TB clinics a great place to offer HIV screening
Key is to train nurses to provide counseling
Though they’re often overlooked, public TB clinics are a wonderful place to do HIV screening, says Stephen Weis, DO, medical dir ector of the Tarrant County, TX, TB clinic and professor of medicine at the University of North Texas Health Science Center at Fort Worth.
The key is one-stop shopping, he says. That is, if TB clinics offer an HIV test at the same time they draw blood for TB purposes, most patients will participate in the HIV screening, he says. Though it’s standard practice at most TB clinics, it simply doesn’t work as well to tell patients they have to make a separate trip to the HIV clinic and have blood drawn a second time.
That’s a shame, says Weis, because TB clinics in many ways are an optimal point of contact for HIV screening. For one thing, there is a high prev alence of HIV infection among clients, he says. Plus, many clients, whether or not they’re already infected, report engaging in many behaviors that place them at high risk for HIV infection and thus can benefit from counseling.
Finally, clients being treated for TB are less likely to be lost to follow-up than they might be at an HIV testing site because they’re already coming back to the TB clinic on a regular basis for check-ups and medication refills. "I think HIV counseling is much easier to do when it’s presented as a routine part of health care for TB," says Weis.
Since 1987, he has been screening for HIV virtually everyone who walks into the county TB clinic. Now, clients are so accustomed to being offered an HIV test that no one thinks anything of it, he adds. "It’s like universal DOT. Once you’ve been doing it for awhile, people get used to the idea, and no one even questions it."
In a recently published article in the American Journal of Public Health, Weis tallies the yield for that nearly nine-year period of HIV surveillance.1 Of 768 TB patients counseled and tested for HIV, 98 tested positive for HIV infection. Of the 98, 93% had one or more risk factors for HIV infection. Among those who tested HIV-negative, 42% had one or more risk factors for HIV infection.
Counseling offered for HIV screening
To make offering HIV testing feasible, Weis says the only change he’s had to make in clinic procedure is to mandate that TB clinic nurses undergo training in how to offer pre- and post-test counseling for HIV screening. That out of the way, it’s a simple matter to offer an HIV test as part of the routine blood work.
Weis is baffled that more TB clinics haven’t done the same. "It sounds bizarre, but most TB clinics don’t do that," he says. "Instead, they send patients over to the HIV clinic to be counseled and have their blood drawn." Predictably, only about half the patients bother making the extra trip. "I mean, be honest," he says, laughing. "Did you wake up this morning and say to yourself, One of my goals today is to have a needle stuck into my arm — twice?’"
Once nurses are trained to provide the requisite counseling, the rest is easy, he says. The state of Texas screens blood samples for HIV at no cost. And getting patient permission to test for HIV is much easier than most people think. "When I present this data, people are always shocked that I get such a high level of participation," he says. "They go, How do you do this? None of our patients would ever agree to have this done.’"
It’s important to make the pitch positive, he adds. His goes something like this: "We need your permission to do this test because if you have HIV, that will affect the way we’ll treat you for TB. The Centers for Disease Control and Prevention recommends that you get this test done. And it’s no big deal, because we’ll use this blood that we’re about to draw anyway." That seems to work for almost everyone, he adds: "We’ve had very, very few people refuse."
Using negative terms can scare patients into saying no, he says. "Some HIV clinics, in my experience, make a point of telling the patient they can’t allow anyone to find out about this — that it could cause them to lose their job or not to be able to get insurance. We look at it like we’re doing our patients a service simply by offering them better health care."
1. Weis SE, Foresman B, Cook PE, et al. Universal screening at a major metropolitan TB clinic: HIV prevalence and high-risk behavior among TB patients. Am J Public Health 1999; 89:73.