SummaryThe National Association of Community Health Centers developed a model for offering free, rapid HIV testing to all patients between the ages of 13 and 64 as part of routine primary medical and dental care. The model integrates testing into the clinic's workflow using existing staff, laboratory, and infrastructure. The testing protocol, which adds approximately 2 to 3 minutes to a patient's visit, requires a close working relationship between the health center and local and state HIV services. A pilot study at six health centers found that the program succeeded in getting patients to agree to HIV testing, many for the first time; testing rates rose substantially at all participating health centers, including from 4 to 38 percent at one center in Mississippi. These pilot successes have laid the groundwork for a subsequent activities, including expansion to new health centers; further assessment of the potential for dental practices to provide testing; and creation of an online data collection, management, and reporting system.Moderate: The evidence consists of pre- and post-implementation comparisons of testing rates in six community health centers with 21 sites in Mississippi, North Carolina, and South Carolina.
Developing OrganizationsNational Association of Community Health Centers, Inc.
Use By Other Organizations
- NACHC continues to share the model and tools with health centers and primary care associations nationwide.
Date First Implemented2006
Patient PopulationHealth centers serve low-income children and adults, including rural and public housing residents, homeless people, and migrant workers. They provide medical care to 25 percent of low-income minorities, one in seven rural Americans, one in eight Medicaid beneficiaries, one in seven uninsured individuals, and one in three people living in poverty.
Problem AddressedAn estimated 1.1 million Americans live with HIV, and as many as 200,000 of them (1 in 5) remain unaware that they are infected, creating risks to their health and that of others.1 Primary care and other health centers represent an untapped opportunity to promote testing and thus reduce the number of individuals unknowingly living with HIV.
- A still too common, deadly disease: Roughly 1.1 million Americans live with HIV, with 56,000 new cases being diagnosed and 14,000 people dying from AIDS each year in the United States.1
- Many not tested, including high-risk groups: Roughly one in five HIV-positive individuals remain unaware of their status because of lack of testing. About 55 percent of adults between the ages of 18 and 64 have never been tested for HIV. An even higher percentage of those between the ages of 18 and 24 have not been tested, even though this group has rates of HIV infection similar to other age groups. High-risk groups also do not get tested as often as they should. For example, only about 60 percent of African Americans report ever having been tested for HIV, yet they represented more than half of newly diagnosed HIV cases in 2008. Gay, bisexual, or other men who have sex with men accounted for more than 55 percent of newly diagnosed HIV cases in 2008, yet many members of these high-risk groups do not get tested. For example, a 2008 study in 21 major U.S. cities found that about 40 percent of men who have sex with men had not been tested in the past year.1
- Failure to realize benefits of earlier diagnosis: Without treatment, HIV infection will develop into AIDS in approximately 10 years. With early treatment, a 25-year-old can live, on average, an additional 39 years, yet many with HIV do not get diagnosed early. For example, in 2007, close to one-third (32 percent) of those testing positive developed AIDS within a year of their test, suggesting they had lived with HIV for a long time without knowing it. During this time, they may have infected others.1
- Primary care and health centers as an untapped opportunity for screening: Few primary care providers include HIV screening as part of routine care or ask patients about behaviors that could put them at risk of infection, despite Centers for Disease Control and Prevention (CDC) recommendations that encourage routine voluntary HIV testing in all health care settings of patients aged 13 to 64 years.2 In addition, only 10 percent of the nation's 1,200 Federally Qualified Health Centers receive dedicated funding to offer HIV testing as part of routine primary care, despite the availability of a rapid HIV test that provides a preliminary diagnosis in less than 20 minutes. In 2009, fewer than 4 percent of health center patients (691,280 out of 18,753,858) received an HIV test.3
Description of the Innovative ActivityThe National Association of Community Health Centers developed a model for offering rapid HIV testing to all patients age 13 to 64 as part of routine primary medical and dental care. The model integrates testing into the clinic's workflow, making use of existing staff, laboratory, and infrastructure. The testing protocol, which adds approximately 2 to 3 minutes to a patient's visit, requires a close working relationship between the health center and state and local HIV resources, including the state's disease intervention specialist, who provides counseling to HIV-positive patients, makes appropriate referrals, and notifies past sexual partners. Additional written materials, patient flow charts, and algorithms are included for providers who prefer to provide traditional HIV laboratory testing (blood work). Critical elements of the program, which can be used in dental practices as well, are described below:
- Testing information in waiting area: Most patients visit the clinic three or four times a year and have an established relationship with one provider. At each visit, the patient has access to HIV testing information in the waiting room.
