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Service Delivery Innovation Profile

Rapid HIV Testing Program Enhances Access to HIV Education and Screening for At-Risk African-American and Hispanic Youth


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Snapshot

Summary

The HIV Testing Program provides sexual health education, counseling, and HIV testing to at-risk youth, along with additional intensive counseling for those who test positive. Rapid HIV testing and counseling is provided in a variety of community-based settings and fourth-generation testing is now offered to youth and adolescents admitted to the hospital for care. Since the program's inception, more than 23,000 individuals have been tested, many of whom likely would not have had access to timely testing in the absence of the initiative. A review of data from a 10-month period suggests that the program has been successful in identifying HIV-positive, minority youth and facilitating their access to care.

See What They Did for an update on program elements; Did It Work? for updated results; How They Did It for new information on sustaining the innovation, resources used, and funding sources; and Tools and Other Resources for updates to the testing technologies used (updated March 2014).

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the number of at-risk youth served since program inception; data from one 10-month period on the number of youth tested, identified as HIV positive, and linked to care; and data from one hospital that implemented routine rapid HIV testing of youth. The underlying assumption is that, in the absence of this program, few if any of these traditionally underserved individuals would have been tested or linked to care.
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Developing Organizations

Drexel University's College of Medicine; St. Christopher's Hospital for Children
Philadelphia, PAend do

Use By Other Organizations

A number of doctors' offices and another local children’s hospital have instituted routine rapid testing for HIV in their practices. Routine rapid testing has become the standard of care in all ambulatory clinics and inpatient departments at St. Christopher’s Hospital for Children, serving as a blueprint for other hospitals locally and regionally to follow suit.

Date First Implemented

2002
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Patient Population

Age > Adolescent (13-18 years); Race and Ethnicity > Black or african american; Hispanic/latino-latina; Vulnerable Populations > Impoverished; Racial minorities; Urban populationsend pp

Problem Addressed

Minority youth are at higher risk for HIV infection, less likely to be educated about HIV/AIDS in school, and consequently more likely to get tested late in their illness than are non-Latino whites, which leads to increased risk of death.1,2,3,4
  • Disproportionately at risk: An estimated 50 percent of new HIV infections occur in those under the age of 25.1 African Americans account for more than half (55 percent) and Latinos for nearly one-fourth (24 percent) of all youth infected with HIV.2
  • Lack of education: Fewer Latinos and African-American students report being taught about HIV/AIDS in school than do non-Latino whites.3
  • Late testing, higher mortality rates: Latinos and African Americans are more likely to be tested late in their illness than are non-Latino whites. Because of poor access to health care, late diagnosis, and lack of treatment, HIV/AIDS mortality rates have declined at a slower rate among Latinos and African Americans than among non-Latino whites.4

What They Did

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Description of the Innovative Activity

