Implementation of Routine Rapid HIV Testing Within the U.S. Department of Veterans Affairs Healthcare System

Innovation and implementation determinants of HIV testing and linkage-to-care in the U.S.: a systematic review

OBJECTIVE

To identify innovation and implementation determinants of HIV testing, diagnosis, and linkage-to-care in the U.S.

DATA SOURCES AND STUDY SETTING

Between November 2020 and January 2022, a broad search strategy was employed in three literature databases: Ovid MEDLINE, PsycINFO, and Web of Science.

STUDY DESIGN

A systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.

DATA COLLECTION/EXTRACTION METHODS

A team of master's and Ph.D.-level researchers screened eligible studies against the inclusion criteria and extracted the data using COVIDENCE software in pairs with consensus performed by a senior member of the team. Barriers and facilitators were extracted and analyzed according to the Consolidated Framework for Implementation Research (CFIR). Frequency of determinants across studies was mapped according to CFIR, valence, study design, delivery setting, unit of analysis, population of interest, region of the U.S., and year.

RESULTS

We identified 1,739 implementation and innovation determinants from 186 articles. Most determinants were for HIV testing rather than linkage-to-care. Most determinants were identified in the inner setting and individuals domains of CFIR, with the fewest identified in the process and innovations domains. Determinants of providers were only slightly more frequently identified than determinants of recipients. However, determinants of organizations and systems were rarely identified.

CONCLUSION

This review provides a synthesis of innovation and implementation determinants of HIV testing and linkage-to-care using the most-cited implementation science (IS) framework, CFIR. This synthesis enables the larger field of HIV science to utilize IS in efforts to end the HIV epidemic and positions IS to consider the application of IS frameworks to fields like HIV.

Moving From Discovery to System-Wide Change: The Role of Research in a Learning Health Care System: Experience from Three Decades of Health Systems Research in the Veterans Health Administration

The Veterans Health Administration is unique, functioning as an integrated health care system that provides care to more than six million veterans annually and as a home to an established scientific enterprise that conducts more than $1 billion of research each year. The presence of research, spanning the continuum from basic health services to translational research, has helped the Department of Veterans Affairs (VA) realize the potential of a learning health care system and has contributed to significant improvements in clinical quality over the past two decades. It has also illustrated distinct pathways by which research influences clinical care and policy and has provided lessons on challenges in translating research into practice on a national scale. These lessons are increasingly relevant to other health care systems, as the issues confronting the VA—the need to provide timely access, coordination of care, and consistent high quality across a diverse system—mirror those of the larger US health care system.

The views and experiences of nurses and midwives in the provision and management of provider-initiated HIV testing and counseling: a systematic review of qualitative evidence

BACKGROUND

Global progress towards HIV prevention and care is contingent upon increasing the number of those aware of their status through HIV testing. Provider-initiated HIV testing and counseling is recommended globally as a strategy to enhance uptake of HIV testing and is primarily conducted by nurses and midwives. Research shows that provider-initiated HIV testing and counseling implementation is sub-optimal. The reasons for this are unclear.

OBJECTIVES

The review aimed to explore nurses' and midwives' views and experiences of the provision and management of provider-initiated HIV testing and counseling.

INCLUSION CRITERIA

TYPES OF PARTICIPANTS

All cadres of nurses and midwives were considered, including those who undertake routine HIV testing as part of a diverse role and those who are specifically trained as HIV counselors. Types of phenomenon of interest: The review sought to understand the views and experiences of the provision and management of provider-initiated HIV testing and counseling (including perceptions, opinions, beliefs, practices and strategies related to HIV testing and its implementation in practice).

CONTEXT

The review included only provider-initiated HIV testing and counseling. It excluded all other models of HIV testing. The review included all countries and all healthcare settings. Types of studies: This review considered all forms of qualitative study design and methodology. Qualitative elements of a mixed method study were included if they were presented separately within the publication.

SEARCH STRATEGY

A three-step search strategy was utilized. Eight databases were searched for papers published from 1996 to October 2014, followed by hand searching of reference lists. Only studies published in the English language were considered.

METHODOLOGICAL QUALITY

Methodological quality was assessed using the Qualitative Assessment and Review Instrument developed by the Joanna Briggs Institute.

DATA EXTRACTION

Qualitative findings were extracted using the Joanna Briggs Institute Qualitative Assessment and Review Instrument.

DATA SYNTHESIS

Qualitative research findings were pooled using a pragmatic meta-aggregative approach and the Joanna Briggs Institute Qualitative Assessment and Review Instrument software.

