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Service Delivery Innovation Profile

Counseling and Testing Process Makes HIV Screening a Routine Part of Primary Care, Increasing Testing Rates and Identification of Infected Individuals


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Snapshot

Summary

Montefiore Medical Center's Adolescent AIDS Program developed ACTS (Advise, Consent, Test, Support), a streamlined, four-step protocol designed to make human immunodeficiency virus (HIV) screening a routine part of care in medical and nonmedical settings using existing resources. The goal is to boost testing rates to identify HIV-positive individuals as early as possible in their disease progress so that they may fully benefit from antiretroviral treatment. Using ACTS, medical providers and/or other trained staff briefly advise patients on the need for screening and answer any questions they may have, obtain consent for and provide the test, and offer any necessary followup support. The program has led to a more than doubling of testing rates and a modest increase in the number of HIV-positive individuals identified at Montefiore clinics. It has also led to significant increases in both testing rates and the number of infected individuals identified at more than 400 public health clinics in the Western Cape of South Africa, where ACTS has been adopted as the official HIV testing method. In addition, South African patients receiving ACTS were more likely to have their CD4 count (a measure of the health of the immune system) documented and to return to the clinic for followup care when compared with the then-standard HIV method.

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of trends in testing rates in five Montefiore clinics randomized to the program to those in similar Montefiore clinics providing usual care; pre- and post-implementation comparisons of testing rates and the number of HIV-positive individuals identified in two clinics that adopted the ACTS model in South Africa and by the City of Cape Town in five subdistricts; and post-implementation comparisons of CD4 documentation and followup care rates between those receiving ACTS and those participating in conventional 30-minute pretest counseling sessions in the South African clinics.
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Developing Organizations

Montefiore Medical Center; New York/New Jersey AIDS Education and Training Center
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Use By Other Organizations

In addition to Montefiore’s own use of ACTS , the New York City Department of Health’s Bronx Knows initiative, a borough-wide campaign to promote routine HIV testing, uses the ACTS model in provider facilities and community-based organizations throughout the Bronx. Montefiore's Adolescent AIDS Program also provides technical assistance to city-wide campaigns in Houston, Miami, Oakland, and Washington, DC, that are using some or all of the ACTS model. As noted, in 2007 Montefiore received a 5-year grant under PEPFAR to scale up testing of this model in South Africa. Since that time, ACTS has been adopted as the official HIV testing method by the city of Cape Town and the Western Cape Department of Health and, consequently, is being implemented in more than 400 public health facilities in the Western Cape province. It is also being pilot tested in several clinics in the KwaZulu-Natal, Eastern Cape, Gauteng, and Northern Cape Provinces. (Updated September 2013.)

Date First Implemented

2004
Protocol development began in 2002; a trial of the protocol in five Montefiore clinics began in 2004.

Problem Addressed

Many individuals are human immunodeficiency virus (HIV)-positive but do not know it, preventing them from receiving treatment that could benefit their health and taking actions to prevent spread of the infection to others. Despite Centers for Disease Control and Prevention (CDC) recommendations to do so, many health care providers fail to offer HIV testing to their patients, leaving many HIV-positive patients unaware of their status. For patients who want tests, most primary care providers do not offer them, thus creating additional barriers by forcing patients to make a separate appointment and trip to a specialized facility.
  • Many undiagnosed patients: Of the estimated 1.1 million persons living in the United States with HIV infection in 2009, 18 percent (207,600) remained undiagnosed and unaware of their HIV-positive status. Those between the ages of 13 and 24 years account for 6.7 percent of those living with HIV, and 59.5 percent of these youth remain unaware of their infection.1 (Updated September 2013.)
  • Little testing in primary care: Many health care providers fail to offer HIV counseling and testing on a routine basis, in part because they believe testing in medical settings requires time-consuming pretest counseling focused on behavior modification. Surveys conducted by Montefiore's Adolescent AIDS Program identified several major barriers to testing in the primary care setting, including lack of knowledge about patients' risk (many providers assume little or no risk); inadequate time to engage in pretest counseling (which, as noted, has historically been quite time consuming); and lack of experience, confidence, and/or comfort in delivering HIV counseling. As a result, many at-risk patients remain unaware of their need for testing. Those who want to be tested are often referred to a specialized facility, thus creating additional barriers to testing, including the time and effort involved in making and attending another appointment and the stigma associated with going to a facility that specializes in HIV/acquired immunodeficiency virus (AIDS).