The HIV Testing Program provides sexual health education, counseling, and HIV testing to at-risk youth, along with additional intensive counseling for those who test positive. Program services started as community-based education and testing but have narrowed in focus to include at-risk minority youth engaged in health care encounters while still continuing HIV education within the community. The program offers universal rather than risk-based screening to the target population based on the seroprevalence, not the behaviors of the individual (updated March 2014). Key elements of the program are described below:
  • Sexual health education and counseling in community settings: Designed to increase awareness of sexually transmitted diseases, the sexual health curriculum uses a variety of formats (e.g., group activities, games, movies) to provide youth (ages 14 to 24) with prevention information. All youth also meet individually with a counselor for approximately 20 minutes. Counselors assess the individual's risk for sexually transmitted diseases and provide additional information on HIV/AIDS, including specific information on exposure, the "window period" (i.e., the time between exposure and when the virus can be detected via testing), and testing and retesting options. For example, counselors use calendars to help youth pinpoint when they may have been exposed to HIV infection and determine the date that they should return for testing or retesting, if needed. Counselors also inform youth of routine, walk-in testing locations.
  • Rapid HIV testing: Youth interested in the rapid HIV test must consent for both testing and care outreach. Counselors obtain information on how to contact the youth if needed (e.g., school name, home address, phone number) in the anticipation that some who test positive may not successfully attend their first appointment (the time when this information would normally be obtained). In addition, the counselor who performs the test becomes a "buddy" to assist with any logistical issues that may arise in the time between testing and successful engagement in care. Youth interested in testing are also screened for their readiness to test. Youth who are intoxicated, at risk for suicide, or who exhibit serious mental health symptoms do not get tested. Those tested engage in additional educational activities after the test until the results become available, which can take anywhere from several minutes up to 20 minutes depending on the rapid test technology used (updated March 2014).
  • Fourth-generation testing at hospital site: For youth who are tested at the home site rather than in the community, there are a variety of options for testing. All patients ages 13 and older in the ambulatory clinics are offered a rapid HIV test, whereas patients admitted to the hospital are offered fourth-generation testing and those admitted to the emergency department may be offered either rapid HIV testing or fourth-generation testing. Fourth-generation testing requires a blood draw and must be run on a machine in the hospital lab. This testing method requires the patient to be present for at least a couple of hours or to be in a situation where a followup can be ensured. The advantage with fourth-generation testing is that the test assays antibody (as the rapid tests do) and also includes HIV antigen, thereby shortening the window period. When rapid fourth-generation tests are more feasible, the program may switch to this testing method for all situations (added March 2014).
  • Retest and posttest counseling and followup: Youth who initially test positive immediately get retested using the OraSure test (the results of which are typically not known for a week), and for the majority, a viral load test is also obtained. Those who test positive on the rapid test also receive counseling from a master's-level social worker, including screening for risk of suicide. A social worker provides the youth with a pager number in case he or she needs support while waiting for the results of the second test. Youth receive these results at the St. Christopher clinic approximately 1 week later; those who test positive are immediately linked to youth-specific, comprehensive HIV care at either the St. Christopher program or an age-appropriate HIV care program of their choice.
  • Multiple locations to enhance access to care: The program offers services in a wide variety of community-based locations, including health fairs, community events, emergency shelters, family court, community colleges, gay and lesbian youth centers, and other youth-based agencies. Information provided in March 2014 indicates that there has been a shift in focus to health care settings over the past few years because of the higher rate of positivity in these settings, and youth have indicated a desire for this to be done.5 However, the disadvantage of health care testing is that the additional HIV prevention and awareness education provided in community settings must be truncated (updated March 2014). Providing these services in many easily accessible locations is essential to reaching minority youth. Within each location, the program generally operates during set hours in two private rooms to maintain confidentiality (one for initial testing and one for followup testing and counseling to those who initially test positive); for example, a location may provide services on the first Tuesday of the month between 4 and 7 p.m. During this time period, counselors come to the site to offer program services. One of the program's full-time testers operates out of St. Christopher’s emergency department in the afternoons and evenings, offering testing to anyone in the target age group that presents, even if there is no complaint.
  • Education for health care providers: In 2009, the program began offering education and technical assistance to health care providers on the importance of providing HIV testing as a routine part of medical care. Trainings take place in a variety of settings, including emergency departments, ambulatory clinics, inpatient services, and community physician practices, and can be tailored to both large groups (such as during grand rounds) or small group roundtable sessions. Information provided in March 2014 indicates that topics include the demographics of HIV in the area, national guidelines for testing, and technical assistance on how to start or enhance testing in each setting. Illustrative cases of youth who have tested positive in the program are also presented. In addition to training, this component of the program also offers providers immediate assistance with posttest counseling for any patients testing positive. In 2010, the program's educational outreach expanded to include more neighborhood physician offices and local hospitals in an effort to increase routine HIV testing in high-risk districts. As of March 2014, 70 provider-to-provider presentations have been conducted.

Context of the Innovation

St. Christopher’s Hospital for Children is a nonsectarian, 189-bed hospital located in Philadelphia, PA. The hospital has more than 270 pediatric specialists who offer a wide range of services exclusively to children and adolescents. These physicians also serve in the Pediatrics Department at the Drexel University College of Medicine. The HIV Testing Program began as a pilot designed to increase access to HIV testing by offering services in the neighborhoods where youth live (rather than requiring them to travel to clinic locations in downtown Philadelphia to receive HIV testing, as had occurred in the past). Two events led to the initiation of the pilot. First, the community experienced the sudden death of an adolescent who did not know that he had full-blown AIDS. Second, a teen participating in a school blood drive accidentally learned that he was infected with HIV after the Red Cross sent test results to his home. These two events raised awareness of the need to increase access to HIV testing and early intervention for at-risk youth in the community.

Did It Work?

