Improving HIV screening and receipt of results by nurse-initiated streamlined counseling and rapid testing

"How much more on the nurse?:" a qualitative analysis of inpatient nurses' perspectives on offering HIV testing

BACKGROUND

The CDC recommends that all individuals who are hospitalized be offered HIV testing. Low HIV testing rates have been reported among hospitalized patients. We investigated expanding HIV testing among hospitalized patients at our medical center, and hospital leadership consistently recommended exploring nursing-driven, universal HIV testing. The goal of this study was to use qualitative methods to evaluate Tufts Medical Center inpatient nurses' perspectives about the barriers and facilitators of implementing an inpatient nursing-based HIV testing protocol.

METHODS

The study employed a qualitative research design through in-depth interviews and focus groups; these guides were developed based on Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Any inpatient nurse employed at Tufts Medical Center in January 2023 was eligible to participate, including case managers and travel nurses. Nurses were recruited through in-person recruitment, email, or flyers.

RESULTS

42 inpatient nurses participated in ten focus groups and two interviews. Eight primary themes emerged that were categorized into barriers and facilitators/strategies. The barriers were (1) concern that HIV testing would increase the nurse charting burden, (2) belief that HIV testing is not a priority for hospitalized patients, (3) concern that HIV testing consent is outside the scope of nursing practice, (4) misinformation about the required HIV testing consenting process, and (5) concern about offending patients. The facilitators/strategies were (6) belief that HIV testing is necessary for personal health, beneficial to public health and necessary for occupational safety; (7) ability to leverage existing systems of care support to HIV testing; and (8) ability to leverage current systems of education to increase HIV testing. Results showed that fostering trust within treatment teams and between patients and nurses would enable nurses to obtain patient consent for HIV testing without fear of negative consequences.

CONCLUSIONS

While nurses have concerns about offering HIV testing to all hospitalized patients, there are existing systems that can be leveraged to make implementing of universal, nursing-driven HIV testing acceptable and sustainable; these include protocolization; engagement and trust; and nursing champions of expanding HIV testing.

Increasing Screening for Sexually Transmitted Infections Among Adolescents and Young Adults Diagnosed With Sickle Cell Disease: A Quality Improvement Project

BACKGROUND

Sexually transmitted infections (STIs) affect 20 million adolescents and young adults in the United States annually.

LOCAL PROBLEM

In a pediatric outpatient sickle cell disease clinic in the southeastern United States, 16% (43/272) of patients aged 16-24 years had a documented sexual health history, and 12% (4/77) completed STI screenings. The clinic aimed to increase sexual health assessment, STI screenings, diagnosis, and treatment.

METHODS

Using process redesign, a standardized sexual health and STI screening process at routine visits was implemented to increase the completion of sexual health histories and STI screening.

RESULTS

Sexual health history collection rates increased from 16% (43/272) pre-intervention to 92% (107/116) pos-tintervention. The rate of STI testing offered increased from 12% (5/43) preintervention to 100% (116/116) postintervention. The STI testing rates increased 22.5% from 40% (2/5) pre-intervention to 49% (20/41) post-intervention.

CONCLUSIONS

Evidence-based standardized interventions can successfully be used to assist in sexual health documentation and STI screening.

Financing Benefits and Barriers to Routine HIV Screening in Clinical Settings in the United States: A Scoping Review

The Centers for Disease Control and Prevention recommends everyone between 13-64 years be tested for HIV at least once as a routine procedure. Routine HIV screening is reimbursable by Medicare, Medicaid, expanded Medicaid, and most commercial insurance plans. Yet, scaling-up HIV routine screening remains a challenge. We conducted a scoping review for studies on financial benefits and barriers associated with HIV screening in clinical settings in the U.S. to inform an evidence-based strategy to scale-up routine HIV screening. We searched Ovid MEDLINE®, Cochrane, and Scopus for studies published between 2006-2020 in English. The search identified 383 Citations; we screened 220 and excluded 163 (outside the time limit, irrelevant, or outside the U.S.). Of the 220 screened articles, we included 35 and disqualified 155 (did not meet the eligibility criteria). We organized eligible articles under two themes: financial benefits/barriers of routine HIV screening in healthcare settings (9 articles); and Cost-effectiveness of routine screening in healthcare settings (26 articles). The review concluded drawing recommendations in three areas: (1) Finance: Incentivize healthcare providers/systems for implementing HIV routine screening and/or separate its reimbursement from bundle payments; (2) Personnel: Encourage nurse-initiated HIV screening programs in primary care settings and educate providers on CDC recommendations; and (3) Approach: Use opt-out approach.

Waiting for medical test results: A delay discounting approach

RATIONALE AND OBJECTIVE

Delay discounting is the devaluation of an outcome as a function of delay until receiving that outcome. In two studies, we used a delay discounting approach to examine how wait times for a medical diagnosis can affect people's decision to undergo medical testing.

METHODS

In Study 1 (N = 151), participants rated the likelihood they would get tested for a severe and a mild disease with wait times ranging from 0 to 180 days (within persons). Study 2 (N = 400) randomized disease severity (severe vs. mild) between persons and manipulated disease curability (curable vs. incurable).

RESULTS

Likelihood of testing decreased as delay until receiving test results increased. This effect of delay on testing was stronger for the mild than for the severe disease, and for the curable than for the incurable disease.

CONCLUSIONS

We found strong evidence for a delay discounting effect, an effect that varied depending on aspects of diseases. The findings illustrate how delay discounting can affect screening uptake and how it is moderated by disease characteristics.

Informed consent for HIV screening in the emergency departments and human rights in patient care: seeking the right balance

HIV exceptionalism refers to the fact that the illness is so different from other diseases that testing needs a special approach to informed consent. HIV infected people often visit health clinics, especially emergency departments, years before receiving a diagnosis without being tested for HIV. There is considerable public interest in increasing HIV testing in emergency departments. However, because these departments are sensitive environments that primarily provide urgent and emergency care, a number of ethical questions have been raised about the appropriateness of these settings for the implementation of universal screening programs. Human rights in patient care therefore constitutes an essential theoretical framework for analyzing ethical and legal dilemmas that arise in clinical encounters, thus strengthening the application of human rights principles to the context of patient care.

Informed consent for HIV screening in the emergency departments and human rights in patient care: seeking the right balance

Abstract HIV exceptionalism refers to the fact that the illness is so different from other diseases that testing needs a special approach to informed consent. HIV infected people often visit health clinics, especially emergency departments, years before receiving a diagnosis without being tested for HIV. There is considerable public interest in increasing HIV testing in emergency departments. However, because these departments are sensitive environments that primarily provide urgent and emergency care, a number of ethical questions have been raised about the appropriateness of these settings for the implementation of universal screening programs. Human rights in patient care therefore constitutes an essential theoretical framework for analyzing ethical and legal dilemmas that arise in clinical encounters, thus strengthening the application of human rights principles to the context of patient care.

