Consent Form Hiv Test (Page 11 of 42) in pdf

HIV testing is a process that uses FDA-approved tests to detect the presence of HIV, the virus that causes AIDS and to see how HIV is

affecting your body. The most common type of HIV test detects antibodies produced by the body after HIV infection. Test results are highly

reliable but a negative test does not guarantee that you are healthy. Generally, it can take up to three months for HIV antibodies to develop.

This is called the “window period.” During this time, you can test negative for HIV even though the virus is in your body and you can give it to

others. A positive antibody HIV test means that you are infected with HIV and can also give it to others even when you feel healthy.

There are two other tests available that can help you and your doctor understand how HIV is affecting your body. The first measures how much

virus is in your blood. This is known as a viral load test. The second measures the number of T-cells in your blood and is known as a

CD4/CD8 test. Viral load and CD4/CD8 tests can only be ordered by a qualified medical provider.

If you consent by filling out and signing this form you will be asked for a blood or oral sample. Generally, test results will be available in about 2

weeks. If a rapid HIV test is used, results will be available the same day. If the rapid test detects HIV antibodies, it is very likely that you are

infected with the virus, but this result will need to be confirmed. You will be asked to submit a second specimen for further testing. The results

from this confirmatory test will be available to you in about 2 weeks.

If you test positive, the local health department will contact you to help with counseling, treatment, case management and other services if you

need them and want them. You will be asked about sex and/or needle-sharing partners, and voluntary partner counseling and referral services

(PCRS) will be offered to you. The HIV test result will become part of your confidential medical record. If you are pregnant, or become

pregnant, the test results will become part of your baby's medical record.

If you test positive, we are requesting that you also allow your blood to be tested using the STARHS method. No additional blood is needed for

STARHS. STARHS was developed to estimate what percentage of people testing positive acquired their infection during the past year.

Learning how and where recent HIV transmission is happening will help us better understand the epidemic and how it affects our communities.

Finding HIV infection early can be important to your treatment, which along with proper precautions, helps prevent spread of the disease. If you

are pregnant, there is treatment available to help prevent your baby from getting HIV. If you have any questions, please ask your counselor,

physician, or call the Florida AIDS Hotline (1-800-FLA-AIDS or 1-800-352-2437) before signing this form.

Client must initial the consent statement and then sign below. The consent form must be dated and witnessed.

CONSENT GIVEN

REQUIRED

______YES ______NO

I have been informed about HIV testing and its benefits and limitations. I understand that some tests require

Initial Here

a second specimen to be taken from me for further testing.

_______________

______________________________________________

_________________________________________

Date

Signature of Client or Legal Representative

Client’s Printed Name

_____________________________________________________

____________________________________________________

Witness Signature

Legal Representative’s Relationship to the Client (If Applicable)

OPTIONAL

______YES ______NO

If I move out of the area or live somewhere else, I want my results forwarded to the appropriate public health

care

Initial Here

provider or the physician listed below so that I may be informed of my results and receive post-test

counseling.

If Applicable

____________________________________________________________________________________________

Preferred Physician or Facility and their Mailing Address

Instructions:

1. Please ensure that clients read and understand the information provided on this consent form. If clients are unable to read or understand this

information, the counselor should read it to them.

The client must initial each of the three consent statements as appropriate and sign and date the bottom of the form.

3. If a legal representative of the client signs the consent form, their relationship to the client must be indicated on the appropriate line.

4. In accordance with state protocol, if the client wants their results forwarded, the STD Program Manager will handle this transaction.

5 . All consent forms must have a witness signature. The counselor conducting the pre-test counseling can serve as the witness.

Attachment 1

DH1818, 05/05. (Obsoletes 03/04 edition which may not be used) Stock Number: 5740-000-1818-9

Operating Procedure 153-31

Consent Form Hiv Test Page 11

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