The availability of effective antiretroviral therapy has transformed HIV into a treatable disease, dramatically reducing death and increasing those living with HIV.1 Much of HIV mortality is attributed to late entry into treatment, often caused by late identification.2 Of the approximately 1.2 million persons in the United States infected with HIV, approximately 300,000 are unaware that they are infected.3 Many have multiple contacts with the medical system before diagnosis.4 Estimates of the cost-effectiveness of HIV testing exceed conventional thresholds of $25,000 per quality-adjusted life year at remarkably low prevalence of HIV positivity—approximately 0.3%.5 As a consequence, the Centers for Disease Control and Prevention recommended routine HIV testing of patients for all patients between the ages of 13 and 64 years.6 Many insurers and health delivery systems followed suit, including the US Department of Veterans Affairs (VA).7
How best to integrate routine HIV testing into primary care (PC) remains an open question. Screening rates in such settings are low.8,9 At the patient level, barriers to testing have included confidentiality fears, anxiety, discomfort discussing risk factors, aversion to venipuncture, and lack of return for posttest results.10 Organizationally, barriers include staffing, provider time, and prioritizing testing, given the competing health concerns addressed during office visits.11
To address these barriers, HIV rapid testing and nurse-initiated screening have been proposed as possible remedies.12 Rapid testing uses a point-of-care device to swab the patient’s gumline to detect the presence of HIV antibodies, eliminating the need for venipuncture or follow-up. Rapid testing has been widely applied in non-PC settings and is acceptable to patients and providers.13,14 Nurse-initiated screening systematizes testing into primary prevention priorities and has been successful in a variety of clinical preventive services.15 Finally, routinizing HIV testing has increased result receipt rates.16 We previously showed that NRT improved testing rates and receipt of results.17 This study evaluated a wider implementation in 2 PC clinics, assessing implementation facilitators, barriers and overall success.
We chose the VA as a model for integrated health care systems generally. Previous studies have shown that HIV positivity rates in VA samples exceed those of the general medical population.18 Here, we describe the implementation and the corresponding increases in HIV testing. The qualitative assessment of barriers and facilitators to implementation is discussed in a forthcoming manuscript.19
We chose 2 study sites in regions with high HIV seroprevalence. Both sites were located at large urban VA hospitals, one in the northeast (site 1) and one in the southwest (site 2). At site 1, 2 of the 4 PC clinics participated; the choice was based on staffing and management input. At site 2, all 5 PC clinics participated.
Both sites were provided with procedures to implement NRT. Policies allowing nurses to order tests under physician supervision were vetted through facility leadership. We exported the previously designed clinical reminder (CR) to participating sites. Following Centers for Disease Control and Prevention guide lines,6 the CR triggered for patients between the ages of 18 and 64 years, with no HIV test in the past year and not previously diagnosed with HIV. In addition to the CR, site IT personnel adapted another previously designed piece of software: the HIV rapid test template. This template presented an easy-to-use single screen wherein nurses ordered the test and coded the result (negative, positive, invalid). If the preliminary result was positive, the template automatically generated follow-up orders for confirmatory testing and referral to the infectious disease clinic. Invalid results triggered another test offer.
Before implementation, registered nurses and licensed vocational nurses attended training sessions and were certified in administration and quality control of the rapid test. At the conclusion of the training, trainees were provided with a pocket card detailing how to order, administer, interpret, and document the test (“Appendix A”). Telephone interview data were collected from key informants and nursing staff in 3 stages. Key informants were interviewed before and at completion; study nurses were interviewed before, during, and at study completion.19
Field notes were generated and uploaded to qualitative data software (NVivo) and analyzed. Patient demographics, visits, diagnoses, International Classification of Diseases, Ninth Edition codes, and laboratory tests were collected from a national VA data warehouse. We summarized the patients’ demographics (i.e., age, sex, marital status, and race) and clinical characteristics (i.e., HIV risk factors—hepatitis B/C infection, sexually transmitted disease [STD], drug use, and homelessness—and common medical problems, e.g., depression, posttraumatic stress disorder [PTSD], anxiety, and diabetes). We evaluated intervention effects by comparing percentages of tests conducted preintervention and postintervention. Finally, we compared the percentage of tests administered among various patient demographic and clinical strata (Tables 1 and 2).
