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Erickson JL, Wu J, Fertel BS, Pallotta AM, Englund K, Shrestha NK, Lehman B. Multidisciplinary Approach to Improve Human Immunodeficiency Virus and Syphilis Testing Rates in Emergency Departments. Open Forum Infect Dis 2022; 9:ofac601. [PMID: 36540389 PMCID: PMC9757684 DOI: 10.1093/ofid/ofac601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Best practice guidelines recommend that patients at risk for sexually transmitted infections (STIs), such as gonorrhea (GC) and chlamydia, should also be tested for human immunodeficiency virus (HIV) and syphilis. This prospective quality assurance study aimed to increase HIV and syphilis testing rates in emergency departments (EDs) across the Cleveland Clinic Health System from January 1, 2020 through January 1, 2022. METHODS A multidisciplinary team of emergency medicine, infectious diseases, pharmacy, and microbiology personnel convened to identify barriers to HIV and syphilis testing during ED encounters at which GC/chlamydia were tested. The following interventions were implemented in response: rapid HIV testing with new a workflow for results follow-up, a standardized STI-screening order panel, and feedback to clinicians about ordering patterns. RESULTS There were 57 797 ED visits with GC/chlamydia testing completed during the study period. Human immunodeficiency virus testing was ordered at 5% of these encounters before the interventions were implemented and increased to 8%, 23%, and 36% after each successive intervention. Syphilis testing increased from 9% before the interventions to 12%, 28%, and 39% after each successive intervention. In multivariable analyses adjusted for age, gender, and location, the odds ratio for HIV and syphilis testing after all interventions was 11.72 (95% confidence interval [CI], 10.82-12.71; P ≤.001) and 6.79 (95% CI, 6.34-7.27; P ≤.001), respectively. CONCLUSIONS The multidisciplinary intervention resulted in improved testing rates for HIV and syphilis.
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Affiliation(s)
- Jessica L Erickson
- Correspondence: Jessica Erickson, MD, Cleveland Clinic Health System, Infectious Disease Department, 9500 Euclid Avenue, Cleveland, Ohio 44195 ()
| | - Janet Wu
- Cleveland Clinic Health System, Cleveland, Ohio, USA
| | - Baruch S Fertel
- Quality & Patient Safety New York - Presbyterian Hospital; Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Hopkins KL, Hlongwane KE, Otwombe K, Dietrich J, Cheyip M, Khanyile N, Doherty T, Gray GE. Level of adult client satisfaction with clinic flow time and services of an integrated non-communicable disease-HIV testing services clinic in Soweto, South Africa: a cross-sectional study. BMC Health Serv Res 2020; 20:404. [PMID: 32393224 PMCID: PMC7212607 DOI: 10.1186/s12913-020-05256-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 04/27/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND While HIV Testing Services (HTS) have increased, many South Africans have not been tested. Non-communicable diseases (NCDs) are the top cause of death worldwide. Integrated NCD-HTS could be a strategy to control both epidemics. Healthcare service strategies depends partially on positive user experience. We investigated client satisfaction of services and clinic flow time of an integrated NCD-HTS clinic. METHODS This prospective, cross-sectional study evaluated HTS client satisfaction with an HTS clinic at two phases. Phase 1 (February-June 2018) utilised standard HTS services: counsellor-led height/weight/blood pressure measurements, HIV rapid testing, and symptoms screening for sexually transmitted infections/Tuberculosis. Phase 2 (June 2018-March 2019) further integrated counsellor-led obesity screening (body mass index/abdominal circumference measurements), rapid cholesterol/glucose testing; and nurse-led Chlamydia and human papilloma virus (HPV)/cervical cancer screening. Socio-demographics, proportion of repeat clients, clinic flow time, and client survey data (open/closed-ended questions using five-point Likert scale) are reported. Fisher's exact test, chi-square analysis, and Kruskal Wallis test conducted comparisons. Multiple linear regression determined predictors associated with clinic time. Content thematic analysis was conducted for free response data. RESULTS Two hundred eighty-four and three hundred thirty-three participants were from Phase 1 and 2, respectively (N = 617). Phase 1 participants were significantly older (median age 36.5 (28.0-43.0) years vs. 31.0 (25.0-40.0) years; p = 0.0003), divorced/widowed (6.7%, [n = 19/282] vs. 2.4%, [n = 8/332]; p = 0.0091); had tertiary education (27.9%, [n = 79/283] vs. 20.1%, [n = 67/333]; p = 0.0234); and less female (53.9%, [n = 153/284] vs 67.6%, [n = 225/333]; p = 0.0005), compared to Phase 2. Phase 2 had 10.2% repeat clients (n = 34/333), and 97.9% (n = 320/327) were 'very satisfied' with integrated NCD-HTS, despite standard HTS having significantly shorter median time for counsellor-led HTS (36.5, interquartile range [IQR]: 31.0-45.0 vs. 41.5, IQR: 35.0-51.0; p < 0.0001). Phase 2 associations with longer clinic time were clients living together/married (est = 6.548; p = 0.0467), more tests conducted (est = 3.922; p < 0.0001), higher overall satisfaction score (est = 1.210; p = 0.0201). Those who matriculated experienced less clinic time (est = - 7.250; p = 0.0253). CONCLUSIONS It is possible to integrate counsellor-led NCD rapid testing into standard HTS within historical HTS timeframes, yielding client satisfaction. Rapid cholesterol/glucose testing should be integrated into standard HTS. Research is required on the impact of cervical cancer/HPV screenings to HTS clinic flow to determine if it could be scaled up within the public sector.
