, which means that testing is conducted according to risk factors (such as sexual or drug use practices), clinical indication (such as having another sexually transmitted infection), or by patient request [
1]. However, there has been a recent increase in HIV infections in Australia, with the highest number of HIV diagnoses in 20 years recorded in 2013 [
4]. In addition, up to 50 % of patients diagnosed with HIV have already developed immune deficiency [
4]. An Australian study showed that over half of the people with HIV sought health care in the year prior to their diagnosis [
5] which indicates that opportunities to test patients for HIV are being missed. Non-traditional approaches to HIV testing (such as opt-out) could identify HIV infections and facilitate earlier treatment, which is particularly important now that HIV is a chronic, manageable disease [
6,
7]. Opt-out testing approaches to other sexually transmitted infections like chlamydia, gonorrhoea, and hepatitis B have been found to be cost-effective and acceptable to patients [
8‐
10]. Experimental research has shown that opt-out testing is particularly effective in increasing testing rates and patient acceptance of stigmatised diseases such as HIV [
11].
Results published in systematic reviews have shown that opt-out HIV testing is generally acceptable to HCPs [
12‐
14]. However, these reviews were conducted in settings that may not be generalizable to Australia, such as low-and middle-income countries [
12] or sub-Saharan Africa [
13]. One systematic review of HIV testing in resource-rich countries included three Australian studies, but these studies did not address the opt-out approach or testing in the general population [
14]. A US systematic review addressed operational aspects of opt-out HIV testing, which may not be transferable to the Australian context due to differences between the countries’ health systems [
15]. A review of opt-out HIV testing in Australian antenatal clinics suggested that it was effective (expectant mothers are the only group in which opt-out HIV testing is recommended in Australia), but it may not be applicable to the general Australian population [
16]. Despite the plethora of international research on the topic, it is not known to what extent opt-out HIV testing is appropriate, acceptable, or feasible to HCPs in general health care settings in Australia. Two Australian studies indicated that educational barriers (such as a lack of HIV content during training) and operational barriers (such as time constraints) prevent Australian HCPs from seeing HIV as relevant to their practice. Informants also stated that Australian general practitioners should make HIV testing a routine part of their practice [
17,
18].
Acceptability and feasibility of the opt-out approach to HIV testing should be thoroughly explored from an HCP perspective before considering a change in testing practice. Diagnostic testing differs from other health interventions because only physicians (or other qualified HCPs) are legally permitted to order and receive financial reimbursement for tests. Fundamentally, every HIV test is the end result of an HCP’s decision-making process, which is affected by his or her attitudes, knowledge, experience, and training; and is influenced by colleagues, professional organisations, health systems, and financial incentives. This means that a change in HIV testing practice cannot occur without exploring the attitudes that influence HCPs’ decision-making processes. Our aim was to explore HCPs’ attitudes toward opt-out HIV testing in an Australian context, to further understanding of its acceptability and feasibility.
Discussion
This initial study of Australian HCPs’ views on opt-out HIV testing revealed new insights and some surprise findings. The majority of participants’ views fell into one of two mutually exclusive categories: favouring or questioning. Participants who tended to question opt-out HIV testing doubted its relevance to Australia, focused on the method’s flaws, and emphasised potentially negative consequences. Surprisingly, they did not identify some of the barriers to opt-out HIV testing that commonly appeared in previous research, such as operational issues [
15,
26,
27], time constraints [
28‐
30] or inadequate linkage to HIV care [
31]. Conversely, participants who were generally comfortable with opt-out HIV testing had similar views to those identified in previous research, such as placing HIV testing in the same domain as testing for other diseases [
27,
31]. Finally, pilot studies provide useful data about changes in clinical practice before wider implementation, but participants in this study did not suggest a pilot test of opt-out HIV testing in an Australian setting.
Participants who had a questioning attitude toward opt-out HIV testing doubted its relevance to the general Australian population, citing a lack of evidence for efficacy in lower prevalence populations. Australia has a low HIV prevalence by global standards; however, the idea that HIV testing is irrelevant in areas with low rates of infection has been considered the “false security” of low prevalence [
29] (p.75), potentially resulting in delayed HIV diagnosis. Participants in this category stated they were able to accurately determine which patients should be tested based on their characteristics (such as age or suburb of residence), a strategy that previous studies have shown to be ineffective in identifying HIV infections [
5,
32‐
34]. Opt-out HIV testing could decrease the potential for error in patient risk assessment.