- Offering rapid HIV test: A nurse or medical assistant offers any patient between the ages of 13 and 64 the opportunity to be screened for HIV and indicates that such screening now represents a routine part of the primary care visit unless the patient declines. This approach generally satisfies the state's legal requirements to obtain either verbal consent for the test or for the patient to opt out of testing. Before testing, the patient signs a consent form only if required by state law.
- Executing the test: If the patient accepts the test, the nurse or medical assistant performs the rapid HIV test, which involves a finger prick to extract a small blood sample or an oral swab. Specimens are typically obtained during the examination and sent to a laboratory area for processing.
- Reviewing test results: The physician performs the clinical examination and orders any necessary follow up visits or referrals. During the examination, the nurse reviews the HIV screening test results and enters them into the center's screening form. Either the nurse or physician discusses results with patients, as indicated below:
- For negative results: The nurse delivers the results to the patient and provides educational handouts. If appropriate, the nurse mentions the existence of a "window period" during which a patient's true infection status may not be known.
- For positive results: The physician informs the patient of the positive (or "reactive") preliminary test result and provides an educational handout explaining this result. The physician also draws a blood sample for a confirmatory Western blot test and schedules a followup appointment in 5 days.
- Appropriate support based on confirmatory test results: Health center staff review the results of the confirmatory test (faxed from the laboratory) and provide support to patients as appropriate based on those results. Potential action steps include the following:
- Review of risk factors, followup if negative: The provider reviews risk factors and prevention strategies with the patient and schedules a repeat Western blot test in 3 months.
- Assistance from specialist if positive: Health center staff contact the state's disease intervention specialist and, in many cases, arrange for the specialist to be present when the patient returns to the clinic to learn of the results. The specialist, who has extensive experience with HIV counseling and medical referrals, provides posttest counseling, a task that health center staff may not be trained to perform. The specialist also refers the patient to appropriate HIV specialists and support services, addresses partner notification issues with the patient, and shares HIV prevention information. Clinic staff document the result in the patient's chart and in a "reactive tracking sheet," to ensure proper monitoring of HIV-positive patients.
- Counseling and followup if indeterminate: If results remain inconclusive, center staff arrange for the disease intervention specialist to be present at the followup appointment to counsel and educate the patient. Center staff draw blood to conduct a repeat Western blot test.
- Addition of laboratory testing: Information provided in January 2013 indicates that in December 2012, the model for implementing routine HIV screening in primary care medical and dental practices was updated to include laboratory testing (or blood work) in addition to the rapid test kits. This enhancement was adopted because many health centers still rely on, and in some cases prefer, laboratory testing. Where written information is distinct for rapid and laboratory testing, separate sections now address these distinctions. Additionally, the organization created new patient visit flow charts to depict how laboratory testing can fit into the medical and dental visit and new algorithms for responding to both positive and negative laboratory test results.
Context of the InnovationThe National Association of Community Health Centers is a nonprofit organization that represents community, migrant, homeless, and public housing health centers. Health centers, also known as Federally Qualified Health Centers, provide medical care to many poor and uninsured Americans. Only a small percentage of community health centers receive Ryan White HIV/AIDS Program funds and therefore have the ability to offer routine HIV testing and counseling. Many clinics, especially rural ones, do not have this funding stream. In 2006, after CDC called for routine voluntary HIV testing in all health care settings, the association received CDC funds to develop a model for integrating rapid HIV testing into community health centers' primary care services, along with posttest counseling and referrals to specialists.