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Results

A formal evaluation is in progress; however, more than 23,000 individuals have been tested since the program's inception both within the hospital and externally at offsite community venues. Many of these individuals likely would not have had access to timely testing in the absence of the initiative. The program has been successful in identifying HIV-positive minority youth and facilitating access to care. Within the last year, with the addition of fourth-generation testing, the program has been able to identify several additional youth with acute HIV and very high transmission risk who would have otherwise tested negative by conventional testing methods (updated March 2014).
  • Thousands of at-risk youth served: The program serves about 2,300 at-risk individuals a year (combined totals of HIV testing conducted within various departments at the hospital as well as externally at offsite community venues and events), and more than 8,000 youth have received program services over the 10 years it has been in operation. More than half (57 percent) of all individuals served since 2003 had never had an HIV test before and approximately 70 percent of the youth routinely tested at St. Christopher's Pediatric Emergency Department have never been tested in the past (updated March 2014).
  • At-risk youth identified and linked to care: The overall rate of youth testing positive since the program's inception is 0.8 percent. As the move to screen more apparently healthy youth has been made, the overall seropositivity has declined (due to a higher number being screened), but the number of positives has increased.6 Over one 10-month period, 450 individuals received testing, including 248 at-risk youth between the ages of 14 and 24. Seven of these 248 individuals tested positive for HIV; of these, 6 were linked to care and had at least 1 medical visit.7 In 2010 and 2011, screening at St. Christopher's Emergency Department alone identified four new HIV-positive individuals, one who had full-blown AIDS and another (an 8-year old boy) who had been infected at birth but never diagnosed. In addition, the recent expansion of educational outreach efforts to other departments within the hospital—including Primary Pediatrics, Ambulatory, and Child Protection Program, and inpatient areas, along with external expansion to St. Christopher's primary care satellite community practices in high-risk neighborhoods—has led to an increase in testing and the identification of HIV-positive youth (updated March 2014).

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the number of at-risk youth served since program inception; data from one 10-month period on the number of youth tested, identified as HIV positive, and linked to care; and data from one hospital that implemented routine rapid HIV testing of youth. The underlying assumption is that, in the absence of this program, few if any of these traditionally underserved individuals would have been tested or linked to care.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Obtaining license to perform offsite testing: This program became the first in Pennsylvania to obtain a mobile license, which allowed staff to test in multiple locations. To apply for the license, the lead physician had to become a laboratory director. In addition, the program had to develop procedures to comply with licensing requirements, such as data collection processes to ensure that required reports could be submitted to the licensing board.
  • Building relationships with community-based organizations: Staff identified and contacted community-based organizations that serve youth who may be at risk for HIV infection (e.g., emergency shelters); they explained the program and explored the potential for collaborative relationships.
  • Conducting site visits: During site visits, staff examined the available space to ensure that confidential services could be provided in two private rooms. After ensuring that appropriate space existed and formalizing the partnership, the two parties scheduled a regular time for the program.
  • Developing procedures to ensure confidentiality: In addition to finding and configuring the space to ensure confidentiality, program leaders developed specific procedures to help safeguard privacy. For example, the program was specifically structured so that multiple activities occur simultaneously. When youth constantly move from one activity to the next, they become less likely to notice and keep track of their peers’ status in the program.
  • Creating cultural change among health care providers: Program leadership spent many hours providing training sessions and refresher trainings for medical teams to encourage a shift to routine testing. Incentives were provided to teams with the highest rates of testing, and monthly newsletters were distributed to retain visibility (added March 2014).
  • Creating youth-friendly curriculum: Staff and peer educators developed and/or acquired educational materials in a variety of youth-friendly formats, including games and movies.

Resources Used and Skills Needed

  • Staffing: Information provided in March 2014 indicates that program staff initially included a full-time coordinator, two full-time testers (one of whom worked out of the St. Christopher's Pediatric Trauma Emergency Department), and five community outreach counseling and testing workers. Generally, 2 to 3 testers can administer rapid HIV testing to 12 to 17 youth during a 3-hour period. To improve utilization of resources for sustainability of the program, staffing transitioned to a full-time coordinator who focuses on creating and maintaining institutional buy-in and one full-time tester for the emergency department; the second tester was shifted into a role of hybrid tester and linkage-to-care outreach worker to ensure that those testing positive were maximizing their health care engagement (updated March 2014).
  • Costs: The testing program's annual budget totals approximately $175,000. The overall annual program budget is $2.3 million, which covers HIV care, case management, and secondary prevention (updated March 2014).
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Funding Sources

Ryan White CARE Act; St. Christopher's Foundation; Commonwealth of Pennsylvania Youth HIV Prevention; Gilead FOCUS
A combination of Federal and State funds and grants support the program. Early intervention grants supported program development.

Gilead FOCUS is an initiative through Gilead Sciences to improve national HIV testing rates (added March 2014).end fs

Tools and Other Resources

For more information about the rapid HIV testing technologies used by this program (OraQuick ADVANCE® and INSTI™), see http://www.orasure.com and http://www.biolyticalcanada.com.

For more information about the fourth-generation, lab-based, HIV testing technology, see http://www.theaidsinstitute.org/sites/default/files/attachments/Brennan.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.).