What They Did

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Description of the Innovative Activity

Montefiore Medical Center's Adolescent AIDS Program developed ACTS (Advise, Consent, Test, Support) a streamlined, four-step protocol designed to make HIV screening a routine part of care in the medical and nonmedical settings using existing resources; the goal is to boost testing rates to identify HIV-positive individuals as early as possible in their disease progress so that they may fully benefit from antiretroviral treatment. Using ACTS, medical providers and/or other trained staff briefly advise patients of the need for screening and answer any questions they may have, obtain consent for and provide the test, and offer any necessary followup support. The ACTS approach, which generally takes less than 5 minutes for those testing negative, is described below:
  • Advise: The protocol recommends that clinics routinely offer an HIV test to all patients between the ages of 13 and 64 years. Clinic staff encourage eligible patients to agree to the test (noting its appropriateness for anyone) and answer any questions they may have about HIV/AIDS and the testing process.Montefiore has developed streamlined talking points and scripts for providers and educational pamphlets for patients to assist in this process. (See the Tools and Other Resources section for more details.) Unlike the historic approach that emphasized intensive pretest counseling as a way to change at-risk behaviors, little or no counseling on risk factors and behavior change takes place during this step. This approach complies with CDC guidelines related to pretest counseling, which have been relaxed over the years in response to evidence suggesting that the pretest phase does not represent an effective "teachable moment," with one counseling session at this stage doing little if anything to change patient behavior. In an effort to identify more at-risk and undiagnosed patients, the CDC relaxed its guidelines in 2006 in medical settings so that counseling need not be a required element of the testing process.
  • Consent: As mandated by New York law, clinic staff (providers, nurses, social workers, or counselors) explain the ways in which HIV can be transmitted, outline the difference between confidential and anonymous testing, and obtain written consent for the test (verbal consent is sufficient when using rapid testing). Virtually every state requires either verbal or written consent, although only a few still require separate written consent.
  • Test: Those who consent receive the test at the clinic. Some Montefiore clinics use the rapid HIV test, although most use the traditional blood test because it creates less disruption to existing workflows. The ACTS approach is highly adaptable, allowing different sites to develop different protocols for who performs the test or collects the blood sample for the lab, with nurses, providers, lay counselors, or some combination of these individuals performing the tasks.
  • Support: Those receiving a rapid HIV test receive the results right away. For those testing negative, several key messages are delivered with the results, the need to take specific actions to stay HIV-negative, the benefits of partner testing and the appropriate timing for retesting. For those testing positive, providers help the client process their results and then deliver three key messages: the availability of support to help cope with the diagnosis, the importance of accessing treatment, and the need to prevent transmission to others. Trained counselors provide additional support, including referrals for confirmatory testing, treatment, and other support services. For those receiving the traditional blood test, results for HIV-negative patients are given as the clinic would any other test, either not at all or via telephone or a letter. However, most clinics do not proactively contact patients about negative HIV test results, notifying them only if they call and reviewing the results with them at their next visit. For those patients tested with a traditional blood test who test HIV positive, staff call to schedule an inperson appointment where the results are shared and additional treatment, referrals, and support provided. In cases in which an HIV-positive patient clearly requires additional support (beyond what the clinic can provide), clinic staff arrange for more intensive counseling and support services from qualified providers in the area.

Context of the Innovation

Montefiore Medical Center is the largest health institution in the Bronx, NY, with 4 hospital campuses, 3 adult emergency departments (EDs), 2 pediatric EDs, and 23 community clinics throughout the borough. Montefiore is affiliated with the Albert Einstein College of Medicine. The first of its kind in the nation, Montefiore's Adolescent AIDS program provides medical and counseling services to adolescents infected with HIV or at risk of infection. The program also provides specialized HIV training to medical and mental health professionals who treat adolescents, designs and implements HIV prevention campaigns targeting at-risk youth, and participates in research on diverse adolescent patient populations.

The impetus for the ACTS program came in 2000 after the Montefiore Adolescent AIDS Program initiated a project in which social marketing campaigns were used to promote HIV testing to youth in New York and six other cities. From this work, program staff learned that, although a demand for testing could be created among at-risk youth, primary care providers remained unprepared to offer such testing. In fact, many providers would dissuade youth from getting tested—even in areas of high HIV prevalence—telling them that they appeared healthy and did not need to be tested. The aforementioned followup survey of these providers uncovered three key reasons for their failure to offer testing: not enough time to deliver conventional pretest counseling, not enough experience to deliver counseling and testing, and a belief that patients were not at risk for HIV. The ACTS program was developed as a way to streamline and demystify the counseling and testing process and to train providers on how to incorporate it into routine care using existing resources. Although originally developed for youth, program leaders quickly recognized its relevance to all age groups and hence decided to promote its use in patients between the ages of 13 and 64.

Did It Work?