Improving sexually transmitted infection screening, testing, and treatment among people with HIV: A mixed method needs assessment to inform a multi-site, multi-level intervention and evaluation plan

Bacterial sexually transmitted infections (STIs) continue to be a worsening public health concern in the United States (US). Though the national incidence of HIV infection has decreased over recent years, that of chlamydia, gonorrhea, and syphilis have not. Despite national recommendations on prevention, screening, and treatment of these STIs, these practices have not been standardized. Nine Health Resources and Services Administration Ryan White HIV/AIDS Program funded clinics across 3 US jurisdictions (Florida, Louisiana, and Washington, DC), were selected as clinical demonstration sites to be evaluated in this mixed method needs assessment to inform a multi-site, multi-level intervention to evaluate evidence-based interventions to improve STI screening and testing of bacterial STIs among people with or at risk for HIV. These 3 US jurisdictions were selected due to having higher than national average incidence rates of HIV and bacterial STIs. Descriptive statistics and deductive analysis were used to assess quantitative and qualitative needs assessment data. Results indicate the following needs across participating sites: inconsistent and irregular comprehensive sexual behavior history taking within and among sites, limited routine bacterial STI testing (once/year and if symptomatic) not in accordance with CDC recommendations, limited extragenital site gonorrhea/chlamydia testing, limited annual training on STI-related topics including LGBTQ health and adolescent/young adult sexual health, and limited efforts for making high-STI incidence individuals feel welcome in the clinic (primarily LGBTQ individuals and adolescents/young adults). These findings were used to identify interventions to be used to increase routine screenings and testing for bacterial STIs.

Ending the HIV Epidemic Among Persons Who Inject Drugs: A Cost-Effectiveness Analysis in Six US Cities

BACKGROUND

Persons who inject drugs (PWID) are at a disproportionately high risk of HIV infection. We aimed to determine the highest-valued combination implementation strategies to reduce the burden of HIV among PWID in 6 US cities.

METHODS

Using a dynamic HIV transmission model calibrated for Atlanta, Baltimore, Los Angeles, Miami, New York City, and Seattle, we assessed the value of implementing combinations of evidence-based interventions at optimistic (drawn from best available evidence) or ideal (90% coverage) scale-up. We estimated reduction in HIV incidence among PWID, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) for each city (10-year implementation; 20-year horizon; 2018 $ US).

RESULTS

Combinations that maximized health benefits contained between 6 (Atlanta and Seattle) and 12 (Miami) interventions with ICER values ranging from $94 069/QALY in Los Angeles to $146 256/QALY in Miami. These strategies reduced HIV incidence by 8.1% (credible interval [CI], 2.8%-13.2%) in Seattle and 54.4% (CI, 37.6%-73.9%) in Miami. Incidence reduction reached 16.1%-75.5% at ideal scale.

CONCLUSIONS

Evidence-based interventions targeted to PWID can deliver considerable value; however, ending the HIV epidemic among PWID will require innovative implementation strategies and supporting programs to reduce social and structural barriers to care.

U.S. nurse practitioners' HIV screening behaviors and health center characteristics

ABSTRACT

One of the most effective strategies to end the human immunodeficiency virus (HIV) epidemic is HIV screening technologies. Routine HIV screening reaches the first-time tester, people with undiagnosed HIV, and those persons who are in need of frequent retesting due to their ongoing risk. This secondary analysis examined nurse practitioners' (NPs) rates of offering routine HIV screening and health center HIV screening characteristics. A convenience sample of NPs completed either a paper and pencil or an online survey in February 2016. Nurse practitioners responded to several questions about their behaviors and the health center characteristics where they work related to HIV screening. Many NPs (31%) never offer routine HIV screening to patients. Efforts are needed to implement structural changes to increase HIV screening rates among NPs and the health centers where they work. Nurse practitioners, health centers, and the health center policies must align to address the HIV epidemic and implement national HIV screening recommendations.

Screening for Military Sexual Trauma Is Associated With Improved HIV Screening in Women Veterans

OBJECTIVE

To examine factors associated with HIV screening among women veterans receiving health care in the Department of Veterans Affairs.

MATERIALS AND METHODS

Cross-sectional study of women veterans receiving Veterans Affairs care between 2001 and 2014 derived from the Women Veteran's Cohort Study. Descriptive and bivariate statistics were calculated comparing patients with and without an HIV screen. Generalized estimating equations were conducted to estimate the odds of HIV screening among women screened for military sexual trauma (MST) and the subset with a positive MST screen. Multivariable analyses were adjusted for demographic characteristics, mental health diagnoses, pregnancy, HIV risk factors, and facility level clustering.

RESULTS

Among the 113,796 women veterans in the sample, 84.3% were screened for MST and 13.2% were screened for HIV. Women screened for MST were over twice as likely to be tested for HIV (odds ratio, 2.8; 95% confidence interval, 2.2-3.5). A history of MST was inversely associated with HIV screening (odds ratio, 0.9; 95% confidence interval, 0.8-0.9).

CONCLUSIONS

Women veterans screened for sexual trauma received more comprehensive preventive health care in the form of increased HIV screening.

Substance use, violence experiences, and mental health issues: are these health risks associated with HIV testing among sexually experienced U.S. high school students?

HIV testing is a critical strategy for prevention of HIV yet testing among sexually experienced adolescents is sub-optimal. The purpose of this study is to examine associations between risk behaviors and experiences related to substance use, violence, and mental health and suicide and receipt of testing. We analyzed cross-sectional data from the 2017 national Youth Risk Behavior Survey, a nationally representative sample of U.S. high school students in grades 9-12. Analyses were limited to sexually experienced participants (n = 5192). Measures included nine indicators related to substance use, violence, and mental health and suicide. Unadjusted and adjusted prevalence ratios were calculated for each indicator to examine associations with testing. Adjusted models controlled for same-sex sexual behavior, sexual risk, and demographic characteristics. Prevalence of HIV testing was 17.2%. In adjusted models, forced sexual intercourse, injection drug use, other illicit drug use, and persistent feelings of sadness or hopelessness were associated with a higher likelihood of testing. Prevalence of HIV testing in this sexually experienced sample was low. Some behaviors and experiences that may be indicative of HIV risk, including sexual dating violence and prescription opioid misuse, were not associated with testing.

Underutilization of HIV Testing Among Men with Incarceration Histories

Annual HIV testing is recommended for individuals at high risk of infection, specifically incarcerated populations. Incarcerated men carry a higher lifetime risk of acquiring HIV than the general population, yet little is known about their HIV testing behaviors. We collected Audio Computer Assisted Self Interview data for 819 men entering a state prison in North Carolina. We assessed correlates of previous HIV testing, including stigmatizing attitudes and beliefs, and explored two outcomes: (1) ever HIV tested before current incarceration, and (2) recency of last HIV test. Eighty percent had been HIV tested before; of those, 36% reported testing within the last year. Being African American, having education beyond high school, prior incarceration, and higher HIV knowledge increased odds of ever having tested. Results of this study highlight the need to expand HIV testing and education specific to incarcerated populations. Additionally, efforts should be made to monitor and encourage repeat screening.

Determining the factors associated with blood-borne virus testing of substance misusers presenting to hospital

BACKGROUND

Diagnosing blood-borne virus (BBV) infection is an essential first step in eliminating transmission and securing access to treatment amongst substance misusers.

AIMS

To determine the proportion of substance misusers presenting to hospital who undergo BBV testing and the factors influencing testing.