Participants who questioned the opt-out approach to HIV testing tended to focus on its potential flaws, which may reflect HCPs’ analytical style [
35‐
39]. While HCPs are trained to look for logical negatives (for instance, they might ask themselves, “what is wrong with this picture?” in the diagnostic process), this frame of mind could lead to pessimism about changes in practice [
40]. Studies have shown that HCPs are particularly reluctant to change their practice in view of new evidence [
35] and are prone to “paralysis by analysis”—which occurs when the discussion about a change becomes so arduous that no action is taken [
41]. Our data also suggest that HCPs sometimes make decisions about HIV testing based on personal beliefs and values, not necessarily logical reasoning, which is consistent with behavioural economic theory [
42]. A change in HIV testing practice should take into account these common HCP analytical patterns. A small, incremental trial should provide feasibility data that could be used to determine the efficacy of opt-out HIV testing, without ‘forcing’ HCPs into a major change too quickly [
43].
Some HCPs seemed to need more support and education about HIV testing and disclosure of results. Participants who viewed opt-out HIV testing less favourably were worried about potential negative consequences, such as stigma, anxiety and suicide, supporting previous research findings [
29,
31,
44,
45]. Studies have shown that HCP education can facilitate implementation of opt-out HIV testing (which would be especially important in Australia, given that many participants in this study had limited knowledge of, or experience with, the approach) [
46]. Academic detailing (brief, one-on-one education sessions) prior to large-scale implementation of opt-out HIV testing has been shown to increase its acceptance among HCPs [
47]. Peer-based education could be particularly effective because it provides a social reference for HCPs (who are often unconsciously influenced by their peers) [
48,
49]. Because many participants in our study were worried about disclosing HIV-positive results, HCPs should receive education about best practices for disclosure, ideally with a protocol for linkage to HIV care already in place [
14,
45,
50]. Education programs have also been shown to promote positive HCP attitudes toward opt-out HIV testing, with HCPs citing patient behaviour change and reduced HIV transmission as affirming aspects of the approach [
31,
51].
Although they tended to disapprove of opt-out HIV testing for the general Australian population, participants who had a questioning attitude had flexible beliefs: they were not necessarily opposed to opt-out HIV testing, provided there was Australian evidence of efficacy and cost-effectiveness. They were willing to revise their attitudes based on new information or experience, which has been associated with increased acceptance of opt-out HIV testing [
32]. Research about opt-out HIV testing has shown that ongoing quality improvement activities (particularly with HCP participation) are essential for making changes in practice [
52]. Similarly, knowledge translation studies have demonstrated the importance of short-term, small-scale pilot tests before expanding new programs [
53]. Surprisingly, regardless of whether they were comfortable with opt-out HIV testing, participants in this study did not suggest short-term trials or small-scale quality improvement projects before considering broader implementation.
Few participants who were comfortable with opt-out HIV testing mentioned its cost, indicating that for them, potential benefits of the approach outweighed the costs. There is scant international evidence about HCP views on the cost of opt-out HIV testing. Further, most studies on opt-out HIV testing were conducted in the US and funded by federal grants, which may account for the lack of cost concerns among US participants [
53]. Future research should explore HCP attitudes about the cost of opt-out HIV testing and their effects on changes in testing practice.
This study has provided an initial insight into the acceptability of opt-out HIV testing in Australia. While some HCPs have embraced the opt-out approach, risk factor-based HIV testing remained entrenched among some participants. Subsequent research could best inform future HIV testing recommendations by addressing the issues raised by the HCPs who viewed opt-out HIV testing less positively [
54]. Given some participants’ concerns about over-testing and excessive cost, existing Australian cost-effectiveness modelling data should be more widely disseminated and replicated [
55]. Efficacy and feasibility data about opt-out HIV testing through a pilot study in an Australian context could meet HCPs’ need for evidence [
32]. Finally, Australian research on opt-out HIV testing should explore the operational barriers (such as time constraints) identified in international research.
Methodological considerations
Our results should be interpreted within their methodological context. The interviews were conducted by a clinician-researcher (SL) who had experience with opt-out HIV testing in the US (where the opt-out approach has been recommended for nearly a decade). During the interviews, the participants sometimes asked the researcher questions about opt-out HIV testing in the US, which was a diversion from the aim of the research, and may have influenced their views (but also supported their need for education). Although we actively recruited participants with negative or differing opinions about opt-out HIV testing, the sampling method may have resulted in a limited spectrum of perspectives. Due to the small sample size, we were not able to make separate subgroup analyses within the sample, such as a comparison of attitudes between HCPs with different levels of experience. Another limitation was that the participants practiced in one Australian state, which may not represent the full range of Australian HCPs’ views.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
SL: Conceived and designed the research, conducted interviews, analysed data, and wrote the manuscript. RM: Conceived and designed the research, analysed data, and revised the manuscript. DB: Conceived and designed the research, analysed data, and revised the manuscript. SW: Revised the manuscript. SG: Conceived and designed the research, analysed data, and revised the manuscript. All authors have read and approved the final manuscript.