Even in the absence of a sexual relationship, a friend or family member of an HIV-infected person is involved in the social network of the patient.1,2 Infectious diseases (ID) and HIV care clinics are locations where members of high-risk social networks, including sex partners of HIV-infected patients, make contact with a medical care setting when they accompany HIV-positive patients to appointments. This provides for a unique opportunity to increase testing among those at risk for HIV. To explore this opportunity to detect HIV, we implemented a program providing free rapid HIV testing as a point-of-care (POC) screening tool in the University of North Carolina (UNC) ID clinic, targeting individuals accompanying HIV-infected patients to their appointments. Notably, the program was developed and implemented without any dedicated funding, but used existing infrastructure and staff.
This initiative implemented free, POC rapid HIV testing in the UNC ID clinic in October 2007 for those 18 years or older. The program established the clinic as an outreach testing site with the NC Department of Public Health (DPH) who provides OraQuick rapid tests to the clinic at no cost. Combined with a waiver of health care system patient registration and use of the standard NC DPH HIV consent form, this allows for free rapid HIV testing. A completed standard DPH Interim Rapid Testing form including rapid test results is submitted to the HIV/STD Prevention and Care Branch for all individuals tested. The program was approved by the UNC Point of Care Procedures Committee and the UNC Health Care System. At any point since implementation, 2 to 3 designated HIV clinic nurses and social workers are trained to and conduct HIV pretest and posttest counseling and perform the rapid test.
Anyone accompanying a patient to the UNC ID clinic is eligible to undergo testing in the program. Flyers promoting the rapid HIV testing program are posted throughout the clinic instructing patients and others to inquire if interested. Generally, HIV providers or clinic staff recommend rapid HIV testing to patients and their companions, or that patients inform their partner or others of rapid testing availability in the clinic. Over time, clinic patients were encouraged and facilitated HIV testing of partners and social contacts by bringing them to the ID clinic and requesting the service. Anyone in clinic can refer a companion to designated social workers or a nurse for pretest counseling, which is conducted in a private room. Individuals may also refer themselves for testing without notifying the patient they accompany. Confidentiality is strictly maintained for individuals tested in the program; relationship to clinic patients is not asked and no information is shared unless individuals testing positive request assistance with disclosure to their companion in clinic. Prior to testing, individuals receive an information sheet on rapid HIV testing, an OraQuick brochure, and they must sign the DPH HIV Antibody Consent form providing consent for testing. An oral swab is obtained for testing with the OraQuick Advance Rapid HIV Antibody test. Clients are then directed to the clinic waiting area for the 20 minutes until a result will be available.
All posttest counseling occurs in a private room within the clinic. Clients testing negative are posttest counseled by the same pretest counselor. Individuals testing positive are posttest counseled by the pretest counselor and a medical provider. During posttest counseling, onsite serologic confirmatory HIV testing is recommended via phlebotomy and immediate follow-up is scheduled in the ID clinic to receive confirmatory results. Participants with confirmed HIV are offered immediate, onsite standard-of-care evaluation for new HIV patients including HIV education, physical assessment, indicated laboratory studies, and treatment. Newly diagnosed individuals also receive immediate linkage to the clinic social worker, financial counselor, and substance abuse counselors who provide tailored support for individual needs. For clients who test positive and decline confirmatory serologic testing at UNC, testing is recommended and facilitated at a local health department (i.e., if cost is the barrier) or other external sites. Positive confirmatory test results are reported to the local health department by clinic staff as mandated for reportable diseases in NC.
One year after the implementation of the program, a voluntary, anonymous survey was distributed to all patients presenting to the ID clinic between 1/12/2009 and 4/1/2009, to determine the testing program’s acceptability among the general clinic population. Surveys were given to all patients presenting to the front desk for check-in during this period regardless of HIV status or whether they or anyone accompanying them to prior appointments had been tested through the program. Data were not collected on refusals to complete the survey. Surveys assessed respondents’ awareness of, direct experience with, and general approval rating of the program.
Data from the DPH Interim Rapid Testing form were entered into a program database located on a secure server. The UNC Institutional Review Board approved the study with a waiver of informed consent, as the HIV rapid testing program follows NC DPH standard procedures for HIV rapid testing and does not collect additional data beyond that provided on standard NC DPH forms. Basic frequencies of those who underwent and received results of rapid HIV testing in the UNC ID clinic, the proportion of positive rapid tests and confirmatory HIV tests performed, the proportion of individuals who underwent rapid HIV testing in the ID clinic that were never tested before, and the level of ID clinic patient satisfaction with the HIV testing program were calculated using STATA 12 (College Station, TX, www.stata.com).