METHODS

A retrospective cross-sectional study was performed of patients presenting to two Sydney teaching hospitals with substance misuse diagnoses between January and April 2015. Proportions tested for human immunodeficiency virus, hepatitis C and hepatitis B previously and during the index hospitalisation presentation were examined. Multivariable analysis was performed to determine factors associated with testing.

RESULTS

Of 239 patients, 47 (19.7%) had a documented BBV at baseline. Of those with unknown BBV status, 29 (12.8%) had undergone some attempt at testing during presentation; 3.1% had their hepatitis B immunity assessed. Factors associated with an increased likelihood of testing during presentation included documented injecting drug use (odds ratio (OR) 15.14; 95% confidence interval (CI) 4.21-54.50; P < 0.001), admission under a physician (OR 11.79; 95% CI 2.82-49.40; P = 0.001) and admission on a Friday (OR 4.46; 95% CI 1.28-15.48; P = 0.02). Patients who had had more than one previous admission in the preceding 6 months (OR 0.24; 95% CI 0.078-0.73; P = 0.01) or a length of stay of 1 day or less (OR 0.17; 95% CI 0.032-0.87; P = 0.033) were less likely to be tested.

CONCLUSION

Despite the high baseline prevalence of BBV infections in the population, there were many missed opportunities for BBV testing. We found patient-, admission- and clinician-level barriers that could be addressed to enhance BBV testing uptake.

Measures and Metrics for Feasibility of Proof-of-Concept Studies With Human Immunodeficiency Virus Rapid Point-of-Care Technologies: The Evidence and the Framework

Supplemental digital content is available in the text.

Objective

Pilot (feasibility) studies form a vast majority of diagnostic studies with point-of-care technologies but often lack use of clear measures/metrics and a consistent framework for reporting and evaluation. To fill this gap, we systematically reviewed data to (a) catalog feasibility measures/metrics and (b) propose a framework.

Methods

For the period January 2000 to March 2014, 2 reviewers searched 4 databases (MEDLINE, EMBASE, CINAHL, Scopus), retrieved 1441 citations, and abstracted data from 81 studies. We observed 2 major categories of measures, that is, implementation centered and patient centered, and 4 subcategories of measures, that is, feasibility, acceptability, preference, and patient experience. We defined and delineated metrics and measures for a feasibility framework. We documented impact measures for a comparison.

Findings

We observed heterogeneity in reporting of metrics as well as misclassification and misuse of metrics within measures. Although we observed poorly defined measures and metrics for feasibility, preference, and patient experience, in contrast, acceptability measure was the best defined. For example, within feasibility, metrics such as consent, completion, new infection, linkage rates, and turnaround times were misclassified and reported. Similarly, patient experience was variously reported as test convenience, comfort, pain, and/or satisfaction. In contrast, within impact measures, all the metrics were well documented, thus serving as a good baseline comparator. With our framework, we classified, delineated, and defined quantitative measures and metrics for feasibility.

Conclusions

Our framework, with its defined measures/metrics, could reduce misclassification and improve the overall quality of reporting for monitoring and evaluation of rapid point-of-care technology strategies and their context-driven optimization.

Suboptimal HIV Testing Among Patients Admitted With Pneumonia: A Missed Opportunity

Patients admitted with pneumonia are at higher risk for HIV and should be routinely screened. We examined a retrospective cohort of patients admitted to Duke University Health System with a primary diagnosis of pneumonia. During the study period, 6,951 persons were admitted with pneumonia. Of 6,646 patients without a known prior diagnosis of HIV, 1,010 (15%) had HIV testing during admission and 1,516 (23%) had a previously documented HIV test result. Forty-one (0.6%) patients had a positive HIV test during admission and 27 (0.4%) patients were diagnosed with HIV a median of 498 (IQR 112-982) days later, with median CD4 count of 64 (IQR 16-281) cells/mm³. HIV testing rates remain low in a population at high risk for HIV. At a minimum, we should be adhering to universal HIV screening recommendations, and certainly we should be screening those at higher risk. Opt-out HIV testing of pneumonia inpatients should be implemented.

A comparison of effectiveness between oral rapid testing and routine serum-based testing for HIV in an outpatient dental clinic in Yuxi Prefecture, China: a case-control study

OBJECTIVE

To compare the outcomes of routine provider-initiated HIV testing and counselling (PITC) and oral rapid HIV testing for dental clinic outpatients in a hospital.

DESIGN

We employed a case-control study design and recruited dental outpatients into routine serum-based and oral rapid testing groups. We compared the acceptance, completion and result notification rate between groups.

SETTING

A dental outpatient clinic in the Yuxi People's Hospital, Yunnan.

PARTICIPANTS

A total of 758 and 816 dental outpatients were enrolled for routine and oral rapid testing, respectively.

RESULTS

The percentage of participants willing to receive routine HIV testing was 28.1% (95% CI 24.9% to 31.3%) and 96.1% (95% CI 94.8% to 97.4%, χ2=186.4, p<0.001) for the rapid testing. Among accepted participants, the percentage of participants who received HIV testing was 26.8% (95% CI 20.9% to 32.7%) in the routine testing group and 100.0% in the oral rapid HIV testing group (χ2=77.5, p<0.001). About 93.0% of routine testers returned for the test results on the next day, whereas all rapid testers received their test results on the same day (χ2=34.6, p<0.001). These correspond to an overall completion rate of 7.0% (95% CI 5.2% to 8.8%) and 96.1% (95% CI 94.8% to 97.4%, p<0.001), respectively. Among the 545 patients who declined routine serum-based HIV testing, the main reasons included, an unnecessary hassle (254/545, 46.6%), having been previously tested (124/545, 22.8%) and self-perceived low risk of HIV infection (103/545, 18.9%). In contrast, only 32 individuals declined oral rapid testing, and having received a previous test was the primary reason. Three patients in the rapid testing group were later confirmed HIV-positive, yielding an HIV prevalence of 0.38%.

CONCLUSION

Oral rapid HIV testing is a feasible and efficient approach in a clinical setting.

A Test of Concept Study of At-Home, Self-Administered HIV Testing With Web-Based Peer Counseling Via Video Chat for Men Who Have Sex With Men

Background

Men who have sex with men (MSM), particularly MSM who identify as African-American or Black (BMSM), are the sociodemographic group that is most heavily burdened by the human immunodeficiency virus (HIV) epidemic in the United States. To meet national HIV testing goals, there must be a greater emphasis on novel ways to promote and deliver HIV testing to MSM. Obstacles to standard, clinic-based HIV testing include concerns about stigmatization or recognition at in-person testing sites, as well as the inability to access a testing site due to logistical barriers.

Objective

This study examined the feasibility of self-administered, at-home HIV testing with Web-based peer counseling to MSM by using an interactive video chatting method. The aims of this study were to (1) determine whether individuals would participate in at-home HIV testing with video chat–based test counseling with a peer counselor, (2) address logistical barriers to HIV testing that individuals who report risk for HIV transmission may experience, and (3) reduce anticipated HIV stigma, a primary psychosocial barrier to HIV testing.  

Methods

In response to the gap in HIV testing, a pilot study was developed and implemented via mailed, at-home HIV test kits, accompanied by HIV counseling with a peer counselor via video chat. A total of 20 MSM were enrolled in this test of concept study, 80% of whom identified as BMSM.