ResultsA pilot study found that the program successfully convinced many patients (including hard-to-reach populations) to get tested, often for the first time. Testing rates rose in all six participating centers, with one health center seeing a near 10-fold increase, from approximately 4 percent to 38 percent.
Moderate: The evidence consists of pre- and post-implementation comparisons of testing rates in six community health centers with 21 sites in Mississippi, North Carolina, and South Carolina.
- Most patients tested, many for first time: Two-thirds (66 percent) of the 17,237 patients in the pilot study agreed to be tested, with 56 percent doing so for the first time.
- Significant increases across all centers: Testing rates at the six centers hovered between 0 and 4 percent before implementation of the program. During the pilot, average testing rates in the centers rose to 24 percent, with one center approaching a 40-percent rate.
- High acceptance among hard-to-reach populations: African Americans and Latinos accepted testing more often than whites. Similarly, women did so more often than men, and uninsured patients did so more often than insured individuals.
Planning and Development ProcessKey steps in the planning and development process included the following:
- Assessing center workflows: To figure out how to integrate HIV testing into established clinic practices, association leaders assessed how health centers delivered primary care, including patient care processes and staffing responsibilities.
- Designing data collection: The association designed patient tracking systems that fit in with current medical record processes; these systems can document offering of the test, whether the patient accepted or declined, and test results.
- Building partnerships: Because most participating centers lacked the skills and capacity to provide posttest HIV counseling, proper referrals, and partner notification to those testing positive, the association established relationships with other HIV experts and community resources to support infected patients. (CDC funds a disease intervention specialist with expertise in these areas in every state.) The association encouraged participating centers to partner with the state health department and these local HIV specialists to provide the support needed to patients who test positive.
- Refining flow sheets, referral arrangements for those who test positive: Participating centers developed or refined routine testing flow sheets to include HIV test results. Centers mailed these sheets to a central location for manual entry into the aforementioned tracking system. Participating centers also refined their referral and reporting arrangements for those who test positive.
- Pilot testing: The association invited health centers in the southeast United States to participate in a pilot test of the approach; six centers (with a total of 21 clinic sites) agreed to participate in the 12-month pilot.
- Training staff: The association held workshops to train staff at participating clinics in administering rapid HIV tests, routine screening, referral processes, and data collection processes.
- Exploring potential for expansion to dental practices: The association recently conducted an assessment in health center dental practices to understand patient attitudes toward and experiences with routine HIV screening. This assessment found that the majority of patients would accept HIV testing as part of the dental visit.
- Expanding the tracking system: Building on the data collection processes established in the pilot, program staff created an online data collection, management, and reporting system. Available 24 hours a day, the system includes forms for data collection, a secure online real-time data repository, and an easy-to-use use dashboard and reporting tool.
- Expanding the model to include laboratory testing: Information provided in January 2013 indicates that the model was amended to add an option for laboratory testing; the organization amended written materials, created new patient visit flow charts to depict how lab testing can fit into the medical and dental visit and created new algorithms for responding to both positive and negative lab test results.
Resources Used and Skills Needed
- Staffing: Clinics typically did not add staff to handle the screening, as the test added only a few minutes to each visit. Nurses, physicians, laboratory technicians, and administrative staff took on the additional duties as part of their regular jobs.
- Costs: Rapid HIV tests range in price from $7 to $10 each. During the 1-year pilot, the cost of implementing the model and administering the test averaged $16,729 for each new HIV case identified. To the extent that early detection may prevent the infection of others, the model may be cost-effective, because the lifetime cost of treating HIV averages $618,900 per patient (2004 dollars).4
Funding SourcesCenters for Disease Control and Prevention
CDC provided approximately $200,000 to the association to develop and implement the pilot testing program at the health centers. HealthCare Providers Direct donated the HIV rapid tests. Going forward, participating centers will likely need to explore the potential to be reimbursed by third-party payers for testing and/or may have to begin charging for the tests or come up with another way to cover the costs.