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Affiliation(s)
- Kathryn L Hopkins
- Perinatal HIV Research Unit, Faculty of Clinical Medicine, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Khuthadzo E Hlongwane
- Perinatal HIV Research Unit, Faculty of Clinical Medicine, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Kennedy Otwombe
- Perinatal HIV Research Unit, Faculty of Clinical Medicine, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Janan Dietrich
- Perinatal HIV Research Unit, Faculty of Clinical Medicine, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Mireille Cheyip
- Centers for Disease Control and Prevention, Pretoria, South Africa
| | | | - Tanya Doherty
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Glenda E Gray
- Perinatal HIV Research Unit, Faculty of Clinical Medicine, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
- Office of the President, South African Medical Research Council, Cape Town, South Africa
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Mattison G, Krause V, Su JY, Broadfoot J, Ryder N. HIV testing rate in the top end of the Northern Territory of Australia: room for improvement. Int J STD AIDS 2012; 23:862-4. [PMID: 23258825 DOI: 10.1258/ijsa.2012.012021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The Northern Territory of Australia has an exceptionally high prevalence of sexually transmitted infections (STIs), particularly in remote areas. In contrast there are few notified cases of HIV at present. This study describes HIV testing rates in both primary care and sexual health clinics in the Top End region. In 2010, medical records were reviewed for a random sample of patients from a sexual health clinic and three remote primary care clinics. Among sexual health clinic patients 51.4% overall, and 59.7% of those with an STI, were tested for HIV. In people diagnosed with an STI in remote primary care clinics 19.1% were tested for HIV. HIV testing rates in the Top End of the Northern Territory do not meet the standard of national and international guidelines, with implications both for the early initiation of therapy and the accuracy of surveillance in a region with very high rates of STIs.
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Affiliation(s)
- G Mattison
- Warwick Medical School, University of Warwick, Coventry, UK
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Hayes R, Sabapathy K, Fidler S. Universal testing and treatment as an HIV prevention strategy: research questions and methods. Curr HIV Res 2011; 9:429-45. [PMID: 21999778 PMCID: PMC3520051 DOI: 10.2174/157016211798038515] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 07/15/2011] [Accepted: 07/29/2011] [Indexed: 02/07/2023]
Abstract
Achieving high coverage of antiretroviral treatment (ART) in resource-poor settings will become increasingly difficult unless HIV incidence can be reduced substantially. Universal voluntary counselling and testing followed by immediate initiation of ART for all those diagnosed HIV-positive (universal testing and treatment, UTT) has the potential to reduce HIV incidence dramatically but would be very challenging and costly to deliver in the short term. Early modelling work in this field has been criticised for making unduly optimistic assumptions about the uptake and coverage of interventions. In future work, it is important that model parameters are realistic and based where possible on empirical data. Rigorous research evidence is needed before the UTT approach could be considered for wide-scale implementation. This paper reviews the main areas that need to be explored. We consider in turn research questions related to the provision of services for universal testing, services for immediate treatment of HIV-positives and the population-level impact of UTT, and the research methods that could be used to address these questions. Ideally, initial feasibility studies should be carried out to investigate the acceptability, feasibility and uptake of UTT services. If these studies produce promising results, there would be a strong case for a cluster-randomised trial to measure the impact of a UTT intervention on HIV incidence, and we consider the main design features of such a trial.