Results

All participants reported that at-home HIV testing with a peer counseling via video chat was a satisfying experience. The majority of participants (13/18, 72%) said they would prefer for their next HIV testing and counseling experience to be at home with Web-based video chat peer counseling, as opposed to testing in an office or clinic setting. Participants were less likely to report logistical and emotional barriers to HIV testing at the 6-week and 3-month follow-ups.

Conclusions

The results of this study suggest that self-administered HIV testing with Web-based peer counseling is feasible and that MSM find it to be a satisfactory means by which they can access their test results. This study can serve as a general guideline for future, larger-scale studies of Web-based HIV test counseling for MSM.

Implementing HIV Testing in Substance Use Treatment Programs: A Systematic Review

People who use drugs are at increased risk for HIV acquisition, poor engagement in health care, and late screening for HIV with advanced HIV at diagnosis and increased HIV-related morbidity, mortality, and health care costs. This systematic review evaluates current evidence about the effectiveness and feasibility of implementing HIV testing in U.S. substance use treatment programs. The literature search identified 535 articles. Full text review was limited to articles that explicitly addressed strategies to implement HIV testing in substance use programs: 17 met criteria and were included in the review; nine used quantitative, qualitative, or mixed-method designs to describe or quantify HIV testing rates, acceptance by clients and staff, and cost-effectiveness; eight organization surveys described barriers and facilitators to testing implementation. The evidence supported the effectiveness and feasibility of rapid, routine, and streamlined HIV testing in substance use treatment programs. Primary challenges included organizational support and sustainable funding.

Establishing an HIV Screening Program Led by Staff Nurses in a County Jail

CONTEXT

Human immunodeficiency virus (HIV) testing in jails provides an opportunity to reach individuals outside the scope of traditional screening programs. The rapid turnover of jail populations has, in the past, been a formidable barrier to offering routine access to testing.

OBJECTIVE

To establish an opt-out, rapid HIV testing program, led by nurses on the jail staff, that would provide undiagnosed yet infected detainees opportunities to learn their status regardless of their hour of entry and duration of stay.

DESIGN

Jail nurses offered rapid, opt-out HIV testing.

SETTING

Fulton County Jail in Georgia, United States.

PARTICIPANTS

A total of 30 316 persons booked to Fulton County Jail.

INTERVENTION

In late 2010, we performed a preliminary evaluation of HIV seroprevalence. Starting January 1, 2011, HIV testing via rapid oral mucosal swab was offered to entrants. In March 2013, finger stick was substituted. Detainees identified as positives were assisted with linkage to care.

MAIN OUTCOME MEASURES

To estimate an upper limit of overall HIV prevalence among entrants, we determined seroprevalence by age and gender group. To measure program performance, we checked offer and acceptance rates for tests and rate of linkage to care among previously known and newly identified HIV+ detainees.

RESULTS

The initial seroprevalence of HIV in Fulton County Jail was at least 2.18%. Between March 2013 and February 2014, 89 new confirmed positives were identified through testing. During these 12 months, 20 947 bookings were followed by an offer of HIV testing (69.10% offer rate), and 17 035 persons accepted (81.32% acceptance rate). A total of 458 previously and newly identified persons were linked to HIV care. Linkage was significantly higher among those aged 40 years and older (P < .05).

CONCLUSIONS

A nurse-led, rapid HIV testing model successfully identified new HIV diagnoses. The testing program substantially decreased the number of persons who are HIV-infected but unaware of their status and promoted linkage to care.

Rapid HIV test in family practice

BACKGROUND

The 2010-2014 HIV/AIDS French program recommends using HIV rapid diagnostic tests in family practice. Our aim was to assess the acceptability and feasibility of the RDT in family practice in France.

METHODS

The first part of this study was to determine the opinions of family practitioners (FPs) concerning the news guidelines for screening and the possible use of rapid HIV tests in their practice. The second part was a feasibility study of the actual use of rapid HIV tests given to FPs during six months. The third part was a qualitative analysis of experience feedback to determine the impediments to using rapid HIV tests.

RESULTS

Seventy-seven percent of the 352 FPs interviewed were favorable to rapid HIV tests use. The three main impediments were: misinterpretation of test result, complexity of quality control, and lack of training: 23 of the 112 FPs having volunteered to evaluate the rapid HIV tests followed the required training session. Sixty-nine tests were handed out, and three rapid HIV tests were used; the qualitative study involved 12 FPs. The participants all agreed on the difficult use of rapid HIV tests in daily practice. The main reasons were: too few opportunities or requests for use, complex handling, difficulties in proposing the test, fear of having to announce seropositivity, significantly longer consultation.

CONCLUSION

Although FPs are generally favorable to rapid HIV tests use in daily practice, the feasibility and contribution of rapid HIV tests are limited in family practice.

The role of nurses in HIV screening in health care facilities: A systematic review

OBJECTIVE

To examine nurse-driven HIV screening in various health care settings in terms of its impact on test offering, acceptance and delivery rates, nursing responsibilities, staff perceptions and long-term implementation.

DESIGN

Systematic review.

REVIEW METHODS

The systematic review conducted in September 2014 adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Two independent reviewers extracted and summarised the eligible studies using a standardised form.

STUDY ELIGIBILITY CRITERIA

All studies published from 2004 to 2014 that explored nurse-driven HIV screening practice in health care facilities in countries with comparable concentrated HIV epidemics were included.

DATA SOURCES

MEDLINE, EBSCO CINAHL.

RESULTS

Overall, 30 quantitative, qualitative and mixed methods studies fulfilled the eligibility criteria. The studies showed a trend in higher test offering, better acceptance and higher delivery rates with the implementation of nurse-driven HIV screening. However, among the 23 studies (77%) that evaluated these aims, only 13 studies (56%) had a control group, and 4 studies (17%) were randomised controlled trials (RCT) in few centres (i.e., 1 or 2). In 2 studies that compared nurse-driven HIV test offering to physician intervention, the participation of nurses was higher than that of physicians (85% vs. 54%, p<0.001; 47% vs. 28%, p<0.05). In a third study, the intervention of a dedicated nurse increased the test offering from 96.5% to 99.5% (OR=7.27, 95% CI=1.02-316.9). Acceptance rates increased with the nurse intervention in 2 RCTs (75% vs. 71%, p=0.025; 45% vs. 19%, p<0.05) and in a cohort study (74.8% vs. 84.3%, OR=1.82, 95% CI=1.14-2.88), whereas it decreased in 2 other studies. The testing rates increased in 7 out of 10 studies, with a maximum absolute increase of 65.9%. Nurse-driven HIV screening was evaluated at the time of routine HIV screening implementation in 27 studies (90%) and provided nurses with new responsibilities in 9 studies (30%). The few studies (23%) that explored how health care professionals, including nurses, perceived the strategy showed that this approach was well received. However, several operational barriers, such as lack of time, prevented its long-term implementation.

CONCLUSION

The review supports the implementation of nurse-driven HIV screening. However, the evaluation of the impact of the nurse approach by RCTs was scarce, calling for additional research to better evaluate the impact of the nursing profession's contribution to HIV screening. Moreover, the perceptions of nurses and health care staff were seldom evaluated and require further exploration to improve nurse-driven HIV screening implementation.

