Lubelchek, Ronald J. MD*,†; Hotton, Anna L. PhD, MPH*,‡,§; Taussig, Daniel MA‖; Amarathithada, David MPH¶; Gonzalez, Marisol RN, MPH‖
*Division of Infectious Diseases, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL;
†Department of Medicine, Rush University Medical Center, Chicago, IL;
‡Chicago Developmental Center for AIDS Research (D-CFAR), Chicago, IL;
§Chicago Consortium, Women's Interagency HIV Study;
‖Department of Prevention and Education, Ruth M. Rothstein CORE Center, Chicago, IL; and
¶STI/HIV Services Division, Chicago Department of Public Health.
Correspondence to: Ronald J. Lubelchek, MD, Division of Infectious Diseases, Ruth M. Rothstein CORE Center, John H. Stroger, Jr. Hospital of Cook County, 2020 W Harrison, Chicago, IL 60612 (e-mail: email@example.com).
The authors have no conflicts of interest to disclose.
Supported by the Chicago Developmental Center for AIDS Research (D-CFAR), an National Institutes of Health (NIH) funded program (P30 AI 082151), which is supported by the following NIH institutes and centers: National Institute of Allergy and Infectious Diseases, National Cancer Institute, National Institutes of Mental Health, National Institute on Drug Abuse, National Institute of Child Health and Development, National Heart Lung and Blood Institute, and National Center for Complementary and Alternative Medicine. This study was also supported by a NIH CFAR supplemental grant awarded to the DC Developmental Center for AIDS Research (PI Alan Greenberg, award number 5P30A1087714) for the Enhanced Comprehensive HIV Prevention Planning Initiative (CFAR ECHPP initiative) with the Chicago D-CFAR serving as a partnering substudy site (site-PI Alan Landay, subaward number 11-M72).
Preliminary data from this article were presented at the CFAR/ECHPP Working Group Meeting, November 19, 2012, Washington, DC.
Despite the availability of both accurate HIV testing, along with highly effective antiretroviral therapy, rates of HIV incidence in the United States failed to decline between 2006 and 2009.1 Of the estimated 1.1 million people living with HIV/AIDS (PLWHA) in the United States, only approximately 25% people have achieved the goal of virological suppression.2 Evaluation of the HIV care cascade reveals missed opportunities for better care of PLWHA at every level—diagnosis, linkage-to-care, engagement-in-care, receipt of antiretroviral therapy, and virological suppression. In response to these inadequate outcomes, the National HIV/AIDS Strategy (NHAS) set out specific goals to decrease HIV incidence, improve access and quality of care for PLWHA, and reduce HIV-related health disparities.3
Scaling up routine HIV testing represents a key component to the NHAS.3 Early HIV diagnosis significantly decreases morbidity and mortality; yet, health systems employing risk and symptom-based HIV testing often diagnose patients late and only after repeated encounters with the medical system.4–9 Given the inadequate outcomes associated with risk and symptom-based testing strategies since 2006 the Centers for Disease Control and Prevention (CDC) has recommended that all adults seeking medical care be routinely offered HIV testing.8 Despite the CDC's routine HIV testing guidelines, almost 20% of PLWHA nationally remain unaware of their HIV diagnosis.10,11
Although efforts to implement routine HIV screening have enjoyed some success, barriers to HIV testing have limited widespread implementation. A systematic literature search on barriers to HIV testing uncovered 41 different barriers to testing, 8 of which were common across different venues [eg, perinatal vs. emergency departments (EDs) vs. primary care provider].9 Lack of knowledge/training was a commonly cited barrier as were concerns about having to disclose positive results and concern about patient follow-up.9
Although much of the effort to scale-up routine HIV testing has focused on EDs and primary care settings, many patients visit each year occur, nonprimary care/non-ED specialty care settings.7,12–16 Combined data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Survey conducted in 2008 showed that of the 1.2 billion outpatient and/or ED visits, only 10% consisted of ED visits versus 90% occurring at physicians' offices or hospital outpatient clinics.17 Although 55% of the 1 billion outpatient office visits in 2010 occurred at primary care settings, patients made the remaining 45% of office visits—an estimated 450 million—to medical or surgical specialty clinics.18 Although many patients visit specialty care providers each year, few efforts to augment routine HIV testing in specialty care settings have been made.
