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Sexually Transmitted Diseases:
doi: 10.1097/OLQ.0b013e31828417a5
The Real World of STD Prevention

Implementation of Nurse-Initiated Rapid HIV Testing at High-Prevalence Primary Care Sites Within the US Veterans Affairs Health Care System

Anaya, Henry D. PhD*†‡; Butler, Jaimi N. MA*; Solomon, Jeffrey L. PhD§; Knapp, Herschel PhD, MSSW*; Hoang, Tuyen PhD*; Kan, Virginia MD∥¶; Rodriguez-Barradas, Maria C. MD#**; Hare, Katherine A. BS; Kertz, Barbara MS#; Bokhour, Barbara PhD§

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From the *Veterans Affairs (VA) Quality Enhancement Research Initiative for HIV and Hepatitis (QUERI-HIV/HEP) and Center for the Study of Healthcare Provider Behavior, VA Greater Los Angeles Health Services Research and Development Center of Excellence, VA Greater Los Angeles Healthcare System, Los Angeles CA; †Division of General Internal Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA; ‡VA Center for the Management of Complex Chronic Conditions and the Quality Enhancement Research Initiative for Spinal Cord Injury (SCI), VA Chicago Healthcare System, Chicago, IL §VA New England Healthcare System, Bedford, MA; ∥VA Medical Center, Washington, DC; ¶Infectious Diseases Section, The George Washington University, Washington, DC; #Infectious Disease Section, Michael E. DeBakey VA Medical Center, Houston, TX; and **Department of Medicine, Baylor College of Medicine, Houston, TX

This research was funded by VA Quality Enhancement Research Initiative (QUERI) grant SDP 07-318 awarded to the first author and supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service. The authors thank the primary care clinics and all the nurses who participated in these testing efforts; their participation, dedication, support, and patience were invaluable. The views and opinions expressed in this article are those of the authors and do not necessarily represent the views of the US Department of Veterans Affairs. The Veterans Health Administration supported this study but had no input in the design or reporting, or decision to submit this manuscript for publication. This study was reviewed and sanctioned by a US Department of Veterans Affairs institutional review board process.

Conflict of interest statement: The first author owns stock in a company that produces biotechnological biomarker tests, one of which is an HIV rapid test. All other authors have no conflict of interest. For the remaining authors, none was declared.

All authors have given a substantial contribution to conception and design, or acquisition of data, or analysis and interpretation of data; assisted in drafting the article or revising it critically for important intellectual content; and given final approval of the version to be published.

Correspondence: Henry D. Anaya, PhD, 11301 Wilshire Blvd 111G, Los Angeles, CA 90073. E-mail: henry.anaya@va.gov.

Received for publication August 27, 2012, and accepted December 18, 2012.

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Abstract

Abstract: Nurse-initiated HIV rapid testing (NRT) increases testing/receipt of results compared with traditional testing. We implemented NRT in primary care clinics at 2 Veterans Affairs hospitals.

At site 1, 2364 tests were conducted; 5 HIV positives were identified. At site 2, 2522 tests were conducted; 9 HIV positives were identified. Success varied across demographic/clinical strata.

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).

Table 1
Table 1
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Table 2
Table 2
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SITE 1

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.

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SITE 2

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).

Table 3
Table 3
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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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REFERENCES

1. Palella FJ Jr, Deloria-Knoll M, Chmiel JS, et al.. HIV Outpatient Study Investigators. Survival benefit of initiating antiretroviral therapy in HIV-infected persons in different CD4+ cell strata. Ann Intern Med 2003; 138: 680–681.

2. Anastos K, Barron Y, Miotti P, et al.. Risk of progression to AIDS and death in women infected with HIV-1 initiating highly active antiretroviral treatment at different stages of disease. Arch Intern Med 2002; 162: 1973–1980.

3. Centers for Disease Control and Prevention (CDC). HIV surveillance—United States, 1981–2008. MMWR Morb Mortal Wkly Rep 2011; 60: 689–693.

4. Gandhi N, Skanderson M, Gordon K, et al. Delayed presentation for HIV care among veterans: An opportunity for intervention. Paper presented at: Annual Meeting, 13th Conference on Retrovirus and Opportunistic Infections, Denver, 2006.

5. Sanders GD, Bayoumi AM, Sundaram V, et al.. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med 2005; 352: 570–585.

6. Centers for Disease Control and Prevention (US)., Revised recommendations for HIV testing of adults. Adolescents, and pregnant women in healthcare settings. MMWR Morb Mortal Wkly Rep 2006; 55: 1–17.

7. Testing for Human Immunodeficiency Virus in Veterans Health Administration Facilities. VHA Directive 2009–036. Washington, DC: Veterans Health Administration, 2009. http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2056.

8. Simmons E, Roberts M, Ma M, et al.. Routine testing for HIV in theUnited States: The intersection between recommendations and practices. AIDS Patient Care STDS 2006; 20: 79–83.

9. Wenrich M, Carline J, Curtis J, et al.. Patient report of HIV risk screening by primary care physicians. Am J Prev Med 1996; 12: 116–122.

10. Spielberg F, Branson BM, Goldbaum GM, et al.. Overcoming barriers to HIV testing: Preferences for new strategies among clients of a needle exchange, a sexually transmitted disease clinic, and sex venues for men who have sex with men. J AIDS 2003; 32: 318–327.

11. McCullock-Melnyk K. Barriers: A critical review of recent literature. Nurs Res 1998; 37: 196–201.

12. Centers for Disease Control (US). Revised guidelines for HIV counseling, testing, and referral. Morb Mortal Wkly Rep MMWR 2001; 50: 1–58.

13. Chen JC, Goetz MB, Feld JE, et al.. A provider participatory implementation model for HIV testing in an ED. Am J Emerg Med 2011; 29: 418–426.

14. Walensky RP, Arbelaez C, Reichmann WM, et al.. Revising expectations from rapid HIV tests in the emergency department. Ann Int Med 2008; 149: 153–160.

15. Gamble GR, Goldstein AO, Bearman RS. Implementing a standing order immunization policy: A minimalist intervention. J Am Board Fam Med 2008; 21: 38–44.

16. Stone EG, Morton SC, Hulscher ME, et al.. Interventions that increase use of adult immunization and cancer screening services: A Meta-Analysis. Ann Intern Med 2002; 136: 641–651.

17. Anaya HD, Hoang T, Golden JF, et al.. Improving HIV screening and receipt of results by nurse-initiated streamlined counseling and rapid testing. J Gen Intern Med 2008; 23: 800–807.

18. Backus L, Mole L, Chang S, et al.. The immunology case registry. JClin Epidemiol 2001; 54: S12–S15.

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.

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APPENDIX A: Pocket Card for Using the OraQuick Advance HIV Rapid Test
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