Nurse-led clinic: effective and efficient delivery of assessment and review of patients with hepatitis B and C

BACKGROUND

Hepatology and gastroenterology services are increasingly utilising the skills and experience of nurse practitioners and nurse specialists to help meet the increasing demand for healthcare. A new nurse-led assessment clinic has been established in the liver clinic at Geelong Hospital to utilise the expertise of nurses to assess and triage new patients and streamline their pathway through the healthcare system.

AIM

The aim of this study is to assess quantitatively the first 2 years of operation of the nurse assessment clinic at Geelong Hospital, and to assess advantages and disadvantages of the nurse-led clinic.

METHODS

Data were extracted retrospectively from clinical records of new patients at the liver clinic. Quarterly 1-month periods were recorded over 2 years. Patients were categorised according to the path through which they saw a physician, including missed and rescheduled appointments. The number of appointments, the waiting time from referral to appointments and the number of 'did-not-attend' occasions were analysed before and after the institution of the nurse-led assessment clinic. The Mann-Whitney rank sum test of ordinal data was used to generate median wait times.

RESULTS

There was shown to be a statistically significant longer waiting time for physician appointment if seen by the nurse first. The difference in waiting time was 10 days. However, there was also a reduction in the number of missed appointments at the subsequent physician clinic. Other advantages have also been identified, including effective triage of patients and organisation of appropriate investigations from the initial nurse assessment.

Implementation of National HIV Screening Recommendations in the Indian Health Service

BACKGROUND

The Indian Health Service (IHS), a federal agency, provides direct patient care to an estimated 1.9 million American Indian/Alaska Native patients across a large and decentralized network of health facilities. The IHS sought to implement HIV screening of adults and adolescents per national recommendations. The IHS facilities received technical support such as electronic clinical reminders (ECRs) and sample HIV-testing policies.

PURPOSE

To determine what facility-wide policy and practices were associated with high HIV screening rates.

METHODS

Survey of clinical directors of 61 federal health facilities on use of ECRs, testing policies/standing orders, and other factors associated with HIV screening. These results were correlated with HIV screening performance results for each facility as derived from the IHS national database.

RESULTS

A total of 51 (84%) of 61 facilities were interviewed. In univariate analysis, factors that were correlated with higher rates of HIV screening were having an HIV screening standing order (unadjusted odds ratio [UOR] 8.7, 95% confidence interval [CI] 2.0-37.3), sexually transmitted disease (STD) screening standing order (UOR 5, CI 1.1-21.7), having an HIV ECR in place for a year or longer (UOR 10.2, CI 2.8-37.5), and inclusion of both providers and nurses in offering HIV screening (UOR 4.8, CI 1.4-16.7). In multivariate analysis, ECRs (adjusted odds ratio [AOR] 9.1, 95% CI 1.8-45.1) and STD standing orders (AOR 7.4, 95% CI 1.1-51.0) remained significantly associated with higher HIV screening.

CONCLUSION

Policy and practice interventions such as ECRs and standing order/testing policies and delegation of screening are correlated with high HIV screening, are scalable across health networks, and will be used for improving other infectious disease screening indicators in such as STD and hepatitis C.

Implementing an HIV Rapid Testing-Linkage-to-Care Project Among Homeless Individuals in Los Angeles County: A Collaborative Effort Between Federal, County, and City Government

Objectives. We developed and implemented an HIV rapid testing-linkage-to-care initiative between federal and local government. Methods. We used mixed methodology; HIV testing data were collected on-site, and qualitative data were collected via telephone. We used postintervention stakeholder and staff interviews to evaluate barriers and facilitators to this initiative. Results. We tested 817 individuals. We identified and confirmed 7 preliminary HIV positive individuals (0.86% seropositivity), 5 of whom were linked to care. Mean testing cost was $48.95 per client; cost per positive result was $5714. Conclusions. This initiative can be used as a template for other health departments and research teams focusing on homelessness and mitigation of the HIV/AIDS epidemic.

Effect of rapid HIV testing on HIV incidence and services in populations at high risk for HIV exposure: an equity-focused systematic review

OBJECTIVE

To assess the effects of rapid voluntary counselling and testing (VCT) for HIV on HIV incidence and uptake of HIV/AIDS services in people at high risk for HIV exposure.

DESIGN

Cochrane systematic review and meta-analysis.

DATA SOURCES

We searched PubMed, EMBASE, AIDSearch, LILACS, Global Health, Medline Africa, PsychInfo, CINAHL, Cochrane CENTRAL, Cochrane HIV/AIDS Group Specialized Register and grey literature from 1 January 2001 to 5 June 2014 without language restriction.

DATA SELECTION

We included controlled studies that compared rapid VCT with conventional testing among people at risk for HIV exposure.

DATA EXTRACTION

Two reviewers extracted data. We used Cochrane risk of bias tool and GRADE criteria: risk of bias, inconsistency, indirectness, imprecision and publication bias. For observational studies we used the Newcastle-Ottawa Scale. We used the PRISMA-Equity reporting guideline.

RESULTS

From 2441 articles, we included 8 randomised controlled trials and 5 observational studies. Rapid VCT was associated with a threefold increase in HIV-testing uptake (relative risk (RR)=2.95 95% CI 1.69 to 5.16) and a twofold increase in the receipt of test results (RR=2.14, 95% CI 1.08 to 4.24). Women accepted testing more often than men in rapid VCT arm, but no differences in effect for age or socioeconomic status. Observational studies also showed rapid VCT led to higher rates of uptake of testing. Heterogeneity was high. A cluster-randomised trial reported an 11% reduction in HIV incidence in intervention communities (RR=0.89, 95% CI=0.63 to 1.24) over 3 years trial.

CONCLUSIONS

Rapid VCT in health facilities and communities was associated with a large increase in HIV-testing uptake and receipt of results. This has implications for WHO guidelines. The routine use of rapid VCT may also help avoid human rights violations among marginalised populations where testing may occur without informed consent and where existing stigma may create barriers to testing.

Development and evaluation of a pilot nurse case management model to address multidrug-resistant tuberculosis (MDR-TB) and HIV in South Africa

Setting

Multidrug-resistant tuberculosis (MDR-TB) unit in KwaZulu-Natal, South Africa.

Objective

To develop and evaluate a nurse case management model and intervention using the tenets of the Chronic Care Model to manage treatment for MDR-TB patients with a high prevalence of human immunodeficiency virus (HIV) co-infection.

Design

A quasi-experimental pilot programme utilizing a nurse case manager to manage care for 40 hospitalized MDR-TB patients, 70% HIV co-infected, during the intensive phase of MDR-TB treatment. Patients were followed for six months to compare proximal outcomes identified in the model between the pre- and post-intervention period.

Results

The greatest percent differences between baseline and six-month MDR-TB proximal outcomes were seen in the following three areas: baseline symptom evaluation on treatment initiation (95% improvement), baseline and monthly laboratory evaluations completed per guidelines (75% improvement), and adverse drug reactions acted upon by medical and/or nursing intervention (75% improvement).

Conclusion

Improvements were identified in guideline-based treatment and monitoring of adverse drug reactions following implementation of the nurse case management intervention. Further study is required to determine if the intervention introduced in this model will ultimately result in improvements in final MDR-TB treatment outcomes.