Academic detailing has been a practice traditionally used by the pharmaceutical industry to influence prescribing practices, but it has also been employed to improve the quality and cost efficiency of clinical decision making.19 Academic detailing can use needs assessments associated with focused trainings during which experts supply medical providers with information geared at changing provider behaviors.19 Such practices have been used to promote routine HIV testing in primary care settings.7,15,20 In this study, we report on an intervention, sponsored jointly by the Chicago Developmental Center for AIDS Research (D-CFAR) and the Chicago Department of Public Health (CDPH), which employed survey-based assessments of barriers to routine HIV testing along with academic detailing-type educational sessions to scale-up routine HIV testing at specialty care clinics associated with Chicago's foremost safety-net health system.
To help fulfill the CDC's Enhanced Comprehensive HIV Prevention Planning goals related to HIV testing, the Chicago D-CFAR, in conjunction with CDPH, endeavored to increase rates of routine HIV testing via first employing a survey to assess specialty care provider-level barriers to routine HIV testing, followed by carrying out academic detailing-type educational sessions at chosen specialty clinics within the Cook County Health and Hospital System (CCHHS).
CCHHS provides safety-net care to approximately 500,000 unique patients annually in the Chicago metropolitan area. Referrals to CCHHS specialty clinics come from patients seen at the CCHHS hospitals EDs, inpatient services, or from its Ambulatory Community Health Network, which provides primary care to more than 175,000 patients annually. The specialty care clinics at the health system's primary hospital experience in excess of 200,000 patient visits each year.
Program staff chose 3 specialty clinics on which to focus our intervention. We based our specialty clinic selection on the presence of receptive and interested leadership at each of the selected clinics along with some data in the HIV literature suggesting that these clinical settings may yield higher HIV seropositivity rates.21,22 The program worked with the dermatology, psychiatry, and trauma specialty clinics to scale-up routine HIV testing. To facilitate comparisons of HIV testing rates between clinics, the hematology clinic was selected to serve as a control specialty clinic at which program staff did not carry out interventions. We did not randomly assign clinics as intervention versus control clinics rather we selected intervention clinics based on the presence of administrative support for such efforts within each specific clinic.
The project to increase routine testing at specialty clinics had 2 phases. For the first phase, project staff, in conjunction with the University of Illinois at Chicago School of Public Health Survey Research Lab, devised a survey to assess provider-level knowledge and attitudes with respect to routine HIV testing. In addition, the survey sought to identify provider-level barriers to routine HIV testing. Our survey used Likert scale ratings to assess attitudes about routine HIV testing. It employed multiple-choice questions to test respondents' basic knowledge regarding HIV testing performance characteristics and guidelines. The survey made use of a prepopulated checklist of potential barriers/facilitators, along with rank order options for each barrier listed, to gauge barriers to routine HIV testing. The survey also used a similar checklist with a rank order option to elicit information as to which trainings would be most useful to providers. The project's HIV testing advisor (TA) administered the paper surveys to clinic providers during in-person lunch meeting-based sessions at each of the project's 3 specialty clinics (dermatology, psychiatry, and trauma) between April and May 2012. The clinical lead physicians at each specialty clinic encouraged attendance at the training sessions and those providers who completed the surveys represent a convenience sample of clinicians who attended the trainings. After the in-person survey administration session at each intervention clinic, the project's TA made 1 additional attempt at each clinic to get providers who previously had not completed the surveys to do so.
The project's second phase consisted of using each clinic's survey results to inform the content of academic detailing-style presentations given by the project's TA to the medical staff at each clinic. The sessions focused on working with each clinic to overcome the key barriers to routine HIV testing revealed by the survey. The TA, along with key project staff, carried out these presentations between May and July 2012.
Outcomes and Analysis
For the first survey phase of the project, we report on basic descriptive statistics, describing the survey responses from each clinic. In addition, we report on key findings related to provider-level knowledge and attitudes related to routine HIV testing and highlighting key barriers cited by specialty clinic survey respondents.