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Affiliation(s)
- Richard Hayes
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
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Leon N, Naidoo P, Mathews C, Lewin S, Lombard C. The impact of provider-initiated (opt-out) HIV testing and counseling of patients with sexually transmitted infection in Cape Town, South Africa: a controlled trial. Implement Sci 2010; 5:8. [PMID: 20205841 PMCID: PMC2825497 DOI: 10.1186/1748-5908-5-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Accepted: 01/30/2010] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The effectiveness of provider-initiated HIV testing and counseling (PITC) for patients with sexually transmitted infection (STI) in resource-constrained settings are of particular concern for high HIV prevalence countries like South Africa. This study evaluated whether the PITC approach increased HIV testing amongst patients with a new episode of sexually transmitted infection, as compared to standard voluntary counseling and testing (VCT) at the primary care level in South Africa, a high prevalence and low resource setting. METHODS The design was a pragmatic cluster-controlled trial with seven intervention and 14 control clinics in Cape Town. Nurses in intervention clinics integrated PITC into standard HIV care with few additional resources, whilst lay counselors continued with the VCT approach in control clinics. Routine data were collected for a six-month period following the intervention in 2007, on new STI patients who were offered and who accepted HIV testing. The main outcome measure was the proportion of new STI patients tested for HIV, with secondary outcomes being the proportions who were offered and who declined the HIV test. RESULTS A significantly higher proportion of new STI patients in the intervention group tested for HIV as compared to the control group with (56.4% intervention versus 42.6% control, p = 0.037). This increase was achieved despite a significantly higher proportion intervention group declining testing when offered (26.7% intervention versus 13.5% control, p = 0.0086). Patients were more likely to be offered HIV testing in intervention clinics, where providers offered the HIV test to 76.8% of new STI patients versus 50.9% in the control group (p = 0.0029). There was significantly less variation in the main outcomes across the intervention clinics, suggesting that the intervention also facilitated more consistent performance. CONCLUSIONS PITC was successful in three ways: it increased the proportion of new STI patients tested for HIV; it increased the proportion of new STI patients offered HIV testing; and it delivered more consistent performance across clinics. Recommendations are made for increasing the impact and feasibility of PITC in high HIV prevalence and resource-constrained settings. These include more flexible use of clinical and lay staff, and combining PITC with VCT and other community-based approaches to HIV testing. TRIAL REGISTRATION Controlled trial ISRCTN93692532.
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Affiliation(s)
- Natalie Leon
- Health Systems Research Unit, Medical Research Council of South Africa (MRC), Cape Town, South Africa
| | - Pren Naidoo
- Independent Public Health Consultant, Cape Town, South Africa
| | - Catherine Mathews
- Health Systems Research Unit, Medical Research Council of South Africa (MRC), Cape Town, South Africa
- School of Public Health and Family Medicine, University of Cape Town (UCT), Cape Town, South Africa
| | - Simon Lewin
- Health Systems Research Unit, Medical Research Council of South Africa (MRC), Cape Town, South Africa
- Preventive and International Health Care Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway
| | - Carl Lombard
- Biostatistics Unit, Health Systems Research Unit, Medical Research Council of South Africa (MRC), Cape Town, South Africa
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Abstract
Summary: Patients’ reasons for attending the genitourinary medicine clinic inform and dictate the range of provisions and advice that the staff should provide. The objective analysis of these reasons would better inform the process of triage, clinical services and contractual arrangements (e.g. new to follow-up ratios). Our findings indicate that almost one in every two patients is presenting first with genitourinary symptoms and the majority of the remainder either identified themselves to be at risk or were identified by the attending clinician as having medical concerns and/or risk factors. This patient group could benefit, and must be offered, tests to exclude all sexually transmitted infections (within the condition's own incubation/test window periods).
