3. Promoting HIV Testing in Diverse Populations
Strategies to Improve Routine HIV Testing
Because a significant proportion of HIV-positive individuals are unaware of their status and the high risk for HIV transmission in some populations, healthcare practitioners and organizations must develop innovative solutions to encourage more people to be tested for HIV and to access prevention and care services. While providers bear much of the responsibility for planning and achieving such solutions, developing cooperative relationships with established community-based organizations can aid significantly in reaching the goal of making HIV testing a part of routine medical care. [CDC Disparities 2007]
Organizing Within Healthcare Practices
All such efforts must begin by establishing in-house policies and procedures that involve all of a facility’s staff—from administrators and practitioners to support staff. Futterman and colleagues at the Montefiore Medical Center developed a 4-step process for implementing a routine HIV screening program [Futterman ACTS 2002]:
Buy-in. A routine testing strategy must originate with a practice’s administration manager and medical leadership, who then should involve all of the practitioners, administrative staff, and other relevant personnel.
Implementation planning. Planning can be done similarly to other changes that have been implemented in a particular practice setting. This will include features like: becoming familiar with the state and local regulations, assigning staff responsibilities, developing protocols to document testing procedures and results, identifying HIV specialists to whom HIV-positive patients will be referred, and determining which tests are to use. Establishing one person or a team to be responsible for planning and problem solving can be valuable.
Training. Two areas of staff training are most relevant: (1) pretest counseling and testing itself and (2) informing patients of positive test results. Many primary care practices may find that contracting with either a local AIDS education and training center or an experienced HIV practitioner is the most efficient way to do this training.
Monitoring and evaluation. Primary care practices should review the effort’s progress (eg, by how much the number of patients has increased) and what remains to be done (eg, whether particular patient groups are not being screened in representative numbers). The CDC recommends that every patient be tested once, and more frequently for those belonging to a high-risk group. [Branson 2006] Because determining whether a particular patient belongs to a high-risk population can be challenging, practitioners may need to consider other potential clinical clues, such as the presence of an STI or a new pregnancy or learning from a patient that he or she has engaged in sexual activity with more than 1 partner. Practitioners should recommend that such patients undergo HIV testing at least annually, particularly if unsafe sexual activity or a new STD is identified.
Implementation of routine HIV screening will also require quality assurance measures: who will perform the tests, where they will be offered, and what type of documentation should be included with a practice’s other routine forms. For this purpose, a check-off system can be valuable, with choices such as [Futterman ACTS]:
- Test offered; patient accepted
- Patient declined test because
- Had already been tested
- Is not ready
- Does not consider self at risk
- Test not offered because practitioner does not consider patient to be at risk
- Test not offered due to lack of time
Before routine screening can be implemented, practitioners need to understand that some patients, when offered an HIV test, will feel that they are being singled out for testing. Any practitioner who is responsible for offering a patient HIV screening should take care not to single out any particular patient. Patients who express concerns should be assured that an HIV test is offered to every patient who seeks care at the facility and no individual is singled out for testing.
All patients should be offered testing because providers are not proficient in identifying who may be at risk for HIV. One CDC report found that 73% of HIV-positive persons who were late testers (i.e., AIDS onset occurred within one year after HIV diagnosis) had seen providers within the previous seven years and were never offered a test because providers did not regard them as at-risk; and 25% of those visits had occurred within the past year. [Attia 2009]