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Results

The program has led to a more than doubling of testing rates and a modest increase in the number of HIV-positive individuals identified at Montefiore clinics and to significant increases in both testing rates and the number of infected individuals identified at at more than 400 public health clinics in the Western Cape of South Africa (updated September 2013). In addition, South African patients receiving ACTS were more likely to have their CD4 count documented and to return to the clinic for followup care.
  • Much higher testing rates, modest increase in identification of infected individuals at Montefiore: The program more than doubled testing rates and led to a modest increase in the number of HIV-positive individuals identified at Montefiore clinics, as outlined below:
    • More than doubling of testing rates: A pilot test conducted in 10 Montefiore clinics that collectively serve between 50,000 and 60,000 unique patients each year in areas with a high prevalence of HIV/AIDS found that the five clinics randomly assigned to adopt the program significantly increased testing rates among eligible patients, from roughly 8 to 9 percent at baseline (2003) to 22 percent by 2005, and then to 28 percent by 2006 (after receiving 1 year of additional technical assistance). Rates fell back slightly in 2007, to 26 percent, as the technical assistance was no longer provided. By contrast, testing rates in the five clinics that did not adopt the program remained at baseline levels through 2005 (roughly 8 percent), and then rose to 14 percent in 2006 (one-half the level of that achieved in the clinics adopting the program). Based on this initial success, the program expanded in 2006 to the five control sites, which subsequently increased their testing rates to roughly 21 percent in 2007,2 and then to between 23 and 24 percent at present.
    • Modest increase in HIV-positive individuals identified: The number of HIV-positive individuals identified at Montefiore clinics randomly assigned to use the program increased only modestly (significantly less than the corresponding increase in testing rates). Followup with providers suggests that many adopting clinics initially targeted the program at those coming in for annual well-care visits, which are longer than sick visits and thus provide more time for screening. Because these individuals tend to be relatively healthy, testing has identified correspondingly few infected individuals. Program developers are working to promote use of ACTS with those coming in for sick visits as well, because these individuals are at greater risk of HIV infection, as demonstrated by the results from South Africa (see next bullet).
  • Significantly more testing and identification of infected individuals in South Africa: A CDC-funded initiative in 2006 supported the pilot implementation of Montefiore's ACTS model at two clinics serving at-risk youth in Cape Town, South Africa; an evaluation found that the program increased the number of patients tested by 61 percent and the number of newly identified HIV-positive individuals by 71 percent between the first and second quarter of 2006.3 Following this success, in 2007 the President's Emergency Plan for AIDS Relief (more commonly known as PEPFAR) funded a larger, 5-year implementation of ACTS in 400+ Western Cape public health facilities.Analysis of data from April 2010 to June 2011 found that these clinics tested 1,042,925 people and identified 88,953 who were HIV-positive, with both figures representing substantial increases over previous periods. A comparison of 179 clinics that received ACTS training with 278 that did not found that training was associated with a significant increase in the mean number of monthly HIV tests. The magnitude of the increase fell slightly after the training ended, but testing rates in sites that received training remained well above those that did not. (Updated September 2013.)
  • More CD4 documentation and followup care in South Africa: Additional analysis in South Africa comparing those receiving ACTS with those participating in more traditional 30-minute pretest counseling sessions found that youth preferred ACTS, and those receiving it were more likely to have a documented CD4 count (86 vs. 63 percent) and to return to the clinic for followup care (38 vs. 29 percent).3

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of trends in testing rates in five Montefiore clinics randomized to the program to those in similar Montefiore clinics providing usual care; pre- and post-implementation comparisons of testing rates and the number of HIV-positive individuals identified in two clinics that adopted the ACTS model in South Africa and by the City of Cape Town in five subdistricts; and post-implementation comparisons of CD4 documentation and followup care rates between those receiving ACTS and those participating in conventional 30-minute pretest counseling sessions in the South African clinics.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Program development: Montefiore Adolescent AIDS Program leaders spent approximately 1 year developing the ACTS program, including protocols, tools, scripts, and other resources to assist primary care providers in implementing the approach.
  • Pilot testing: The program was pilot tested in a comparison study for several years, with five Montefiore clinics in an area with high HIV/AIDS prevalence adopting it and five other clinics in similar areas continuing to offer traditional care. The randomized clinics received training and implementation support from the Montefiore Adolescent AIDS Program staff (see below for more details on the implementation process).
  • Program expansion: Based on the success demonstrated in the pilot, the program was adopted by the five control clinics in 2007. A 2010 change to New York State’s HIV testing law requires that all providers in medical settings offer HIV testing to all of their clients ages 13 to 64 years. ACTS is currently being used by the Montefiore Medical Center to implement the new law in all sectors of the institution. Montefiore clinics/departments go through a multistep implementation process, as outlined below2:
    • Gaining buy-in: In an effort to gain buy-in and support, site leaders address any philosophical barriers to routine testing among staff.
    • Implementation plan: Site leaders analyze current personnel and operations and develop a site-specific plan for implementation.
    • Training: All clinic staff receive briefings on how routine testing will be administered at the site. Those providing the testing receive training from Montefiore Adolescent AIDS Program staff on how to administer the ACTS model.
    • Technical and other support: The Montefiore Adolescent AIDS program provides adopting clinics with written materials on the model (for both patients and providers) and with ongoing technical support, including periodic reports that document the program's impact on testing rates.

