Brooks, Lesley MD*; Rietmeijer, Cornelis A. MD, PhD*†; McEwen, Dean MBA*; Subiadur, Julie A. RN*; Mettenbrink, Christie J. MSPH*
From the *Denver Public Health Department and †Colorado School of Public Health, University of Colorado Denver, Colorado
Correspondence: Cornelis A. Rietmeijer, MD, PhD, Denver Public Health Department, 605 Bannock Street, Denver, CO 80204-4507. E-mail: firstname.lastname@example.org.
Received for publication September 19, 2008, and accepted September 29, 2008.
Background: Increased awareness of HIV serostatus is a cornerstone of HIV prevention efforts. Thus, routine HIV testing in clinical settings has been identified as a priority. We report on our experience with making rapid HIV testing a routine procedure in a large STI clinic.
Methods: A series of logistical changes were implemented to enhance HIV testing uptake, including introduction of rapid testing, changes in sequence of clinical procedures, and an opt-out consent process. The impact of these changes on HIV testing was measured by the ratio of HIV testing and syphilis RPR testing, with the latter defined as the gold standard of routine testing in an STI clinic setting.
Results: Over time and in relationship to the introduction of clinic changes, the HIV/RPR ratio increased from 0.79 at baseline to 0.96 after full implementation. Overall HIV positivity rates did not vary significantly over time.
Conclusion: After the introduction of several changes in clinic procedures, we experienced an increase HIV testing uptake relative to routine syphilis testing. In STI clinics, HIV testing can be made as normal as other routine STI testing.
The centers for disease control and Prevention (CDC) estimates that 850,000 to 950,000 persons are living with HIV in the United States and that 180,000 to 280,000 (25%) are unaware of their serostatus.1,2 In a meta-analysis of 11 studies performed by Marks et al., HIV-infected persons aware of their infection demonstrated a markedly lower prevalence of high-risk sexual behavior than HIV-infected persons unaware of their infection.2 Indeed, awareness of HIV infection status may be the most important reason for risk reduction among persons with HIV. Thus, knowledge of HIV serostatus has been one of the cornerstones of HIV prevention in the United States. Over the past few years, the CDC has initiated a number of campaigns, including the Serostatus Awareness in Fighting the Epidemic (SAFE) campaign3 and the Advancing HIV Prevention initiative1 both of which emphasize the role of HIV testing and serostatus awareness to prevent transmission.
Increased awareness, however, requires a willingness to be tested and timely delivery of test results. Until recently, HIV testing in many clinical settings involved a separate process with unique requirements that made it cumbersome and time-consuming for clinicians and patients alike. Specifically, pre-and posttest counseling by specially trained personnel, written consent for testing separate from consent for all other clinic procedures, and, in the case of ELISA testing, the need for a follow-up phone call or return clinic visit led to increased logistic complexity, longer clinic visits, and subsequently, decreased interest in testing and failure to obtain test results. A clinic process that normalizes and streamlines HIV testing such that it has the same impact as other diagnostic services offered (e.g., nucleic acid amplification tests for chlamydia and gonorrhea, RPR for syphilis) has the potential to increase testing and subsequent awareness of HIV status.
In August 2006, the CDC issued the “2006 STD Treatment Guidelines”4 and “Revised Recommendations for HIV Testing in Adults, Adolescents, and Pregnant Women in Health Care Settings,”5 respectively. These documents outline numerous recommendations for the “normalization” of HIV testing, including offering HIV testing as a routine part of medical care in all health care settings using opt-out screening, lifting long-standing recommendations for pre-and post-test prevention counseling, and establishing recommendations for the use of rapid HIV testing to increase the number of persons who receive their test results.
In this article, we report on our efforts in a large urban STI clinic to normalize HIV testing and increase serostatus awareness through rapid testing and opt-out consenting and the resulting trends in HIV testing uptake and newly diagnosed HIV infections.
