Section 699.APPENDIX A Sample HIV Testing Forms

Section 699.ILLUSTRATION B Sample Written Informed Consent to Perform a Rapid HIV Test in the Labor and Delivery Setting

WRITTEN INFORMED CONSENT TO PERFORM A RAPID

HIV TEST IN THE LABOR AND DELIVERY SETTING

Test Subject or

Number:

Date:

Time:

I hereby grant my permission for a test to detect whether I have antibodies to HIV (human immunodeficiency virus) in my body.

HIV testing is voluntary and requires your consent in writing. The purpose of rapid HIV testing is to show whether you are infected with HIV, the virus that causes AIDS.

If you are HIV infected, rapid HIV testing will allow you to receive immediate medication during labor and delivery to reduce the risk of transmitting HIV to your newborn, and will allow your baby to receive the same medication immediately after birth.

Before you consent to be tested for HIV, speak to your health care provider about:

· How HIV can be passed from person to person and mother to baby;

· Medication that may prevent the transmission of HIV from mother to baby;

· Illinois law that requires all newborn infants to be tested for HIV after birth if the mother's HIV status is unknown, unless the parent provides a written refusal; and

· The meaning of preliminary HIV test results and how a positive HIV test is confirmed.

If you agree with the following statements and want to consent to rapid HIV testing, please sign this form.

I have been counseled about the benefits of having a rapid HIV test and understand that:

· Human immunodeficiency virus (HIV) is the virus that causes AIDS.

· One of the ways in which HIV is spread is by sexual intercourse, so all sexually active women are potentially at risk for HIV infection.

· HIV can be passed from a mother to her baby during pregnancy, at delivery, and through breastfeeding;

· If I have HIV, it is a serious illness that can affect my health and the health of my baby.

· HIV antibody test results are confidential, and the law protects me from discrimination.

If I am found to be HIV infected, treatment is available to reduce the risk that HIV will be transmitted to my baby:

· If I have not yet delivered my baby, I may receive medication as soon as possible to reduce the chance of passing the virus to my baby.

· My baby may receive medication that reduces the risk of his/her becoming HIV infected.

· In many cases, medications prevent the risk of transmission of HIV. If these medications are given to me during labor and delivery, or to my newborn infant immediately after birth, the chance that my baby will be HIV infected is significantly reduced.

· If treatment is started, my health care provider will discuss with me any consequences of taking the medication.

I understand that a preliminary positive result does not mean that I have AIDS, but that my blood may have been exposed to the human immunodeficiency virus, and antibodies to that virus may be present in my body. I understand that if my test results are positive, I will be offered HIV counseling.

I understand that HIV test results may indicate that a person has HIV antibodies when the person does not have the antibodies (a false positive result) or the test may fail to detect that a person has antibodies to the virus when the person does in fact have these antibodies (a false negative result).

The test that I am consenting to take will provide me and my health care provider with results within 12 hours:

· If I have the rapid HIV test, I will be given the results no later than 12 hours after my blood is drawn.

· If the rapid HIV test result is negative, no further testing will be done at this time.

· If my rapid HIV test result is negative, it most likely means that I am not infected with HIV, but it may not detect recent infection.

· A preliminary positive HIV test result means there is a possibility that I am HIV infected and that my baby may have been exposed to HIV. A second test, to confirm a preliminary positive HIV test result, will be done.

· I understand that if my preliminary test result is positive, I still may not have HIV infection (false positive test results can occur), but it may be best to start treatment to help prevent the transmission of infection to my baby while I wait for the confirmatory test result.

All preliminary positive test results will be confirmed:

· If the confirmatory HIV test result is negative, I will immediately be taken off of medication that was started to help prevent transmission of HIV from me to my baby.

· If the confirmatory test is positive, any medication that was given to help to prevent transmission of HIV from me to my baby will be continued.

· If the confirmatory test is positive, I will be referred to a physician for my own ongoing medical care.

Confidentiality of HIV Information:

If you take the rapid HIV test, your test results are confidential. Under Illinois law, confidential HIV information can be given only to people to whom you allow it to be given by your written approval, to people who need to know your HIV status in order to provide medical care and services, including: an authorized agent or employee of a health facility or a healthcare provider if the health facility or provider is authorized to obtain test results; those who are exposed to blood/body fluids in the course of their employment; and organizations that review the services you receive.

The law also allows your confirmed HIV test results to be released: to public health officials as required by law; for payment for care and treatment; to a temporary caretaker of children taken into protective custody by the Illinois Department of Children and Family Services; and to any other entity permitted by the AIDS Confidentiality Act.

I understand that my test results will be kept confidential to the extent provided by law. In addition, I understand that I may withdraw from the testing at any point in time prior to the completion of laboratory tests. I understand that my testing is voluntary.

I agree to be tested using a rapid HIV antibody test and I agree that I may be told of my test results.

I have been counseled that if the result of the rapid HIV antibody test is preliminary positive, then I must undergo additional testing to confirm whether I am HIV positive. I consent to that additional testing.

I understand that a preliminary positive result from my rapid HIV antibody test will be released to designated health care professionals to provide necessary treatment to prevent HIV transmission from mother to child.

I agree that if the result of my HIV test is preliminary positive or if the result of my rapid HIV antibody test is confirmed positive, I may be referred to another health care provider for follow-up testing and care. I consent to the release of my medical information, including my HIV test results and contact information, to that provider for the purpose of follow-up testing and care.

If I choose not to have a rapid HIV test, I understand that:

· I may be positive for HIV, which is a serious illness that can affect my health and the health of my baby.

· I may be positive for HIV and may not receive appropriate treatment for this serious illness.

· I may be HIV positive and my child is at risk of my transmitting HIV to him/her through labor and delivery. As a result, my child could also be HIV positive. I understand that HIV in my child is a serious illness (see above) and this illness (see above) could result in my newborn infant's death, unless my newborn infant is tested and treated.

I have been advised about the purpose, potential uses, limitations, and meaning of the test results; the voluntary nature of the test; the right to withdraw consent at any time prior to the completion of laboratory tests; the medical risks if I refuse; and the confidentiality protections under the law. The information presented above has been completely and clearly explained to me, and all of my questions have been answered. I hereby authorize my physician or facility to collect an oral or blood specimen and perform an HIV antibody test on that specimen.

Patient/Client Signature or Signature of Legally Authorized Representative
Date
Facility/Provider Witness

Placement of My Medical Information in My Newborn Infant's Medical Record I understand that, in order to effectively treat my newborn infant, the results of the tests and my HIV status should be placed in my newborn infant's medical record. If this information is placed in my newborn infant's medical record, I understand that my test results and my HIV status in the newborn infant's medical record may be disclosed to those providing care and treatment to my newborn infant. I also understand that my information in my newborn infant's medical record may be disclosed to my spouse; to a legally authorized representative; to a person whom I have designated through an authorization (my written authorization permitting him or her to release my information); to my newborn infant at a later time; or to a court or other entity that has the legal authority to have access to my newborn infant's medical record.
YES. I consent to have my HIV test results and my HIV status placed in my newborn infant's medical record.
	Patient/Client Signature or Signature of Legally Authorized Representative
	Date
NO. I do not want my HIV test results and my HIV status placed in my newborn infant's medical record. I understand that this may adversely affect medical treatment for my newborn infant.
	Patient/Client Signature or Signature of Legally Authorized Representative
	Date