For the project's second academic detailing phase, we compared HIV testing rates at each of the intervention specialty clinics with the testing rates at the hematology clinic, which served as a control clinic, and compared testing before and after the implementation of the intervention at each of these 4 clinics. We considered patients with no previous HIV test result noted in our electronic medical record (EMR) as eligible for HIV testing and included these patients in our analysis. We calculated the proportion of patients tested among the total patients eligible for testing at each location by month and evaluated trends in testing over time with the Cochran–Armitage test for trend. We compared overall differences in the proportion of patients tested at each clinic using χ2 tests. Our analysis considered 3 distinct analytic periods: the preintervention period—January and February 2012; the intervention period—March through July 2012; and postintervention period—August and September 2012. At each clinic, we used logistic regression to determine whether the odds of testing differed during the intervention and postintervention periods compared with the preintervention period. We analyzed data using SAS Version 9.2 (SAS Institute, Cary, NC).
Phase 1—Specialty Clinic Survey Results
We surveyed 43 specialty clinic providers regarding their knowledge and perceived barriers related to routine HIV testing. Table 1 shows key characteristics of the specialty clinics and the providers surveyed.
Knowledge of HIV Testing Guidelines
We asked all respondents to answer several questions regarding their knowledge of the CDC's 2006 HIV testing guidelines recommending routine HIV testing for all adolescents and adults with unknown HIV status. Ninety percent of dermatology clinic versus 86% of psychiatry clinic versus 42% of trauma service respondents correctly answered the question regarding routine HIV testing guidelines (χ2 = 9.10, P = 0.011).
Attitudes About HIV Testing
Figure 1 summarizes survey respondents' attitudes regarding HIV testing who rated their degree of confidence or level of agreement with the testing-related domains of discussing HIV testing, discussing positive HIV test results, and importance of offering routine HIV testing to all patients.
Barriers to HIV Testing
Table 2 summarizes the barriers to routine HIV testing revealed by our survey of specialty clinic providers. The 2 most frequently cited reasons for not offering routine HIV testing in the specialty clinics surveyed included: “I don't know how to arrange follow-up for positive patients”—cited by 33% of respondents, and “I'm not confident the patient will return for results”—cited by 28% of respondents. The most commonly noted administrative or structural barrier was “I don't have enough time to explain HIV testing to patients,” noted by 30% of respondents. We also asked respondents to rank potential barriers to routine HIV testing in the order of importance. Twenty-six percent of respondents ranked “I'm not confident the patient will return for results” as their first or second chief reason for not offering routine HIV testing. Eighty-five percent of respondents ranked “I don't know how to link positive patients to care” as the top structural or administrative barrier to routine HIV testing in their specialty care site.
Phase 2—Academic Detailing and Its Effects on Routine HIV Testing Rates
In 2012, from January through September, 507 of 5543 (9.2%) of the eligible patients were routinely tested for HIV at the 4 specialty clinics (3 intervention and 1 control). Overall testing rates varied by clinic: from 15.6% (192/1229) at the dermatology clinic to 10.8% (105/974), 4.6% (124/2718), and 13.8% (86/622), at the psychiatry, trauma, and hematology (control clinic) clinics, respectively (χ2 P < 0.001) (Fig. 2). At baseline, testing was highest at the hematology (control) clinic (17.4%) followed by trauma (11.6%), dermatology (8.2%), and psychiatry (7.7%). Trends over time in the proportion of eligible patients tested varied by clinic; testing increased over time in the dermatology and psychiatry clinics remained relatively stable in the hematology (control) clinic and decreased in the trauma clinic (Fig. 2). For the hematology (control) clinic, the odds of routine testing were lower in the intervention [odds ratio (OR): 0.69; 95% confidence interval (CI): 0.41 to 1.17] and postintervention (OR: 0.66; 95% CI: 0.34 to 1.31) periods compared with the preintervention period, though the differences were not statistically significant. In the dermatology clinic, compared with the preintervention period, the odds of testing were 2.43 (95% CI: 1.53 to 3.85) and 2.57 (95% CI: 1.51 to 4.36) times greater during the intervention and postintervention periods, respectively. At the psychiatry clinic, the odds of testing were significantly higher in the postintervention period (OR: 2.36; 95% CI: 1.30 to 4.30) compared with the preintervention period. In the trauma clinic, the odds of testing were significantly lower during the intervention (OR: 0.23; 95% CI: 0.15 to 0.35) and postintervention (OR: 0.27; 95% CI: 0.17 to 0.45) periods compared with the preintervention period.