RESULTS

This review included 21 publications from 18 research studies, representing a wide range of countries and healthcare settings. There were 245 findings which were aggregated into 12 categories and five synthesized findings. 1. Nurses/midwives are supportive of provider-initiated HIV testing and counseling if it is perceived to enhance patient care and to align with perceived professional roles. 2. Nurses'/midwives' ability to perform provider-initiated HIV testing and counseling well requires an appropriate infrastructure and adequate human and material resources. 3. At the organizational level, nurses'/midwives' engagement with provider-initiated HIV testing and counseling is facilitated by an inclusive management structure, alongside the provision of ongoing training and clinical supervision. Provider-initiated HIV testing and counseling is hindered by difficulties in fitting it into existing workloads and routines. 4. Nurses/midwives perceive that good quality care in provider-initiated HIV testing and counseling involves finding a balance between public health needs and individual patient needs. Good care requires time and the ability to apply a patient centred approach. 5. The emotional work involved in provider-initiated HIV testing and counseling can be stressful. Nurses/Midwives may require support to deal with complex moral and ethical issues.

CONCLUSIONS

This review shows that provider-initiated HIV testing and counseling is supported by nurses/midwives who strive to implement it according to principles of good care and a patient centered approach. Nurses/midwives face multiple operational, infra-structural, resource and ethical challenges in the implementation of provider-initiated HIV testing and counseling.

IMPLICATIONS FOR PRACTICE

The implementation process for provider-initiated HIV testing and counseling would benefit from using a quality improvement framework. Nurses/midwives undertaking provider-initiated HIV testing and counseling require management support, ongoing training and adequate infrastructure/resources. Additional guidance is required on legal/ethical issues in testing of children and in third party disclosure.

IMPLICATIONS FOR RESEARCH

Operational research is required to determine an optimal skill mix and optimal methods of integrating provider-initiated HIV testing and counseling into existing work routines.

Barriers to Implementation of Rapid and Point-of-Care Tests for Human Immunodeficiency Virus Infection: Findings From a Systematic Review (1996-2014)

Implementation of human immunodeficiency virus rapid and point-of-care tests (RDT/POCT) is understood to be impeded by many different factors that operate at 4 main levels-test devices, patients, providers, and health systems-yet a knowledge gap exists of how they act and interact to impede implementation. To fill this gap, and with a view to improving the quality of implementation, we conducted a systematic review.

METHODS

Five databases were searched, 16,672 citations were retrieved, and data were abstracted on 132 studies by 2 reviewers.

FINDINGS

Across 3 levels (ie, patients, providers, and health systems), a majority (59%, 112/190) of the 190 barriers were related to the integration of RDT/POCT, followed by test-device-related concern (ie, accuracy) at 41% (78/190). At the patient level, a lack of awareness about tests (15/54, 28%) and time taken to test (12/54, 22%) dominated. At the provider and health system levels, integration of RDT/POCT in clinical workflows (7/24, 29%) and within hospitals (21/34, 62%) prevailed. Accuracy (57/78, 73%) was dominant only at the device level.

INTERPRETATION

Integration barriers dominated the findings followed by test accuracy. Although accuracy has improved during the years, an ideal implementation could be achieved by improving the integration of RDT/POCT within clinics, hospitals, and health systems, with clear protocols, training on quality assurance and control, clear communication, and linkage plans to improve health outcomes of patients. This finding is pertinent for a future envisioned implementation and global scale-up of RDT/POCT-based initiatives.

HIV Rapid Testing in a VA Emergency Department Setting: Cost Analysis at 5 Years

OBJECTIVES

To conduct a comprehensive cost-minimization analysis to comprehend the financial attributes of the first 5 years of an implementation wherein emergency department (ED) registered nurses administered HIV oral rapid tests to patients.

METHODS

A health science research implementation team coordinated with ED stakeholders and staff to provide training, implementation guidelines, and support to launch ED registered nurse-administered HIV oral rapid testing. Deidentified quantitative data were gathered from the electronic medical records detailing quarterly HIV rapid test rates in the ED setting spanning the first 5 years. Comprehensive cost analyses were conducted to evaluate the financial impact of this implementation.

RESULTS

At 5 years, a total of 2,620 tests were conducted with a quarterly mean of 131 ± 81. Despite quarterly variability in testing rates, regression analysis revealed an average increase of 3.58 tests per quarter. Over the course of this implementation, Veterans Health Administration policy transitioned from written to verbal consent for HIV testing, serving to reduce the time and cost(s) associated with the testing process.

CONCLUSIONS

Our data indicated salient health outcome benefits for patients with respect to the potential for earlier detection, and associated long-run cost savings.

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.

A Novel Approach to Realizing Routine HIV Screening and Enhancing Linkage to Care in the United States: Protocol of the FOCUS Program and Early Results

BACKGROUND

The United States health care system remains far from implementing the Centers for Disease Control and Prevention's recommendation of routine human immunodeficiency virus (HIV) screening as part of health care for adults. Although consensus for the importance of screening has grown, innovations in implementing routine screening are still lacking. HIV on the Frontlines of Communities in the United States (FOCUS) was launched in 2010 to provide an environment for testing innovative approaches to routine HIV screening and linkage to care.