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Affiliation(s)
- A R Markos
- Department of Genitourinary Medicine, Mid Staffordshire General Hospitals, NHS Trust, Weston Road, Stafford ST16 3SA, UK
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Weaver MR, Myaya M, Disasi K, Regoeng M, Matumo HN, Madisa M, Puttkammer N, Speilberg F, Kilmarx PH, Marrazzo JM. Routine HIV testing in the context of syndromic management of sexually transmitted infections: outcomes of the first phase of a training programme in Botswana. Sex Transm Infect 2008; 84:259-64. [PMID: 18256107 PMCID: PMC2771901 DOI: 10.1136/sti.2007.028217] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective: In 2004, the Ministry of Health adopted revised protocols for the syndromic management of sexually transmitted infections (STI) that included routine HIV testing. A training programme for providers was developed on the revised protocols that featured interactive case studies and training videos. An objective of the first phase of the training programme was to test its effect on four measures of clinical practice: (1) routine HIV testing; (2) performance of physical examination; (3) risk-reduction counselling and (4) patient education. Methods: Clinical practice in a district where providers were trained was compared with a district without training. The measures of clinical practice were reported by 185 patients of providers who had been trained and compared with reports by 124 patients at comparison clinics. Results: Relative to patients at comparison clinics, a higher percentage of patients of trainees reported that the provider: (1) offered an HIV test (87% versus 29%; p<0.001); (2) conducted a physical examination (98% versus 64%; p<0.001); (3) helped them to make a plan to avoid future STI acquisition (95% versus 76%; p<0.001) and (4) provided patient-specific information about HIV risk (65% versus 32%; p<0.001). Among patients offered HIV testing, the percentage who accepted did not differ between groups (38% of 161 patients of trainees versus 50% of 36 comparison patients; p = 0.260). Overall, 33% of patients of trainees and 14% of comparison patients were tested (p<0.001). Conclusion: A multifaceted training programme was associated with higher rates of HIV testing, physical examination, risk-reduction counselling and better HIV risk education.
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Affiliation(s)
- M R Weaver
- Department of Health Services, University of Washington, 901 Boren, Seattle, WA 98104, USA.
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Waxman MJ, Kimaiyo S, Ongaro N, Wools-Kaloustian KK, Flanigan TP, Carter EJ. Initial outcomes of an emergency department rapid HIV testing program in western Kenya. AIDS Patient Care STDS 2007; 21:981-6. [PMID: 18154494 DOI: 10.1089/apc.2007.0075] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This paper reports the initial operational outcomes of an emergency department-based HIV testing program in a high-prevalence and resource-limited setting by describing (1) the number and percentage of patients approached, tested, and found to be HIV positive and (2) the linkage of care to the HIV clinic. A retrospective log and chart review of the initial 5 months (January 2006 to April 2006) of the HIV testing program was performed. Patients were selected for HIV testing by routine screening and by provider initiated referrals. Out of the 1371 patients who were approached for HIV testing, 1339 (97.7%) patients were tested for HIV. Three hundred twelve (22.7%) of the patients tested were HIV positive. Within a sample group of patients newly diagnosed with HIV in the department, 82% were compliant with their initial HIV clinic visit and 65% were compliant with a 1-month follow-up visit. The implementation of an emergency department-based HIV testing program in a high HIV prevalence and resource poor country is feasible with a high percentage of patients accepting HIV testing and a high percentage of positive patients presenting to follow-up care. Establishment of rapid HIV testing in emergency departments can identify significant numbers of HIV-positive patients who would otherwise remain undiagnosed and provides an education opportunity for those patients who are HIV negative.
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Affiliation(s)
- Michael Jay Waxman
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Division of Infectious Diseases, Brown Medical School, The Miriam Hospital, Providence, Rhode Island
| | - Sylvester Kimaiyo
- Department of Internal Medicine, Moi University School of Medicine, Eldoret, Kenya
| | - Neford Ongaro
- Department of Surgery, Moi University School of Medicine, Eldoret, Kenya
| | - Kara K. Wools-Kaloustian
- Division of Infectious Disease, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Timothy P. Flanigan
- Division of Infectious Diseases, Brown Medical School, The Miriam Hospital, Providence, Rhode Island
| | - E. Jane Carter
- Division of Infectious Diseases, Brown Medical School, The Miriam Hospital, Providence, Rhode Island
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Obermeyer CM, Osborn M. The utilization of testing and counseling for HIV: a review of the social and behavioral evidence. Am J Public Health 2007; 97:1762-74. [PMID: 17761565 PMCID: PMC1994175 DOI: 10.2105/ajph.2006.096263] [Citation(s) in RCA: 272] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2006] [Indexed: 01/31/2023]
Abstract
Against the background of debates about expanding HIV testing and counseling, we summarize the evidence on the social and behavioral dimension of testing and its implications for programs. The discrepancy between acceptance of testing and returning for results and the difficulties of disclosure are examined in light of research on risk perceptions and the influence of gender and stigma. We also summarize the evidence on the provision of testing and counseling, the implementation of practices regarding confidentiality and consent, and the results of interventions. We demonstrate that social factors have a considerable impact on testing, show that the services linked to testing are key determinants of utilization, and consider the implications of these findings for HIV testing programs.
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