These findings demonstrate that academic detailing-style educational sessions can enhance rates of routine HIV testing for public safety-net health system specialty clinical services. Both the dermatology and the psychiatry clinics experienced significant increases in testing rates over time, which were not seen at the control hematology clinic. In contrast, the trauma service did not achieve an increase in its rate of routine HIV testing, despite similar interventions.
The findings from our survey assessing specialty provider knowledge and attitudes regarding routine testing may, in part, explain the different outcomes seen in the dermatology and psychiatry clinics compared with the trauma service. The trauma service demonstrated the lowest degree of knowledge regarding national HIV testing recommendations. Additionally, the survey demographics results reveal significant staffing differences between the trauma and the other specialty services surveyed—with residents, who rotate monthly, representing a majority of the providers for the trauma service versus attending physicians comprising a majority in the psychiatry clinic. Although the dermatology is staffed primarily by residents, they are nonrotating dermatology residents who provide year-long staffing for outpatient dermatology services. Although the trauma service does have attending physicians who provide nonrotating staffing supervision, an academic detailing intervention based on 1 or 2 training sessions does not fulfill the training needs for a service that experiences significant monthly staffing turnover.
Our project has several important limitations. Interventions within complicated health systems do not occur in a vacuum. Often multiple system-related changes and interventions, which may impact an outcome such as HIV testing rates, occur concurrently. Within the CCHHS during the study period, inpatient and emergency medicine services, such as the trauma service, transitioned to physician order entry through the EMR. As a part of the physician order entry implementation for inpatient and emergency services, the health system installed a prompt to remind providers to order an HIV test.23 This EMR order prompt served to increase the preintervention testing rate for the trauma service. Interestingly, when the trauma service attending physicians discovered that their service's residents had been ordering routine HIV testing because of the EMR prompt without a trauma service HIV testing policy in place, the trauma service administration prohibited ongoing routine HIV testing on the service before a policy being formulated and approved by the service's leadership. Despite our project's attempt to coauthor and help implement a trauma service HIV testing policy to facilitate routine testing; such a policy had not been implemented by the time this project ended. This dynamic likely accounts for the trauma service's downtrending HIV testing rate.
Although the CDC released recommendations advocating routine HIV testing for all people between the ages of 16 and 64 with an unknown HIV status back in 2006, the imperative of fully implementing these guidelines persists.8 Although there has been some decline in the rate of PLWHA unaware of their diagnosis, recent surveillance data show that proportion still stands at nearly 20%.24 Achieving 2015 NHAS goals of decreasing HIV incidence, limiting HIV transmission, increasing the proportion of PLWHA engaged in care, and improving the proportion of PLWHA who achieve virological suppression are all predicated on reaching the goal of raising the proportion of PLWHA aware of their diagnosis to 90%.25 In their analysis of projected costs and cost efficiencies related to reaching 2015 NHAS goals, Holtgrave et al26 demonstrated that to achieve the NHAS virological suppression goals, the only economically viable scenarios require that the rate of PLWHA aware of their diagnosis needs to increase to the strategy's stated goal of 90%. These economic projections underscore the importance of continuing emphasis on developing better strategies to scale-up routine HIV testing.
The poor response to training in the trauma clinic underscores the limitations of our training approach which did not correspond to the needs of service that experiences monthly staffing turnover. The lack of improved routine HIV testing rates in the trauma service, despite EMR order prompts, also reveals the potential limitations of system/process-related interventions to scale-up routine HIV testing. Despite these limitations, the significant increase in routine HIV testing rates in 2 of the 3 intervention clinics/services does suggest that an academic detailing-type intervention, which employs an initial needs assessment, followed by focused trainings, can improve rates of routine HIV testing in public safety-net specialty care settings and may represent a useful component to be incorporated into system-wide interventions to scale-up routine HIV testing.
The authors would like to acknowledge and thank L. Lira for his work as the HIV testing advisor on this project. The authors thank all the specialty clinic providers who completed our surveys and participated in the trainings in addition to clinic leadership who facilitated the trainings at each clinical site.