The Denver Metro Health Clinic (DMHC) is the largest clinic for sexually transmitted infections in the Rocky Mountain region of the US. Normalization of HIV testing at DMHC occurred in 4 stages: (1) introduction of optional rapid HIV testing (November 2003); (2) adjustment of clinic flow such that clerical staff (rather than clinicians) obtain consent for all services including HIV at the beginning of the visit in contrast to clinician-obtained consent for HIV test during examination (December 2003–May 2004); (3) discontinuation of the HIV ELISA test in favor of the rapid test; and (4) revision of general consent form to reflect opt-out HIV testing (March 2005). To evaluate the normalization process, we chose the rapid plasma regain (RPR) syphilis test as the gold standard for comparison of “normal.” All patients receive RPR evaluation at their initial visit for a new problem, and, dependent on risk factors, at least annually when they present for follow-up visits. With very few exceptions, patients accept RPR testing as routine. We evaluated the HIV/RPR ratio and the HIV positivity rate for patients presenting for evaluation of a new problem during 4 time frames. Period 1: 11 months before introduction of optional rapid HIV testing; Period 2: 6 months during which rapid testing was optional and standard ELISA testing slowly phased out; Period 3: 10 months after discontinuation of ELISA and introduction of logistic changes to improve clinic flow; and Period 4: 19 months following introduction of opt-out HIV consenting.
Across all 4 periods, 33,772 visits occurred at which an RPR test was obtained. At these visits, 30,405 (90%) HIV tests were performed. As shown in the Figure 1, the HIV/RPR ratio increased from 0.79 in Period 1, to 0.86 in Period 2, to 0.92 in Period 3, and 0.96 in Period 4. HIV positivity varied from 0.5% in Period 1% to 0.8% in Period 2% to 0.6% in Period 3% to 0.7% in Period 4. Patients obtaining their HIV test results increased from 66% in Period 1% to 99% in Period 4.
Logistics and clinic flow played a major role in facilitating enhanced uptake of HIV testing at DMHC. Offering HIV testing as a routine part of clinic procedure, consolidated consenting for all clinic procedures, opt-out consenting, and conducting blood draws before seeing the clinician all served to avoid lengthy clinic visits and unnecessary interruptions in the clinical encounter. Rapid HIV tests, conducted in the clinic and initiated even before the clinical encounter, allowed for test results that could reliably be delivered to patients during the clinic visit thus ensuring awareness of serostatus.
Although an HIV diagnosis is still a life-altering event, advances in medical technology and availability of more effective drug regimens have changed the face of this once-devastating disease. It is now possible for patients to effectively manage their disease and live longer, near-normal lives. The CDC’s Serostatus Awareness in Fighting the Epidemic campaign and Advancing HIV Prevention initiative emphasize HIV testing and serostatus awareness.1,3 The “2006 STD Treatment Guidelines” encourage routine HIV testing in all medical settings.4 Indeed, these recommendations call for a concomitant “normalization” of the clinical diagnosis and management of HIV. Our experience with implementing routine HIV testing through use of rapid HIV tests and logistic changes in clinic practice suggest that these guidelines can be implemented in busy urban STI clinic settings. More importantly, our experience suggests that HIV testing can be made as normal and routine as other STI clinic procedures with acceptance by clinic patients and staff.
1. CDC. Advancing HIV prevention: new strategies for a changing epidemic-United States, 2003. MMWR Morb Mortal Wkly Rep 2003; 52:329–332.
2. Marks G, Crepaz N, Senterfitt JW, et al. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: Implications for HIV prevention programs. J Acquir Immune Defic Syndr 2005; 39:446–453.
3. Janssen RS, Holtgrave DR, Valdiserri RO, et al. The serostatus approach to fighting the HIV epidemic: Prevention strategies for infected individuals. Am J Public Health 2001; 91:1019–1024.
4. CDC. Sexually transmitted diseases treatment guidelines, 2006. MMWR Morb Mortal Wkly Rep 2006; 55(RR-11):1–94.
5. CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Morb Mortal Wkly Rep 2006; 55(RR-14):1–17.