Community health nurses' HIV health promotion and education programmes: a qualitative study

BACKGROUND

Globally, nurses practice in many settings with people with human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), taking an increasing share of the professional burden of care and helping to reduce morbidity and mortality. International literature is sparse about Thai community nurses providing primary healthcare programmes for people with HIV.

AIM

This study aimed to describe background, experiences and strategies of community nurses regarding their design and delivery of programmes for people living with HIV and AIDS in Chiang Mai Province, Thailand.

DESIGN

This study used a qualitative mixed-methods study employing a qualitative survey and in-depth interviews.

METHODS

Twenty community health nurses from 18 small community hospitals completed a survey comprising demographic data and 13 open-ended questions. Four of them later engaged in in-depth interviews using the same questions. Survey, interview data and field notes were analysed using interpretive content analysis.

FINDINGS

Four themes and six sub-themes portrayed participants' rich experiences and knowledge of HIV health promotion and education; challenges of daily work, discrimination and ethical issues; success through programme diversity comprising promotion of community volunteerism, networking and relationships; and holistic connections with Thai cultural traditions and Buddhism.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Findings help to recognize the diversity, uniqueness and contributions of Thai community nurses regarding culturally appropriate health promotion and education programmes for people living with HIV and AIDS. Findings inform nurses and health officials in and outside of the country to complement innovation in future HIV health promotion and education programmes.

LIMITATIONS

Our sample came from one province of Thailand. Findings might not be reflective of nurses elsewhere.

IMPLICATIONS FOR HEALTH AND NURSING POLICY

Three decades of collective experience in providing holistic and multifaceted HIV and AIDS nursing care, education and health promotion by community health nurses have the potential to effect new and existing policies and protocols on HIV community care in Thailand, but more research is required for this.

Knowledge, Attitudes, and Ordering Patterns for Routine HIV Screening among Resident Physicians at an Urban Medical Center

BACKGROUND

We sought to measure resident physician knowledge of HIV epidemiology and screening guidelines, attitudes toward testing, testing practices, and barriers and facilitators to routine testing.

METHODS

Resident physicians in internal medicine, pediatrics, obstetrics and gynecology, and emergency medicine were surveyed.

RESULTS

Overall response rate was 63% (162 of 259). Half knew details of the HIV screening guidelines, but few follow these recommendations. Less than one-third reported always or usually performing routine testing. A significant proportion reported only sometimes or never screening patients with risk factors. This was despite a strong belief that HIV screening improves patient care and public health. The most common barriers to testing were competing priorities and forgetting to order the test. Elimination of written consent and electronic reminders was identified as facilitators to routine testing. Although an institutional policy assigns responsibility for test notification and linkage of HIV-positive patients to care to the HIV care program, only 29% were aware of this.

CONCLUSIONS

Few resident physicians routinely screen for HIV infection and some don't test patients with risk factors. While competing priorities remain a significant barrier, elimination of written consent form and electronic reminders has facilitated testing. Increasing the awareness of policies regarding test notification and linkage to care may improve screening.

Comparative Cost Analysis of Clinical Reminder for HIV Testing at the Veterans Affairs Healthcare System

OBJECTIVE

To estimate the cost and health outcomes associated with a new HIV testing strategy that utilizes routine-based clinical reminders.

METHODS

We conducted an economic analysis of 1) traditional pretest/post-test counseling; 2) counseling and a new clinical reminders system; and 3) only clinical reminder in the veterans' health care system. A payer-perspective decision model was conducted to calculate the 1-year budget impact of three HIV testing strategies. Parameter values were obtained from the literature, including patients' probability of accepting test, and costs associated with HIV testing procedures. Deidentified patient data, including total population screened and number of new HIV cases, were collected from one clinic in Los Angeles, California, from August 2004 to December 2011. Annual total costs and costs per new case were calculated on the basis of parameter values and patient data. Sensitivity analyses were conducted to evaluate the robustness of the critical variable on costs.

RESULTS

The total cost of the clinical reminder system with pretest counseling was $81,726 over 1 year compared with $109,208 for traditional HIV testing. Under a clinical reminder system with no pretest counseling, the number of HIV tests performed and the number of new diagnoses increased for that year. In addition, cost per new diagnoses was the lowest.

CONCLUSIONS

The clinical reminder system can reduce the cost per cases identified and promote better performance of HIV testing compared with traditional HIV testing. The fundamental decision model can be used for hospital facilities outside the Veteran Affairs adopting a similar program for improving the HIV testing rate.

Effects of rapid versus standard HIV voluntary counselling and testing on receipt rate of HIV test results: a meta-analysis

Rapid HIV voluntary counselling and testing (RVCT) is an alternative method of standard HIV voluntary counselling and testing (SVCT). Less is known about whether RVCT improves the receipt rate of HIV test results among clients who seek HIV counselling and testing. We aimed to evaluate effectiveness of RVCT on result receipt rate. We conducted a comprehensive search of databases containing Medline, EBSCO, Web of science, and Cochrane library to identify studies published up to August 2012. Reviewers extracted information independently. Risk of bias was evaluated with Cochrane Collaboration's tool for assessing study quality. Five randomised controlled trials were included and analysed for the result receipt rate using a random-effects model. The pooled receipt rate of HIV test results in the RVCT was significantly higher than in the SVCT (RR = 1.74, 95% CI = 1.47-2.07). Our results suggest RVCT as a favourable method to increase the receipt of HIV test results. Only two included studies assessed the modification of risk behaviour after HIV-CT in a different manner; also, the sample size was small in the current meta-analysis. In future research, it is necessary to confirm the effect of RVCT on disinhibition of post-test risk behaviour.

Feasibility of HIV Universal Voluntary Counseling and Testing in a Thai General Practice Clinic

An HIV transmission prevention program incorporating universal voluntary counseling and testing (UVCT) was conducted in a general practice (GP) clinic of a Thai hospital. Of the 494 participating patients, 356 (72%) accepted HIV-UVCT. Independent factors associated with HIV-UVCT acceptance included participating in the program after office hours (4-8 pm; P < .001), living with domestic partner with no marriage (P = .01), and having primary school education or less (P = .02). The main reasons for declining HIV-UVCT were time constraint (38%) and perceiving self as no risk (35%). Among the 356 patients undergoing HIV-UVCT, having moderate to high HIV risk (P < .001) and male sex (P = .01) were independently associated with low HIV risk perception. By HIV-UVCT, the rate of new HIV infection was 4 (1.1%) of 356 patients. Of these 4 newly diagnosed HIV-infected patients, 3 (75%) were homosexual men. The findings suggest feasibility of HIV-UVCT in our GP clinic and factors to be considered for improving the program.