1. Prejean J, Song R, Hernandez A, et al.. Estimated HIV incidence in the United States, 2006-2009. PLoS One. 2011;6:e17502.
2. Gardner EM, McLees MP, Steiner JF, et al.. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52:793.
3. Millett GA, Crowley JS, Koh H, et al.. A way forward: the National HIV/AIDS Strategy and reducing HIV incidence in the United States. J Acquir Immune Defic Syndr. 2010;55:S144.
4. Kitahata MM, Gange SJ, Abraham AG, et al.. Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med. 2009;360:1815–1826.
5. Walensky R, Paltiel A, Losina E, et al.. The survival benefits of AIDS treatment in the United States. J Infect Dis. 2006;194:11–19.
6. Wang C, Vlahov D, Galai N, et al.. Mortality in HIV-seropositive versus—seronegative persons in the era of highly active antiretroviral therapy: implications for when to initiate therapy. J Infect Dis. 2004;190:1046–1054.
7. Anaya HD, Butler JN, Solomon JL, et al.. Implementation of nurse-initiated rapid HIV testing at high-prevalence primary care sites within the US Veterans Affairs health care system. Sex Transm Dis. 2013;40:341–345.
8. Branson B, Handsfield H, Lampe M, et al.. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55:1–17.
9. Burke R, Sepkowitz K, Bernstein K, et al.. Why don't physicians test for HIV? A review of the US literature. AIDS. 2007;21:1617.
10. Lansky A, Prejean J, Hall I. Challenges in identifying and estimating undiagnosed HIV infection. Future Virol. 2013;8:523–526.
11. Chen M, Rhodes PH, Hall HI, et al.. Prevalence of undiagnosed HIV infection among persons aged ≥ 13 years—National HIV Surveillance System, United States, 2005–2008. MMWR Morb Mortal Wkly Rep. 2012;61:57–64.
12. Brown J, Shesser R, Simon G, et al.. Routine HIV screening in the emergency department using the new US Centers for Disease Control and Prevention guidelines: results from a high-prevalence area. J Acquir Immune Defic Syndr. 2007;46:395.
13. Haukoos JS, Hopkins E, Byyny RL, et al.. Design and implementation of a controlled clinical trial to evaluate the effectiveness and efficiency of routine opt-out rapid human immunodeficiency virus screening in the emergency department. Acad Emerg Med. 2009;16:800–808.
14. White DA, Scribner AN, Schulden JD, et al.. Results of a rapid HIV screening and diagnostic testing program in an urban emergency department. Ann Emerg Med. 2009;54:56–64.
16. Schappert S, Rechtsteiner E. Ambulatory medical care utilization estimates for 2007. Vital Health Stat 13. 2011;13:4–5.
19. Soumerai SB, Avorn J. Principles of educational outreach (“academic detailing”) to improve clinical decision making. JAMA. 1990;263:549–556.
20. Fischer MA, Avorn J. Academic detailing can play a key role in assessing and implementing comparative effectiveness research findings. Health Aff (Millwood). 2012;31:2206–2212.
21. Sloan EP, McGill BA, Zalenski R, et al.. Human immunodeficiency virus and hepatitis B virus seroprevalence in an urban trauma population. J Trauma. 1995;38:736–741.
22. Wanyenze RK, Nawavvu C, Namale AS, et al.. Acceptability of routine HIV counselling and testing, and HIV seroprevalence in Ugandan hospitals. Bull World Health Organ. 2008;86:302–309.
23. Lubelchek RJ, Beavis KG, Niklinkski W, et al.. Effective use of an electronic order prompt to scale-up lab-based HIV screening in a busy, urban emergency department. Paper presented at: 19th International AIDS Conference; July 22–27, 2012; Washington, DC.
24. CDC. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 US dependent areas—2010. HIV Surveillance Supplemental Report. 2012;17.
26. Holtgrave DR, Hall HI, Wehrmeyer L, et al.. Costs, consequences and feasibility of strategies for achieving the goals of the National HIV/AIDS strategy in the United States: a closing window for success? AIDS Behav. 2012;16:1365–1372.