Research, clinic experience pave way for HIV screening

Partnerships with state health departments

For community health care centers involved in the study of initiating rapid HIV screening, one of the key take-home messages is that this can be done efficiently with a little help from friends.

"With the pilot project we received funding for testing supplies, so that made it affordable," says Evette Patterson, RN, BSN, director of nursing at Piedmont Health Services in Carrboro, NC.

"Then we had to figure out how to implement it in our day-to-day process to make it routine," Patterson says.

Without grant or study money, community health care centers could develop partnerships with their local health departments, suggests Kathy McNamara, RN, assistant director of clinical affairs at the National Association of Community Health Centers (NACHC) of Bethesda, MD.

For some centers, including Piedmont Health's six sites, the public health department provides the $7 to $10 rapid HIV testing kits.

"We have linked with our health department to continue to provide routine HIV testing," Patterson says. "They provide us with free testing supplies, and we provide them with data about all the testing."

Community health centers and other primary care clinics that are considering initiating routine HIV screening might first implement a pilot project to see what their HIV positive rate is and whether it would be feasible to expand HIV screening, according to the 2006 HIV screening guidelines by the Centers for Disease Control and Prevention (CDC) of Atlanta, GA.

"You have to test for a year to create your own baseline results," McNamara says.

For centers where HIV prevalence is high, the rapid HIV screening program is a great service to the community, McNamara says.

"Some [community health centers] would say they were providing an additional service to their health population," she adds. "Patients were thrilled, and there was a lot of acceptance from patients and staff alike."

For example, one of the Piedmont Health clinics delayed initiating the screening program for four months because this particular site was very short-staffed as positions waited to be filled, Patterson says.

"Some of our patients know other patients who go to other sites, and one patient came in and asked, 'When are you guys going to do that fingerprick HIV testing because I'm scared of having my blood drawn, but I want to know what my results are now,'" she recalls. "He was one of the first people tested at that site as soon as they started the HIV screening."

It makes sense for community health care centers to become involved in both HIV testing and care because of the nature of their service populations, including high transience among some patients, McNamara says.

"These patients who are most at risk are moving in and out of three systems of care: the safety net which is the community health centers, jails and substance abuse programs, and, third, the public health system," she explains. "What we have to do is build capacity so this three-legged stool works together more effectively."

This means having these different entities share data and align their efforts in the community so the health care is seamless from the patient's perspective, McNamara says.

"The patients who are most at risk have the biggest burden in navigating these three systems on their own," she adds. "If I had to create a model, I'd suggest we'd provide routine HIV testing in substance abuse programs where people are sitting in treatment for six weeks."

Also, all jails and state and federal prisons should provide routine HIV testing, McNamara says.

"From the patient's perspective this makes the most sense," she says.

Piedmont Health Services had been testing all prenatal patients before implementing rapid HIV screening, but less than 3% or 4% of the general population were offered HIV tests, Patterson says.

"We were doing risk-based testing for HIV and not general routine testing," she says.

The center agreed to be involved with the pilot project and conducted its own studies on how long the rapid HIV test took to administer, she notes.

"We wanted to see how we could implement it in the most efficient way so it would not take up too much of staff time," Patterson says.

The next step was to educate staff about the new HIV screening program.

"We educated everyone in the center from the front desk staff to clinical staff about the importance of doing HIV testing and why it was especially important to us in the South with the rising numbers of new HIV cases," Patterson says.

The educational program began with an hour-long session at each of six sites. A NACHC representative visited to speak with employees about North Carolina's HIV rates and the importance of general population screening.

"Then we put up posters for our staff, as well as for our patients," Patterson says. "These were brightly-colored and showed a family in the picture with the words, 'Know your HIV status today.'"

Also, HIV testing was added to the clinic's checklist.

Each site gave staff a script that medical assistants would follow as they offered HIV testing to patients, Patterson says.

The script read, "It's now recommended that all people between the ages of 13 and 64 should be tested for HIV. We're able to offer that test to you today free of charge," she says.

"Unfortunately, we did not do opt-out," she adds. "We asked patients if they wanted to take the test."

If patients declined the test, then the medical assistant would ask them: "Is there a reason why you don't want to be tested today?"

At Piedmont, most of the patients who said they would decline the test did so because they didn't feel they were at risk, Patterson says.

Then once patients were in a room with the provider, the provider would ask them a few more questions about why they felt they were not at risk, she says.

"At that point, the provider could persuade many patients to have the test done," she adds. "Seventy percent of our patients accepted the test, and our HIV new infection rate was between 0.5 and 1%."

NACHC is continuing to promote routine HIV screening in its 1,200-plus health care centers and more than 7,500 delivery sites, which together represent 20 million patients, McNamara says.

The health centers are independents and not-for-profits, and each one has a board that consists of at least 51% of consumers of the health care provided by the center, she notes.

"So when we designed training for HIV screening we designed it for our board members, chief executive officers, and clinical staff," McNamara says. "I can't tell you how many telephone calls, Webinars, articles, etc. we've presented just within our network of primary care providers, and we also did this in the HIV world at CDC and Ryan White conferences."

The overarching goal is for everyone to come together to the table to design a strategy that will work in their own community, she adds.

From patients' perspectives, HIV screening works and makes sense, Patterson says.

"One of the important things is it's an empowering thing for patients to know what their status is, even if it's [positive]," Patterson says.

"We're reaching a time when HIV can be managed, and we can prolong the lives of people, and we're doing people an injustice by not testing them and not letting them know early if they're positive," she adds.