What Makes Me Screen for HIV? Perceived Barriers and Facilitators to Conducting Recommended Routine HIV Testing among Primary Care Physicians in the Southeastern United States

The Centers for Disease Control and Prevention have recommended routinely testing patients (aged 13-64) for HIV since 2006. However, many physicians do not routinely test. From January 2011 to March 2012, we conducted 18 in-depth individual interviews and explored primary care physicians' perceptions of barriers and facilitators to implementing routine HIV testing in North Carolina. Physicians' comments were categorized thematically and fell into 5 groups: policy, community, practice, physician, and patient. Lack of universal reimbursement was identified as the major policy barrier. Participants believed endorsement from the United States Preventive Services Tasks Force would facilitate adoption of routine HIV testing policies. Physicians reported HIV/AIDS stigma, socially conservative communities, lack of confidentiality, and rural geography as community barriers. Physicians believed public HIV testing campaigns would legitimize testing and decrease stigma in communities. Physicians cited time constraints and competing clinical priorities as physician barriers that could be overcome by delegating testing to nursing staff. HIV test refusal, low HIV risk perception, and stigma emerged as patient barriers. Physicians recommended adoption of routine HIV testing for all patients to facilitate and destigmatize testing. Physicians continue to experience a variety of barriers when implementing routine HIV testing in primary care settings. Our findings support multilevel approaches to enhance physician routine HIV testing in primary care settings.

Pharmacist Testers in Multidisciplinary Health care Team Expand HIV Point-of-Care Testing Program

Knowledge of HIV serostatus is the first step to accessing treatment, reducing transmission, and mitigating public health challenges. We describe the expansion of an HIV point-of-care testing (POCT) program within a health care system utilizing pharmacists as testers. The testing program’s expansion is detailed and its impact assessed. The POCT program was evaluated by comparing the number of traditional HIV venipuncture tests to the number of POCTs performed across the health system as well as comparing the number of POCTs performed by clinical pharmacists to the number of tests at other POCT locations. Although pharmacists’ contributions to HIV prevention are well documented, pharmacists’ involvement in HIV testing initiatives is still nascent. Our POCT program demonstrates an effective HIV testing initiative driven by pharmacists and other health care providers.

Central implementation strategies outperform local ones in improving HIV testing in Veterans Healthcare Administration facilities

BACKGROUND

Pilot data suggest that a multifaceted approach may increase HIV testing rates, but the scalability of this approach and the level of support needed for successful implementation remain unknown.

OBJECTIVE

To evaluate the effectiveness of a scaled-up multi-component intervention in increasing the rate of risk-based and routine HIV diagnostic testing in primary care clinics and the impact of differing levels of program support.

DESIGN

Three arm, quasi-experimental implementation research study.

SETTING

Veterans Health Administration (VHA) facilities.

PATIENTS

Persons receiving primary care between June 2009 and September 2011 INTERVENTION: A multimodal program, including a real-time electronic clinical reminder to facilitate HIV testing, provider feedback reports and provider education, was implemented in Central and Local Arm Sites; sites in the Central Arm also received ongoing programmatic support. Control Arm sites had no intervention

MAIN MEASURES

Frequency of performing HIV testing during the 6 months before and after implementation of a risk-based clinical reminder (phase I) or routine clinical reminder (phase II).

KEY RESULTS

The adjusted rate of risk-based testing increased by 0.4 %, 5.6 % and 10.1 % in the Control, Local and Central Arms, respectively (all comparisons, p < 0.01). During phase II, the adjusted rate of routine testing increased by 1.1 %, 6.3 % and 9.2 % in the Control, Local and Central Arms, respectively (all comparisons, p < 0.01). At study end, 70-80 % of patients had been offered an HIV test.

CONCLUSIONS

Use of clinical reminders, provider feedback, education and social marketing significantly increased the frequency at which HIV testing is offered and performed in VHA facilities. These findings support a multimodal approach toward achieving the goal of having every American know their HIV status as a matter of routine clinical practice.

Averting HIV infections in New York City: a modeling approach estimating the future impact of additional behavioral and biomedical HIV prevention strategies

Background

New York City (NYC) remains an epicenter of the HIV epidemic in the United States. Given the variety of evidence-based HIV prevention strategies available and the significant resources required to implement each of them, comparative studies are needed to identify how to maximize the number of HIV cases prevented most economically.

Methods

A new model of HIV disease transmission was developed integrating information from a previously validated micro-simulation HIV disease progression model. Specification and parameterization of the model and its inputs, including the intervention portfolio, intervention effects and costs were conducted through a collaborative process between the academic modeling team and the NYC Department of Health and Mental Hygiene. The model projects the impact of different prevention strategies, or portfolios of prevention strategies, on the HIV epidemic in NYC.

Results

Ten unique interventions were able to provide a prevention benefit at an annual program cost of less than $360,000, the threshold for consideration as a cost-saving intervention (because of offsets by future HIV treatment costs averted). An optimized portfolio of these specific interventions could result in up to a 34% reduction in new HIV infections over the next 20 years. The cost-per-infection averted of the portfolio was estimated to be $106,378; the total cost was in excess of $2 billion (over the 20 year period, or approximately $100 million per year, on average). The cost-savings of prevented infections was estimated at more than $5 billion (or approximately $250 million per year, on average).

Conclusions

Optimal implementation of a portfolio of evidence-based interventions can have a substantial, favorable impact on the ongoing HIV epidemic in NYC and provide future cost-saving despite significant initial costs.

The uptake of HIV and syphilis testing in a nurse-delivered service during Gay Pride events

Novel HIV testing strategies may improve the uptake of the test. The aim of the present study was to investigate the uptake of HIV testing during Birmingham Pride events in 2009 and 2010. The project was a collaboration between Whittall Street Clinic and Healthy Gay Life. This was a nurse-delivered service that was offered for nine hours each day during the events (total of 36 hours in two years). The OraSure™ assay for HIV and syphilis testing was used. A total of 405 men visited our marquee during the 2009 (n = 201) and 2010 (n = 204) events. A total of 398 (98%) men accepted HIV testing during the events in 2009 and 2010. Six men (1.5%) were HIV-positive, an incidence of 37.7 cases per 10,000 persons perday. The uptake of syphilis testing was similarly high; 390 (96%) individuals agreed to be tested and one (0.5%) patient was diagnosed with syphilis. The uptake of HIV testing during the Pride event was high. Pride events provide a unique opportunity for testing undiagnosed HIV-infected patients. HIV testing should be provided in other cities during Pride events.

Provision of rapid HIV tests within a health service and frequency of HIV testing among men who have sex with men: randomised controlled trial

OBJECTIVE

To determine if the provision of rapid HIV testing to men who have sex with men attending a health service would increase their frequency of HIV testing over time.

DESIGN

Non-blinded randomised controlled trial.

SETTING

Public sexual health service in Australia.

PARTICIPANTS

Men who reported having a male sexual partner within the previous year and an HIV test within the previous two years. Of 400 men entered, 370 (92.5%) completed the study.

INTERVENTIONS

Men attending the service between September 2010 and March 2011 were randomised 1:1 to either ongoing access to rapid HIV testing obtained with finger prick or to conventional HIV serology with venepuncture, over 18 months.

MAIN OUTCOME MEASURE

The incidence of all HIV testing after enrolment, including testing outside the study clinic, analysed by intention to treat.

RESULTS

Of 200 men randomised to the rapid testing arm, 196 were followed for 288 person years. Of 200 men randomised to the conventional testing arm, 194 were followed for 278 person years. Median time since the last HIV test was six months for both arms. Men in the rapid test arm had 469 tests (mean 1.63 tests a year), and men in the conventional test arm had 396 tests (mean 1.42 tests a year); incidence rate ratio 1.15, 95% confidence interval 0.96 to 1.38; P=0.12. In a post hoc analysis, rates of initial HIV testing during follow-up were 1.32 and 1.01 tests a year, respectively (1.32, 1.05 to 1.65; P=0.02).