At site 1, nurses forwarded results to providers who delivered results during the visit. A red checkmark on the encounter form indicated to providers that the patient had a rapid test done.
At site 2, the nurses delivered negative results. In instances of preliminary-positive results, nurses forwarded to providers who then delivered results during the visit.
There were 8265 patients seen in PC study clinics during the 6-month intervention period at site 1 and 27,771 patients seen during the 4-month period at site 2. Regarding our patient demographic profile, both sites were similar in patient age and sex: mean (SD) age was 60 (14) years, and 90% were male. Sites were different regarding patients’ marital status (single: 23% vs. 12%, respectively), race (white: 21% vs. 51%, respectively), and homelessness (8% vs. 4%, respectively); all comparisons are statistically significant at P < 0.05. The 2 most prevalent HIV risk factors were hepatitis C virus (HCV) infection (8%–10%) and illicit drug use (9%–10%). The 2 most prevalent medical problems were mental health (39%–40%) and diabetes (28%–35%).
At site 1, 2364 (28.6%) patients received a rapid test during the intervention period as compared with only 101 (1.2%) patients during the 6-month preintervention period. At site 2, 2522 (9.1%) patients received a rapid test during the 4-month intervention period as compared with only 10 (0.04%) patients tested during the 4-month preintervention period (Table 3).
Younger patients were more likely to be tested at both sites: testing rates were 17% to 34% among patients younger than 50 years as compared with 0 to 15% among patients older than 70 years. African Americans were more likely to be tested than whites (12%–31% vs. 7%–20%). Single patients were more likely to be tested than married patients (12%–29% vs. 8%–26%; all comparisons are statistically significant at P < 0.05).
Implementation of NRT resulted in significant increases in testing. At site 1, we identified 5 previously undetected HIV-positive veterans during our study period. At site 2, we identified 9 HIV positives during the study period. Given the overall patient count at sites 1 (8265) and 2 (27,771) during the study period, overall HIV prevalence was 0.06% and 0.03%, respectively. Although we did not attempt to determine the number of “indeterminate” readings, anecdotal accounts established that the rare times this did occur did not significantly affect patient or workflow. Because it was not part of our study protocol (nor consent process), we were precluded from ascertaining these patients’ CD4 and viral load status upon identification of their HIV infection. However, it may be cautiously prudent to assume that they were identified before the transition to an AIDS diagnosis, which, in terms of the increased life expectancy that is associated with early identification1,2 and cost-savings for the VA,6 are significant reasons to consider this a worthwhile endeavor.
As has been previously indicated, the qualitative portion of this project identified several other potential barriers to sustainability along with other general barriers and facilitators to an HIV rapid testing strategy.19 As of this writing ( >1 year post implementation), testing is being sustained at both sites.
One of the study limitations was a direct consequence of the overall success of the testing effort at one of our study sites. Nurses performed such a high volume of tests at site 2 that the testing budget was exhausted well before the 6-month study period was completed. In consultation with our biostatistician and site investigator, we decided to censor the study and halt the intervention at the 4-month mark upon exhausting all test kits. This action prevented analytic comparisons between study sites.
Nurse-initiated HIV rapid testing has the ability to improve identification of HIV-infected patients with the added advantage of timely notification, which mitigates the linkage-to-care gaps evident with traditional venepuncture testing. This work is additional evidence that nurse-initiated HIV testing can be integrated into a variety of clinical domains, specifically in this instance, PC clinics.
This work has been the foundation of expansion efforts throughout the VA health care system, most recently, a regional expansion of HIV rapid testing in VA substance use disorder clinics on the eastern seaboard of the United States, where the HIV epidemic is especially virulent.
HIV rapid testing has been proven to be a significant addition to efforts in identification and mitigation of HIV infection, particularly in light of existing barriers to traditional HIV testing methods.
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19. Author. Qualitative assessment of nurse-initiated HIV rapid testing at two high prevalence primary care sites within the us department of veterans affairs healthcare system. Under review.
APPENDIX A: Pocket Card for Using the OraQuick Advance HIV Rapid Test
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