Between October 2007 and June 2013, 452 individuals (Table 1) participated in the testing initiative, of which 450 (99.6%) received their results on the same day as testing. For 82 (18.1%) participants, this was the first time they underwent HIV testing. Twenty-two individuals (4.9%) tested HIV positive, of which 16 (72.7%) were newly positive, including 3 never previously tested (Table 2). Excluding individuals with a prior positive test result, HIV prevalence in the program was 3.6% (16/446). Among those testing HIV positive, 17 (77.3%) reported at least one of the following risk factors: injection drug use, sex with HIV positive person, sex with injection drug use, sex with men who have sex with men, sex in exchange for drugs or money, current sexually transmitted disease diagnosis, child of HIV infected women, sex while using noninjectable drugs, sex with other HIV risk, hemophilia or blood recipient, health care exposure, or victim of sexual assault. Confirmatory results were available for 19 (86.4%) of 22 participants and confirmed HIV infection; the 3 remaining individuals declined confirmatory testing at UNC. All those undergoing confirmatory testing at UNC were engaged in HIV care at UNC.
Over a 3-month period 1 year after program implementation, an anonymous acceptability survey was administered to all UNC ID clinic patients to evaluate the acceptability of the HIV testing program. Four hundred individuals responded to the standardized acceptability survey, with 96% indicating approval of the HIV testing initiative in the clinic. Only 4% indicated that they either “somewhat disapprove” or “strongly disapprove” of the testing program and were associated with general confidentiality concerns for persons testing in the program despite overall support for the program in some cases and not related to specific events in the clinic.
The high rate of 3.6% new positive HIV test results (16/452) among participants when compared with the HIV positivity rates of other HIV testing sites in NC (1.0 % in nontraditional testing sites, 0.3% in outreach settings, and 0.3% in sexually transmitted disease clinics)3 suggests that the testing population represents a high-risk population meriting targeted testing initiatives. The high rate of favorable responses among the general clinic population who completed the anonymous acceptability survey regarding the testing program further enforces that individuals are willing to discuss and accept HIV testing in a medical setting according to Centers for Disease Control and Prevention guidelines.4 The study’s high positivity rate and acceptability of the program among clinic patients provide evidence that a clinic-based testing program expands the number of individuals entering the HIV treatment cascade by targeting the social networks of HIV-positive individuals and capitalizing on previously missed opportunities for earlier HIV diagnosis. Such initiatives delivered in a setting where individuals already encounter the health care system represent a low investment strategy to increase testing rates in an at-risk population by leveraging existing medical infrastructure and staff, through the use of a rapid, POC assay without phlebotomy or cost to the patient.
Our findings on the feasibility of the program have several limitations. First, results are from a single ID clinic and thus may not be generalizable to other clinic settings. Assessment of the overall program uptake is limited by the logistical challenge of collecting data on how many individuals accompanied clinic patients to their appointments during the assessment period or if and why individuals declined testing after it was offered or recommended. We are unable to compare HIV prevalence among sexual partners versus social contacts among those tested in the program because no data on their relationship to clinic patients were collected. A true assessment of the acceptability of the program is also limited by the lack of data on how many clinic patients declined to complete the acceptability survey, and whether those who declined had personal experience with the program (tested or companion tested).
In addition to expanding the number of individuals tested and diagnosed, this program achieved linkage to care for all confirmed diagnoses since testing occurred within an HIV clinic and potentially improves retention in care by spanning many steps in the care cascade.5 The program improves linkage by directly linking them into care at the time and day of diagnosis and allowing individualized access to ancillary support services provided in the clinic. Importantly, these resources help retain patients in care by immediately addressing patient concerns such as financial and transportation issues, or providing psychological support, all of which are common barriers to entering and remaining in HIV care among socioeconomically disadvantaged persons.6 Our results confirm that the provision of rapid HIV testing in an academic ID clinic capitalizes on missed testing opportunities and provides a feasible, acceptable, and needed HIV testing strategy for an at-risk population with minimal investment, and should be considered among HIV testing initiatives and in clinics currently providing HIV care.
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2. Friedman SR, Neaigus A, Jose B, et al. Sociometric risk networks and risk for HIV infection. Am J Public Health 1997; 87: 1289–1296.
3. North Carolina Department of Health and Human Services Division of Public Health. Health NCDoHaHSDoP. Epidemiologic Profile for HIV/STD Prevention & Care Planning December 2012. 2012. Available at: http://epi.publichealth.nc.gov/cd/stds/figures/Epi_Profile_2012.pdf
4. Stefan MS, Blackwell JM, Crawford KM, et al. Patients’ attitudes toward and factors predictive of human immunodeficiency virus testing of academic medical clinics. Am J Med Sci 2010; 340: 264–267.
5. Mugavero MJ, Amico KR, Horn T, et al. The state of engagement in HIV care in the United States: From cascade to continuum to control. Clin Infect Dis 2013; 57: 1164–1171.
6. Christopoulos KA, Massey AD, Lopez AM, et al. “Taking a half day at a time”: patient perspectives and the HIV engagement in care continuum. AIDS Patient Care STDS 2013; 27: 223–230.