Introduction.
In 2006, the Centers for Disease Control and Prevention (CDC) recommended that healthcare providers should shift away from targeting HIV testing based on risk factors and move towards a strategy of routine screening for all persons between the ages of 13 and 64 [1]. This was in response to findings that an estimated 21% of HIV-infected individuals in the United States are unaware of their HIV status [2], and many others are diagnosed late in infection [3], [4]. Routine screening has potential advantages over targeted testing because HIV-infected persons frequently access care prior to diagnosis [3], [5], [6] and routine screening may identify persons who are unaware of their risk or who do not disclose participation in risky behaviors if they are asked.

In 2009, Public Health - Seattle & King County (PHSKC) estimated that approximately 10–15% of the 7000–8000 persons living with HIV in King County, Washington were unaware of their HIV status [7]. In January 2010, the Washington Administrative Code (WAC 246–100–207) was revised to facilitate routine HIV screening by aligning state HIV testing rules with the 2006 CDC recommendations [Table 1]. Healthcare providers are no longer required to evaluate behavioral or clinical HIV risk factors prior to testing, provide pre-test risk-reduction counseling, or document consent for HIV testing. Under the new WAC, patients must be informed that HIV testing will be performed unless they opt out, and they must have an opportunity to ask questions. Post-test counseling is not required for persons with a non-reactive HIV test.

We designed this survey to ascertain the knowledge, attitudes, and practices of healthcare providers in King County regarding routine HIV screening, the CDC recommendations, and the 2010 WAC revisions. We were particularly interested in identifying any residual barriers that would prevent implementation of routine HIV screening.

Abstract
Objective
In 2006, the Centers for Disease Control and Prevention (CDC) recommended routine HIV screening in healthcare settings for persons between 13 and 64 years old. In 2010, the Washington Administrative Code (WAC) was changed to align testing rules with these recommendations. We designed this survey to ascertain the current state of HIV testing and barriers to routine screening in King County, Washington.

Methods
Between March 23 and April 16, 2010, a convenience sample of healthcare providers completed an online survey. Providers answered true-false and multiple choice questions about national recommendations and the WAC, policies in their primary clinical settings, and their personal HIV testing practices. Providers were asked to agree or disagree whether commonly reported barriers limited their implementation of routine HIV screening.

Results
Although 76% of the 221 respondents knew that the CDC recommended routine HIV screening for persons regardless of their risk, 99 (45%) providers reported that their primary clinical setting had a policy to target testing based on patient risk factors. Forty-four (20%) providers reported that their primary clinical setting had a policy of routine HIV screening, 54 (25%) reported no official policy, and 15 (7%) did not know whether a policy existed. Only 11 (5%) providers offer HIV testing to all patients at initial visits. When asked about barriers to routine screening, 57% of providers agreed that perception that their patient population is low risk limits the number of HIV tests they perform. Only 26 (13%) providers agreed that concern about reimbursement posed a barrier to testing.

Conclusions
Most providers participating in this survey continue to target HIV testing, despite knowledge of national recommendations. Efforts are still needed to educate providers and policymakers, clarify the recent WAC revisions, and implement structural changes in order to increase HIV testing in Washington State.