CONCLUSIONS

Provision of access to rapid HIV testing in a health service did not result in a sustained increase over time in HIV testing by men who have sex with men; however, the rate of initial HIV testing did increase by a third. Further research is required to determine how to achieve sustained increases in the frequency of HIV testing by populations at risk.

TRIAL REGISTRATION

ACTR No 12610000430033.

Implementation science in the real world: a case study of HIV rapid testing

Implementation science theories offer technical principles for carrying out activities designed to create or improve systems; however, such theories tend not to provide pragmatic or streamlined guidance when it comes to executing the actual implementation. We assembled a streamlined and comprehensive six-step theory-based implementation science model (ADAPTS - Assessment, Deliverables, Activate, Pretraining, Training, Sustainability) derived from the methods we have used to successfully execute multiple self-sustaining implementation efforts within the Veteran's Affairs Healthcare System. This paper provides a case study of our ADAPTS implementation science model, using a complex multisite HIV rapid testing implementation project as an exemplar.

Evaluating the implementation of nurse-initiated HIV rapid testing in three Veterans Health Administration substance use disorder clinics

Individuals with substance use disorders (SUDs) are at higher risk of HIV infection, yet recent studies show rates of HIV testing are low among this population. We implemented and evaluated a nurse-initiated HIV oral rapid testing (NRT) strategy at three Veterans Health Administration SUD clinics. Implementation of NRT includes streamlined nurse training and a computerized clinical reminder. The evaluation employed qualitative interviews with staff and a quantitative evaluation of HIV testing rates. Barriers to testing included lack of laboratory support and SUD nursing resistance to performing medical procedures. Facilitators included the ease of NRT integration into workflow, engaged management and an existing culture of disease prevention. Six-months post intervention, rapid testing rates at SUD clinics in sites 1, 2, and 3 were 5.0%, 1.1% and 24.0%, respectively. Findings indicate that NRT can be successfully incorporated into some types of SUD subclinics with minimal perceived impact on workflow and time.

Integrating routine HIV screening into a primary care setting in rural North Carolina

Blacks living in the southern United States are disproportionately affected by HIV infection. Identifying and treating those who are infected is an important strategy for reducing HIV transmission. A model for integrating rapid HIV screening into community health centers was modified and used to guide implementation of a testing program in a primary care setting in a small North Carolina town serving a rural Black population. Anonymous surveys were completed by 138 adults who were offered an HIV test; of these, 61% were female and 89.9% were Black. One hundred patients (72%) accepted the test. Among those Black survey respondents who accepted an offer of testing, 58% were women. The most common reason for declining an HIV test was lack of perceived risk; younger patients were more likely to get tested. Implementation of the testing model posed challenges with time, data collection, and patient flow.

A qualitative assessment of emergency department patients' knowledge, beliefs, attitudes, and acceptance toward revised HIV testing strategies

OBJECTIVES

The objective of this study was to explore emergency department (EDs) patients' knowledge, beliefs, attitudes, and acceptability toward revised human immunodeficiency virus (HIV) testing recommendations.

METHODS

Participants were recruited in proportion to the racial, sex, and ethnic makeup of the study ED. Interviewers presented participants with a stimulus followed by questions about opt-out consent, elimination of separate written consent, and curtailed counseling. Three investigators coded all transcripts using an iterative coding strategy until thematic saturation was achieved.

RESULTS

Thirty-four semistructured, in-depth, individual interviews were conducted, including five with patients ages 13 to 17 years and five with Spanish-speaking patients. Nineteen (56%) participants were women. The mean (± SD) age was 31 (± 12) years. Most were Hispanic (38%) or African American/black (44%). Only one (2.9%) participant knew about the revised testing recommendations. Participants believed that opt-out consent would result in increased testing, but this was confounded by misunderstanding of the consent process: "so the opt-out is, you basically don't have a choice." Participants thought eliminating separate written consent was a positive change but that it could result in people being tested without their knowledge. Attitudes diverged over curtailed counseling, but participants felt patients "should have options" for counseling because "everybody isn't the same."

CONCLUSIONS

Emergency department patients were unaware of revised HIV testing recommendations. Most felt that opt-out consent and elimination of separate written consent were positive changes but could result in a patient being tested without his or her knowledge. The response to curtailed counseling was polarized but participants agreed on the need to accommodate personal preferences. This information may be useful when designing ED-based HIV testing programs.

Preference for physician vs. nurse-initiated opt-out screening on HIV test acceptance

Provider-initiated opt-out HIV screening suggests that providers should routinely order HIV tests unless a patient declines. However, data on how providers will respond to this new screening model are scarce. Documented concerns from the providers' perspectives have included time constraints of a typical patient encounter, and discomfort with discussing sexual history and risk behavior with patients. To address these potential barriers, nurse-initiated screening has been proposed as an approach to increasing screening rates in general medical and urgent care settings. This study compares patient acceptability of provider-initiated opt-out HIV screening with nurse-initiated opt-out HIV screening among 220 patients between the ages of 18-64 from two publically funded "safety-net" outpatient clinics in Los Angeles County. Our study found that 77% of patients agreed to HIV testing using opt-out screening, and that HIV test acceptance was higher with the physician-initiated opt-out model compared with the nurse-initiated opt-out model (adjusted odds ratios = 2.92; 95% CI = 1.37-6.22). These findings indicate that adding opt-out screening to primary care providers responsibilities may be an acceptable and effective strategy for addressing the perennially low HIV testing rates, particularly among low income, traditionally underserved patient populations among whom the epidemic is expanding most rapidly.

How to effectively detect and manage people living with HIV/AIDS in China: establishment of a community-based model

This study explored a novel systemic community-based model for detecting and managing people living with HIV/AIDS (PLWHA). Both quantitative and qualitative research methods were used in this study. A quantitative questionnaire investigation was conducted in a sample of 1192 subjects which were randomly selected from two areas with high HIV prevalence, Xiangfan City and Shiyan City of Hubei Province, China. Twenty-two medical and health service staffs were interviewed by semi-structured questionnaire focusing on awareness, status, problems, and suggestions about community-based Voluntary Counseling and Testing and Provider Initiated Testing and Counseling (VCT/PITC). And they were organized to discuss about the aforementioned issues in Xiangfan City and Shiyan City, respectively. Our results showed that the accessibility and availability of the general VCT/PITC were bad. About 28.3% had known and only 4.9% had made use of VCT/PITC. Developing community-based VCT/PITC had some special advantages that can overcome some existing problems to remedy the aforementioned defects. We are led to conclude that, to maximize the availability and uptake rate of the VCT/PITC, we plan to detect PLWHA by developing the community-based VCT/PITC through 4 paths. Then we establish the community HIV health care center constituted of 8 sectors to provide an overall management. Thus, we can effectively detect and manage the PLWHA with a new systemic community-based model.

Understanding barriers to routine HIV screening: knowledge, attitudes, and practices of healthcare providers in King County, Washington

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.