Adoption Considerations

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Getting Started with This Innovation

  • Identify potential partner organizations: The program's launch depends on identifying and partnering with local organizations that serve youth at risk of HIV infection. These organizations provide a set time and place where these youth can come for testing. By contrast, offering the program at large-scale community events (e.g., health fairs) raises awareness but does not target high-risk individuals.
  • Explain confidentiality procedures to potential partners: Some organizations may be reluctant to collaborate due to concerns about confidentiality. These concerns can be addressed by informing potential partners that the results of HIV tests may be released to those ages 14 and older without parental consent and by explaining procedures that ensure confidentiality (e.g., using private rooms and conducting multiple activities simultaneously).
  • Assess baseline knowledge and perceptions: Work with health care teams to identify their baseline knowledge and perceived barriers to testing. Individualize testing options for them based on this assessment (added March 2014).

Sustaining This Innovation

Seek ongoing funding: With shifts in public policy towards testing, it is important to be aware of national guidelines on testing and tailor methodologies to meet these guidelines. As the landscape changes with more patients having insurance with the Affordable Care Act, it may be possible that insurance will reimburse for a majority of testing, relieving the amount needed in grant funding (updated March 2014).

Use By Other Organizations

A number of doctors' offices and another local children’s hospital have instituted routine rapid testing for HIV in their practices. Routine rapid testing has become the standard of care in all ambulatory clinics and inpatient departments at St. Christopher’s Hospital for Children, serving as a blueprint for other hospitals locally and regionally to follow suit.

Additional Considerations

  • Encourage youth to be tested each year: Counseling sessions should focus not just on how to prevent HIV, but also on the need for individuals to be tested at least once a year (and more often if they may have been exposed to HIV).
  • Maximize HIV education opportunities: National surveys and State-level data for Philadelphia have revealed a high level of sexual activity among youth that is not matched with a high level of knowledge related to prevention and recommended testing of sexually transmitted diseases (added March 2014).

More Information

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Contact the Innovator

Barbara L. Bungy, MPH, CHES
Program Director, Dorothy Mann Center for Pediatric & Adolescent HIV
St. Christopher's Hospital for Children
Section of Immunology, Nelson Pavilion
Erie Avenue at Front Street
Philadelphia, PA 19134
(215) 427-5284; (215) 427-5561
E-mail: barbara.bungy@drexelmed.edu

Clint Steib
Community & Healthcare HIV Testing Program Manager
Dorothy Mann Center for Pediatric & Adolescent HIV
St. Christopher's Hospital for Children
Section of Immunology, Nelson Pavilion
Erie Avenue at Front Street
Philadelphia, PA 19134
(215) 427-5284; (215) 427-3882
E-mail: clint.steib@drexelmed.edu

Innovator Disclosures

Ms. Bungy and Mr. Steib reported receiving salary support under a research grant from Gilead Sciences; in addition, information on funders is available in the Funding Sources section.

Recognition

In 2010, St. Christopher's Hospital for Children received an award in the patient care category of the Achievement Awards Program by the Hospital and Healthsystem Association of Pennsylvania. This award program recognizes hospitals and health systems that have demonstrated innovation in patient care. More information about this award is available at: https://www.haponline.org/PA-Hospitals/Achievement-Awards.

Footnotes

1 Henry J. Kaiser Family Foundation. The HIV/AIDS epidemic in the United States. April 2014. Fact sheet. Available at: http://kff.org/hivaids/fact-sheet/the-hivaids-epidemic-in-the-united-states/.
2 Centers for Disease Control and Prevention. HIV prevention in the third decade: activities of CDC's Division of HIV/AIDS prevention. Atlanta: U.S. Department of Health and Human Services. 2005. Available at: http://stacks.cdc.gov/view/cdc/11375.
3 Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance—United States, 2007. MMWR Surveill Summ. 2008;57(SS04);1-131. [PubMed] Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5704a1.htm.
4 Henry J. Kaiser Family Foundation. Latinos and HIV/AIDS. September 2009. Fact sheet. Available at: http://www.s-cap.org/events/documents/LatinoandHIV_AIDSFacrtSheet9-2009.pdf.
5 Haines CJ, Uwazuoke K, Zussman B, et al. Pediatric emergency department-based rapid HIV testing: adolescent attitudes and preferences. Pediatr Emerg Care. 2011;27(1):13-6. [PubMed]
6 Laguerre-Frederique R, Pereira L, Conway D, et al. Implementation of routine HIV testing in a children's hospital. Pediatric Academic Societies. 2014 May. Vancouver, BC.
7 Foster JA, Vibert YM, Conway JS, et al. Rapid testing for children and youth: results from a pilot project in Philadelphia. Presented at the 12th Conference on Retroviruses and Opportunistic Infections; 2005 Feb 22-25; Boston, MA.
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Original publication: November 24, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 16, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 02, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.