OBJECTIVE

The strategy of the FOCUS program was to develop models that maximize the use of information systems, fully integrate HIV screening into clinical practice, transform basic perceptions about routine HIV screening, and capitalize on emerging technologies in health care settings and laboratories.

METHODS

In 10 of the most highly impacted cities, the FOCUS program supports 153 partnerships to increase routine HIV screening in clinical and community settings.

RESULTS

From program launch in 2010 through October 2013, the partnerships have resulted in a total of 799,573 HIV tests and 0.68% (5425/799,573) tested positive.

CONCLUSIONS

The FOCUS program is a unique model that will identify best practices for HIV screening and linkage to care.

HIV rapid testing in a Veterans Affairs hospital ED setting: a 5-year sustainability evaluation

Routine HIV testing in primary care settings is now recommended in the United States. The US Department of Veterans Affairs (VA) has increased the number of patients tested for HIV, but overall HIV testing rates in VA remain low. A proven strategy for increasing such testing involves nurse-initiated HIV rapid testing (HIV RT). The purpose of this work was to use a mixed methodology approach to evaluate the 5-year sustainability of an intervention that implemented HIV RT in a VA emergency department setting in a large, urban VA medical center to reduce missed diagnostic and treatment opportunities in this vulnerable patient population. In-person semistructured interviews were conducted with providers and stakeholders. Interview notes were qualitatively coded for emerging themes. Quarterly testing rates were evaluated for a 5-year time span starting from the launch in July 2008. Findings indicate that HIV RT was sustained by the enthusiasm of 2 clinical champions who oversaw the registered nurses responsible for conducting the testing. The departure of the clinical champions was correlated with a substantial drop-off in testing. Findings also indicate potential strategies for improving sustainability including engaging senior leadership in the project, engaging line staff in the implementation planning from the start to increase ownership over the innovation, incorporating information into initial training explaining the importance of the innovation to quality patient care, providing ongoing training to maintain skills, and providing routine progress reports to staff to demonstrate the ongoing impact of their efforts.

A five-year self-sustainability analysis of nurse-administered HIV rapid testing in Veterans Affairs primary care

In 2008, nurse-administered HIV oral rapid testing (RT) was introduced at the Veterans Affairs Primary Care Clinic in Downtown Los Angeles. Analysis at five years revealed variable yet increasing rates of HIV RT at that facility despite the fact that no post-launch support was provided by the implementation team. Qualitative interviews among stakeholders conducted at five years revealed the pre-existing implementation practices endemic to this clinic that facilitated this unprecedented success (e.g. history of positive quality improvement implementations, leadership support, clinician involvement at each step of the process to facilitate empowerment, ownership and feasible customisation of the implementation, cohesive communication among clinicians and leadership, training, efficient supply pathway, progressive performance feedback and ongoing encouragement).

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.

Effectiveness and feasibility study of routine HIV rapid testing in an urban methadone maintenance treatment program

BACKGROUND

Universal Human Immunodeficiency Virus (HIV) testing and treatment are strategies to decrease AIDS-related morbidity and mortality and to reduce HIV transmission.

OBJECTIVE

This study examined the feasibility and effectiveness of routine HIV rapid testing implemented in the largest New York City (NYC) Methadone Maintenance Treatment Program (MMTP).

METHODS

A routine HIV rapid testing program performed by medical providers without pretest counseling or the provision of incentives was compared to HIV rapid testing done by referral to HIV counselors with pretest counseling and incentives over the prior 12 months.

RESULTS

Routine HIV rapid testing proved feasible and effective when performed by the medical staff in the setting of a large urban MMTP. The program increased HIV testing in all genders, race/ethnicities, and ages. HIV-positive individuals were diagnosed and successfully linked to care. The elimination of HIV prevention counseling may have facilitated expanded testing.

CONCLUSION

This study confirms that routine HIV rapid testing without HIV-prevention counseling or the provision of incentives for patients is feasible on a large scale in a busy, urban methadone clinic.

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.

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.

HIV screening in the health care setting: status, barriers, and potential solutions

Thirty years into the human immunodeficiency virus (HIV) epidemic in the United States, an estimated 50,000 persons become infected each year: highest rates are in black and Hispanic populations and in men who have sex with men. Testing for HIV has become more widespread over time, with the highest rates of HIV testing in populations most affected by HIV. However, approximately 55% of adults in the United States have never received an HIV test. Because of the individual and community benefits of treatment for HIV, in 2006 the Centers for Disease Control and Prevention recommended routine screening for HIV infection in clinical settings. The adoption of this recommendation has been gradual owing to a variety of issues: lack of awareness and misconceptions related to HIV screening by physicians and patients, barriers at the facility and legislative levels, costs associated with testing, and conflicting recommendations concerning the value of routine screening. Reducing or eliminating these barriers is needed to increase the implementation of routine screening in clinical settings so that more people with unrecognized infection can be identified, linked to care, and provided treatment to improve their health and prevent new cases of HIV infection in the United States.