Resources Used and Skills Needed

  • Staffing: The program requires no new staff, as existing clinic personnel incorporate it into their regular routines. As noted, the entire process typically takes less than 5 minutes, except in cases in which an HIV-positive patient is identified (which tends to occur less than 1 percent of the time, even in areas with a high prevalence of infection).
  • Costs: The program costs little to implement or operate, although staff time is required to undergo relevant training.
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Funding Sources

Montefiore Medical Center; New York/New Jersey AIDS Education and Training Center
President’s Emergency Plan for AIDS Relief (PEPFAR)end fs

Tools and Other Resources

An array of tools that can assist with implementation of the model are available free of charge at http://www.adolescentaids.org/healthcare/acts.php#i_acts. These resources include a training presentation and modules, a four-part implementation manual, a checklist to prepare for implementation, a pocket guide for clinicians, a program brochure (available in both English and Spanish), and a newsletter.

The CDC guideline on HIV infection: detection, counseling, and referral can be found in the National Guidelines Clearinghouse at http://www.guideline.gov/content.aspx?id=25579.

Adoption Considerations

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Getting Started with This Innovation

  • Leverage existing resources: As noted, a wide array of tools are available free of charge that can assist with implementation, including scripts, manuals, checklists, and templates.
  • Educate providers on would-be benefits: Clinicians may initially be reluctant to introduce routine HIV testing into everyday operations, fearing it may threaten their jobs and/or disrupt workflow. To overcome this resistance, share information on the potential of the model to identify and assist previously undiagnosed individuals. After adopting the model and seeing its benefits, most providers quickly realize they should have been following this approach all along.

Sustaining This Innovation

Share data on program benefits: Periodically share information on the program's impact in terms of enhancing testing rates and getting HIV-positive individuals the care they need to continue living healthy, productive lives. Seeing this information keeps physicians and nurses motivated to continue screening efforts, something that can be challenging given time constraints and the need to screen for other conditions, such as diabetes and heart disease.

Use By Other Organizations

In addition to Montefiore’s own use of ACTS , the New York City Department of Health’s Bronx Knows initiative, a borough-wide campaign to promote routine HIV testing, uses the ACTS model in provider facilities and community-based organizations throughout the Bronx. Montefiore's Adolescent AIDS Program also provides technical assistance to city-wide campaigns in Houston, Miami, Oakland, and Washington, DC, that are using some or all of the ACTS model. As noted, in 2007 Montefiore received a 5-year grant under PEPFAR to scale up testing of this model in South Africa. Since that time, ACTS has been adopted as the official HIV testing method by the city of Cape Town and the Western Cape Department of Health and, consequently, is being implemented in more than 400 public health facilities in the Western Cape province. It is also being pilot tested in several clinics in the KwaZulu-Natal, Eastern Cape, Gauteng, and Northern Cape Provinces. (Updated September 2013.)

More Information

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Contact the Innovator

Donna Futterman, MD
Stephen Stafford

Adolescent AIDS Program
Montefiore Medical Center
111 East 210th Street
Bronx, NY 10467
(718) 882-0232
E-mail: DFutterman@AdolescentAIDS.org and SStafford@AdolescentAIDS.org

Innovator Disclosures

Dr. Donna Futterman and Mr. Stephen Stafford have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Futterman D, Stafford S, Lyle M, et al. ACTS (Advise, Consent, Test, Support): a paradigm shift in HIV testing that strengthens healthcare services by reorganizing existing personnel. Poster presented at the 2008 International AIDS Conference in Mexico City, Mexico.

Futterman D, Stafford S, deAzevedo V, et al. ACTS (Advise, Consent, Test, Support): a task-shifting program for scaling-up HIV testing in South African youth-serving clinics. Poster presented at the 2008 International AIDS Conference in Mexico City, Mexico.

Information on the program is also available at http://www.adolescentaids.org/healthcare/acts.php.

Footnotes

1 Centers for Disease Control and Prevention. HIV testing among high school students—United States, 2007. Morb Mortal Wkly Rep. 2009;58(24):665-8. [PubMed]
2 Futterman D, Stafford S, Lyle M, et al. ACTS (Advise, Consent, Test, Support): a paradigm shift in HIV testing that strengthens healthcare services by reorganizing existing personnel. Poster presented at the 2008 International AIDS Conference in Mexico City, Mexico.
3 Futterman D, Stafford S, deAzevedo V, et al. ACTS (Advise, Consent, Test, Support): a task-shifting program for scaling-up HIV testing in South African youth-serving clinics. Poster presented at the 2008 International AIDS Conference in Mexico City, Mexico.
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Original publication: December 09, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 13, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 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.