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CDC issues new guidelines for community centers
Routine HIV testing, counseling update
Emphasizing the importance of community health centers (CHCs) in HIV testing of at-risk populations, the Centers for Disease Control and Prevention has issued new guidance that includes a testing algorithm and counseling advice. (See chart.)
CHCs are important places to offer HIV testing because the patients who receive medical care there are often members of groups that may be at high risk of HIV infection, the CDC emphasized. Routine HIV and STD screenings not only provide the opportunity to educate patients about transmission of HIV and STDs, but also can allow people who are infected to receive care and services. Patients who seek care in CHCs are disproportionately low income, uninsured or publicly insured, and members of minority races or ethnicities.
Adding routine HIV testing to a CHC starts with identifying the flow of patients' visits. Each health center needs to map the current patient flow, identify where HIV testing is to occur, assign someone to administer the test, and determine who gives the results. In addition, documentation of results needs to be confirmed. In health centers without Ryan White funding, a tracking system needs to be developed to ensure both that results are documented and that a reminder/recall system is in place to contact persons with reactive HIV tests or those with indeterminate results.
The guidelines address the difficult issue of post-test counseling, offering recommendations that include the following:
Negative HIV test results: It is important to let the patient who has tested negative for HIV know that this result does not mean immunity from infection. Nor does it mean that the patient is not engaging in activities that continue to put him or her at risk. For patients who continue to engage in risky behavior, it is important to identify barriers to risk reduction and to give information about steps patients can take to minimize or eliminate possible exposure to HIV. The provider should address the importance of being re-tested if the patient has engaged in unsafe behaviors during the "window period"the time period after exposure during which an HIV test will be negative. Determine whether there is a need for referrals to other social service organizations that treat co-factors such as substance abuse, mental illness, or addictive sexual behaviors. Explore how friends and family can support behavior change or whether these people may apply pressure to continue risky behavior. Identify how the health center can play a role in supporting positive behavior changes.
Positive HIV-test results: As you prepare to tell a patient that the test result is preliminarily positive (rapid test) or confirmed as positive (conventional test), be sure that there are additional supportive resources available to the patient, the CDC advised. This may mean a mental health counselor, social worker, or psychologist. If you are planning a post-test counseling session at the center, communicate with the appropriate staff in advance of the appointment so the time on the staff member's schedule is blocked out for when the patient may need that person's help.
Remember, some patients might be better prepared to receive positive test results than others, the CDC warned. The emotional impact of hearing these results may prevent patients from clearly understanding information in the post-test counseling session. Health centers should strongly consider partnering with local health department workers who may be able to assist with delivering results, with post-test counseling, and with partner services. These may be particularly important resources for sites that lack social workers or other staff trained in this area.
Depending on the patient's state of mind and behavior during the post-test counseling session, it might be appropriate to assess whether the patient is at risk of committing suicide or other violent behavior. If you have any concerns about the patient's safety or the safety of others (for example, a patient who may go after a partner whom he or she suspects of transmitting the virus), obtain the immediate assistance of a mental health counselor.
After patients receive their positive results, usually from a health center provider they trust, they need to be informed about taking precautions regarding risky behavior, given the name of their contact at the health center, and given ways to contact additional sources of information, such as the health department and CDC hotline numbers (Call 1-800-CDC-INFO [1-800-232-4636], 24 hours a day, 7 days a week, or email email@example.com.) All patients should be offered confidential partners' services through the health department. Participation in partners' services should be voluntary and non-coercive.
(Editor's note: The CDC guidelines "Implementation of Routine HIV Testing in Health Care Settings: Issues for Community Health Centers" are available t: http://1.usa.gov/fljdZf)