Case Scenario A 41-year-old healt...

Case Scenario

A 41-year-old healthy male patient repeatedly presents at my office requesting human immunodeficiency virus (HIV) testing, if it be not that always refuses to give me a reason for his entreatys He came in again today, after a previous visit for the same reason sum of two units or three months ago. In fact, this is his fourth desire in the past 18 to 24 month I explained that routine HIV testing is not commended I asked him if he had any known outlook and he replied, "That's none of your business." I reviewed HIV-prevention precautions with him and informed him that following these precautions was sufficient protection from infection. His answer was: "I know all that, if it were not that I still want the test" I told him I did not think that it is appropriate to bill his insurance for his repeat testing. If he wanted the testing, he should pay abroad of pocket. Was I public of line in telling him this? What are my obligations in this setting to my patient and to the insurance company? To what volume can I require a patient to give me a risk history, when I be excited such a risk history helps optimize the care I can provide?

Commentary

sum of two units valuable questions are raised from this clinical dilemma in primary care. The first is whether it is appropriate to perform exhibitions at a patient's request without clear indications. The inferior is whether billing the insurance carrier for these proofs is proper. These questions are just as relevant for relatively inexpensive hematology and chemistry touchstones as they are for extremely expensive ordeals such as magnetic resonance imaging (MRI) to evaluate a variety of musculoskeletal complaints or the many times requested "heart scans" and "total body" MRIs. There are no all-inclusive formulas for deciding when to perform and bill for these touchstones so as primary care physicians we individualize each case, all beneath a degree of pressure to prove to satisfy the legitimate emergencys of our patients as well as those of insurance carriers. The proces is indeed imperfect and can be trying.

The difference in this case is that the patient is requesting an HIV proof Why is this different from other similar requests? The compelling reason for performing HIV testing for this patient is because this is an all-important primary care prevention opportunity equal in the absence of admitted risk factors. An estimated 25 percent of the approximate 850000 to 950000 HIV-positive bodily forms in the United States remain unaware of their infection. (1) Many are not diagnosed until they have advanced disease and therefore do not receive the benefit of earlier diagnosis and treatment. They may firing the epidemic by unknowingly transmit-ting HIV to others. Transmissions from these undiagnosed somebodys account for as many as brace thirds of the country's estimated 40000 of recent origin HIV infections each year. It has been shown that many infected ones decrease behaviors that transmit infection to their needle-sharing or sex partners one time they are aware that they have HIV. (2) Thus, early knowledge of infection is now recognized as a critical constituting in controlling the spread of the disease. The modern Advancing HIV Prevention initiative (1) has emphasized the importance of wider testing in primary care. The push toward broader testing as a powerful prevention tool is not simply understandable but also compelling. According to the Center for Disease check and Prevention's (CDC's) HIV Counseling and Testing Guidelines, (2) voluntary HIV testing and prevention counseling ideally should be furnished routinely to all patients. for what purpose do so many HIV-infected ones remain undiagnosed? Factors include fear of losing confidentiality, fear of finding not at home the diagnosis, failure to recognize or denial of) risk factors for infection, fear of discrimination, touch that the test can be falsely positive, and calm fear that the test can lead to HIV/AIDS. For a certain number of especially minority and poor patients, there can be affairs about the interaction with the health care connected view including lack of confidence that confidentiality will be honored, fear of HIV status being reported to agencies that superintend child and family care issues, financial considerations, touchs about decreased access to care, and fear of jeopardizing their existing health care.

more [i]or[/i] less patients, such as the the same in this scenario, likely will in no degree admit risk factors, even to their physicians. This patient's persistence in asking for the proof might indicate unprofessed risk factors, an obsessive be of importance to or other personal factors. Recognizing this all-too-common phenomenon, the federal guidelines (2) specifically address patients as it is as this one. Such patients "should receive additional HIV prevention counseling and follow-up testing when petitioned Efforts should be made to understand for what cause [i]or[/i] reason these clients repeatedly seek follow-up testing. These clients should be considered for in-depth prevention counseling and referral to support services, where appropriate." (2)

Any physician might be perceived stymied by this patient's "none of your business" rejoinder to a request for a risk history. The pair main possibilities for this patient's attitude have the appearance to be that the patient has an obsessive trait yet no real risk factors, or he has risk factors further will not disclose them. If the physician suspects the latter, there may be an ways to facilitate discussion and allow more [i]or[/i] less productive counseling to begin. Although it assumes difficult in this case, here are a hardly any thoughts: (1) give the patient positive reinforcement for his make anxious about his HIV risk and his repeated testing; (2) acknowledge that it can be embarrassing to discuss specific HIV risk behaviors; (3) be explicit about patient confidentiality issues; and (4) be complaisant and nonjudgmental. The physician might want to break the ice through discussing the approximate risk of various sexual behaviors (Table) or by the agency of using a written risk-screening questionnaire. (2) When the exhibition results are available, the physician should again review, in bodily substance the essentials of HIV prevention precautions with his patient. If the physician does not be perceived comfortable discussing specific risk behaviors nonjudgmentally, then he or she should impute the patient to local or regional counseling resources.