Routine, rapid HIV screening can work well in community health center settings

Study finds different levels of success

Health care providers have struggled with instituting routine HIV screening for adolescents and most adults since the Centers for Disease Control and Prevention (CDC), recommended such testing for everyone between 13 and 64 years of age in 2006.

There have been pilot tests of routine HIV screening in emergency rooms and other settings, and while results mostly are positive, the practice remains staff intensive and costly, and most health systems still have not implemented the practice.

Now researchers show how routine HIV screening could be handled in resource-limited community health centers. The study's findings show that these clinics, which serve uninsured and indigent patients, can make routine testing work, particularly if they're given the rapid test kits.

The National Association of Community Health Centers (NACHC) of Bethesda, MD, has been committed to integrating HIV care in primary care clinics for a long time, and when the CDC issued its new routine testing guidelines, the organization saw this as an opportunity to increase HIV detection, says Janet Myers, PhD, MPH, an assistant professor of medicine at the University of California - San Francisco in the department of medicine. Myers was the lead author of the recent study of routine HIV testing in community health centers.

"We collaboratively developed an evaluation and asked health centers to add a documentation form where they would document for each patient whether the HIV test was offered and whether or not patients accepted the test," Myers explains.

The evaluation also included patients' test results.

Six community health centers agreed to do this work, and so they were included in the study, which began in late 2006 with data collection ending in 2008.

Prior to the study the six community health centers had performed 3,078 HIV tests, which amounted to 3% of their patient populations. During the study period, the centers offered HIV testing to 6,148 patients, which was 28% of patients between 13 and 64 years, and 67% or 10,769 people accepted testing. The study found 17 newly-detected infections.1

The HIV confirmed positive rate was just over the CDC's threshold for offering routine testing, meaning that it was cost-effective for community health centers, in general, Myers says.

"To be honest, they didn't find as many new positives as they thought they would," she adds. "They tended to test people who already were engaged in care, and these are people who typically are not the knew positives."

Some of the clinics that tested a higher proportion of patients found no HIV positive results, says Kathy McNamara, RN, assistant director of clinical affairs at NACHC.

"They were in a low prevalence area, so according to the CDC guidelines they shouldn't continue routine HIV screening," she adds.

The goal of the study was to create a model for primary care sites to implement routine testing, and this goal was met successfully, McNamara and Myers say.

"I was impressed with the increased access patients had as a result of this initiative," Myers says. "Although it provided HIV tests to a significant proportion of folks who had not been tested before, there was variability across health centers and across patient demographics."

For instance, some health centers were able to test most of their patients while others were less successful, testing less than 10% of patients, she adds.

Tight staffing situations had among the biggest impact on the proportion of patients reached with the routine HIV screening, McNamara says.

"It makes sense to do routine HIV testing in primary care settings, and it can be built into practice," McNamara says.

But these health centers, which are federally-funded, may have patient back-up problems, she notes.

"Sometimes, HIV screening fell off the radar because of staffing issues," McNamara says. "They had too many patients; they had too sick of patients, and HIV testing is an optional thing while they still had to do their main work."

Piedmont Health Services in Carrboro, NC, provides an example of this point.

The six-site health center provided extensive staff training for routine HIV screening as part of a recent study of how such screening was implemented in six community health centers.

The research project provided free rapid HIV test kits but no additional funding, and sites were encouraged to offer testing to all patients, ages 13 to 64.1

But even highly-motivated centers like Piedmont often were unable to offer HIV testing to most patients. About 20% to 25% of patients who sought medical care at the center were offered an HIV test. Among those who were offered a test, about 70% accepted the test, says Evette Patterson, RN, BSN, director of nursing at Piedmont Health Services.

"If it's really busy in the clinics, HIV testing is something that we'll have to let go of," Patterson says. "Like during the flu season when we were giving 100 to 125 flu shots a day, it was hard to continue to do the routine HIV testing."

For the centers that offered routine HIV screening to a majority of patients, the key was integrating it into their patient flow so that it became automatic and a habit, Myers says.

"It was just like getting a patient's blood pressure and weight; they'd offer an HIV test," she explains. "All of the clinics were supposed to do the opt-out method, but some were less comfortable with that."

The goal was to integrate the idea of HIV testing and the importance of HIV care into the primary care mindset, Myers says.

"That was also the CDC's intent to reduce the stigma of HIV by making testing routine," she adds. "But I still think there's stigma out there."

Evidence from the study's data shows that acceptance of HIV testing varied across demographics, she notes.

"One striking thing to me was that Latinos were more likely to take the HIV test when offered," Myers says.

The study found that men offered the HIV test were most likely to accept it if they were Latino, with 77% of Latino men offered the test going through with HIV testing. White men were least likely with only 50% who were offered HIV testing having the test, and African American men accepted the rapid HIV test 69% of the time.1

Among women, 77% of Latino women accepted the HIV test, while 71% of African American women had the test when offered, and 58% of white women went ahead with the test.1

Also, younger people were more likely to accept testing than older people, which investigators surmised was probably due to a higher perceived risk.1

Routine, rapid HIV screening is feasible, and now the public health community needs to find a way to pay for it, Myers says.

Health care centers need to examine their own facility's financial constraints and find a way to make it work more efficiently, she suggests.

"In San Francisco, for example, one thing a clinic has done is integrate HIV testing every time a person gets a blood draw," Myers explains. "They'll automatically run an HIV test on the blood sample after obtaining the proper consent."

This is a creative approach to the limitations of phlebotomists' time.

Another strategy is to approach HIV screening with a team approach in which a nurse or phlebotomist might obtain the sample for testing, and physicians will deliver the results, Myers says.

Reference

  1. Myers JJ, Modica C, Kang Dufour MS, et al. Routine rapid HIV screening in six community health centers serving populations at risk. J Gen Intern Med. 2009;24(12):1269-1274.