Tools and Other ResourcesThe National Association of Community Health Centers maintains a repository of models, tools, and other resources that health centers can use to incorporate routine HIV screening into their primary care programs. This repository can be accessed from the NACHC Web site at http://www.nachc.com/clinicalhiv.cfm.
Getting Started with This Innovation
- Get leadership buy-in: Educate community health center providers, boards of directors, and other leaders about the value of routine HIV testing in patients ages 13 to 64.
- Assess current workflow, determine whether rapid HIV tests or laboratory testing will be used, and integrate testing accordingly: Assess how the clinic currently performs routine laboratory work and what staff, laboratory, and infrastructure changes may be required to integrate HIV testing. Incorporate HIV screening into the current workflow by identifying how the patient will be informed of the test, whether written consent will be required, when the test will be offered (and by whom), and how patients will be informed of results. If written consent is required by the state, the health center can obtain such consent as part of its overall process for obtaining consent for care.
- Create (or tap into existing) data collection capacity: Data collection represents an essential component of an organization's routine HIV screening program. Patient level data, collected each time a test is offered to a patient, can be used to document and track routine HIV screening activity, to drive quality improvement, to secure ongoing funding, and to demonstrate to leadership the need for continued testing. Data collected locally also informs policy at the national, regional, and state levels.
- Build or enhance partnerships with specialists: Determine whether HIV follow up care will be provided in-house or through referrals to other organizations. Establish partnerships with these organizations and with the state's disease intervention specialist to assist with counseling, partner notification, and referrals.
Sustaining This Innovation
- Investigate potential funders for HIV tests: As noted, CDC funds covered the administrative costs of running the pilot program, while an outside organization donated the rapid HIV tests. Going forward, however, clinics will have to determine whether to charge for the test, bill for testing when possible, absorb the cost on their own, or apply for additional funds. The prevalence of HIV in a clinic's service area can guide this decision.
- Create protocol for responding to false positives: Approximately 3 of every 1,000 rapid HIV tests can be expected to produce a false positive. As a result, clinicians must be trained to position a positive result as preliminary and inform the patient that not all such results are correct.
- Provide feedback to staff: Continually evaluate the impact of the screening program (including outcomes for those identified as being infected) and share results with staff to keep them enthusiastic about offering the testing.
Contact the InnovatorKathy McNamara, RN
Assistant, Director of Clinical Affairs
National Association of Community Health Centers Inc.
7501 Wisconsin Ave. Suite 1100W
Bethesda, MD 20814
Phone: (301) 347-0400
Fax: (301) 347-0459
Caryn Bernstein, MPH
Manager, Special Clinical Projects
Clinical Affairs Division
National Association of Community Health Centers
7501 Wisconsin Avenue, Suite 1100W
Bethesda, MD 20814
Direct: (301) 652-7913
Innovator DisclosuresMs. McNamara and Ms. Bernstein have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesCenters for Disease Control and Prevention. CDC Vital Signs. HIV Testing in the US. Available at: http://www.cdc.gov/VitalSigns/HIVTesting/.
Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR14):1-17. [PubMed] Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm.
U.S. Department of Health and Human Services, Health Resources and Services Administration. Selected Diagnoses and Services Rendered. National Summary for 2009. Available at: http://www.hrsa.gov/data-statistics/health-center-data/NationalData/2009/2009_national_diagnosesservices.html.
Schackman BR, Gebo KA, Walensky RP, et al. The lifetime cost of current human immunodeficiency virus care in the United States. Med Care. 2006;44(11):990-7. [PubMed]
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Original publication: April 27, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: April 05, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: January 22, 2013.
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.