SummaryMontefiore 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 hundreds of clinics in the Western Cape Province of South Africa, where ACTS has been adopted as the official HIV testing method. In addition, South African youth 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.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.
Developing OrganizationsMontefiore Medical Center; New York/New Jersey AIDS Education and Training Center
Date First Implemented2004
Protocol development began in 2002; a trial of the protocol in five Montefiore clinics began in 2004.
Vulnerable Populations > Urban populations
Problem AddressedMany 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 2006, nearly one-fourth (232,700) remained undiagnosed and unaware of their HIV-positive status. Those between the ages of 13 and 24 years represented a disproportionate share of the undiagnosed, accounting for 9.9 percent of undiagnosed HIV cases but only 4.4 percent of all cases. HIV-positive individuals who remain unaware of the infection cannot get needed counseling and treatment that can help maintain health or change behaviors to reduce the risk of infecting others.1
- 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).
Description of the Innovative ActivityMontefiore 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.
References/Related ArticlesFutterman 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.
Contact the InnovatorDonna Futterman, MD
Adolescent AIDS Program
Montefiore Medical Center
111 East 210th Street
Bronx, NY 10467
Phone: (718) 882-0232
E-mail: DFutterman@AdolescentAIDS.org and SStafford@AdolescentAIDS.org
Innovator DisclosuresDr. 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.
ResultsThe 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 two South African clinics. In addition, South African youth receiving ACTS were more likely to have their CD4 count documented and to return to the clinic for followup care.
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.
- 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 supported 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 Since then, the President's Emergency Plan Fund for AIDS Relief (more commonly known as PEPFAR) has funded a larger implementation of ACTS and the City of Cape Town has rolled out ACTS to all of its public health facilities. By 2009, five of its eight subdistricts had implemented ACTS and had achieved dramatic increases in both numbers of patients tested and numbers of HIV-positive clients diagnosed. In a comparison of annual HIV testing numbers at baseline (2008) with 1 year after ACTS implementation (2009), the five ACTS subdistricts achieved a 135 percent increase in testing (an increase of 21,446 tests from 61,019 to 82,465). In contrast, during that same period the three control subdistricts that had not yet begun ACTS experienced a 3 percent decline in HIV testing (increasing from 44,800 to 43,554 annual tests). ACTS sites also improved by 125 percent the number of HIV-positive clients identified over this period (from 9,115 to 11,379 diagnoses). During this period, the control sites identified 13 percent fewer HIV-positive clients (increasing from 8,764 to 7,629 diagnoses).
- 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
Context of the InnovationMontefiore Medical Center is the largest health institution in the Bronx, NY, with 3 hospital campuses, 3 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.
Planning and Development ProcessKey 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. 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.
Funding SourcesMontefiore Medical Center; New York/New Jersey AIDS Education and Training Center
President’s Emergency Plan for AIDS Relief (PEPFAR)
Tools and Other ResourcesAn 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.
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 OrganizationsIn 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, D.C. that are using some or all of the ACTS model. Montefiore also received a 5-year grant under PEPFAR to scale up testing of this model in South Africa. ACTS was adopted in 2010 as the official HIV testing method for the Western Cape Province and is being implemented in more than 500 public health facilities there, and is also being implemented in several pilot clinics in the Gauteng and KwaZulu-Natal Provinces.
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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Service Delivery Innovation Profile
Original publication: December 09, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 15, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.