The views and experiences of nurses and midwives in the provision and management of routine (provider initiated) HIV testing: protocol for a systematic review of qualitative evidence

Review question/objective The objective of this review is to explore nurses’ and midwives’ views and experiences in the provision and management of routine (provider initiated) HIV testing in healthcare settings. The specific questions to be addressed are: 1. What are nurses‘/midwives’ views and experiences of conducting routine ‘provider initiated HIV testing and counselling’ (PITC)? 2. What are nurses‘/midwives’ views and experiences of establishing and managing routine HIV (PITC) testing services? 3. From a nurse/midwife's perspective, what personal factors, practices or contexts facilitate or hinder the implementation of routine HIV (PITC) testing within their role or setting? 4. From a nurse/midwife's perspective, what constitutes high quality care in the provision of routine HIV (PITC) testing and what factors facilitate or hinder the provision of high quality care in routine HIV (PITC) testing services? Background Globally, HIV remains one of the world's most significant health problems; with approximately 34 million people affected.1 Enormous effort has been invested in recent years into scaling up prevention, treatment and care. More people now than ever have access to antiretroviral therapy (ART). The latter development is particularly encouraging due to new research that suggests that, under certain conditions, effective treatment can prevent onward transmission of HIV.2 Indeed, the World Health Organization estimates that ART has substantially contributed to the global decrease of 20% in the estimated number of new HIV infections between 2001 and 2011.3 There is now a tantalizing prospect that an end to the era of AIDS may be a possibility. Thus, whilst behavioral prevention interventions (such as condom use) remain a priority,4 there is an increasing policy focus on ‘treatment as prevention’ or TasP. As such, several governments are considering altering their HIV treatment guidelines towards a ‘test and treat’ policy.5‐7 Enhancing treatment efforts as a public health measure is contingent on many health system and service delivery factors; the most important one being to encourage the widespread uptake of HIV testing.8,9 In many countries, between 25‐80% of the HIV positive population is unaware of their status.10,11 For individuals who are HIV positive, HIV testing is the gateway through which the complications associated with late diagnosis can be minimized, effective treatment started and onward transmission avoided.12 For those who are HIV negative, HIV testing still offers an important opportunity for discussion of concerns and for health promotion around lifestyle‐related risk factors.13 A wide variety of models have been developed to promote HIV testing, which is now usually conducted using a rapid test; this involves a saliva swab or finger prick and the results are ready in 1‐20 minutes depending upon the test.8,14 Historically, the most common route of HIV testing has been through a client‐initiated model referred to as ‘voluntary counselling and testing’ (VCT). Within this model, clients seek testing in response to a concern or to a referral from a health provider. VCT Centers are often run by the voluntary sector, but may also be offered as a separate service within public sector service provision. Within a VCT model, the HIV test is usually accompanied by extensive pre‐ and post‐test counselling. Services may be run by nurses, community health workers, volunteers or other providers, e.g. social workers. In spite of wide spread coverage of VCT services, HIV testing rates have remained low in many settings. In response, provider initiated (‘opt‐out’ or ‘routine’) HIV testing models are now being strongly promoted.9 These are often referred to as PITC (‘provider initiated testing and counselling’). This HIV testing model is operationalized in the context of routine every day care within existing health facilities and services. Patients do not seek out an HIV test; rather, the health provider will offer the test as a routine part of care (regardless of the presenting complaint) and clients need to opt‐out if they do not wish to be tested. One of the most common forms of PITC is found in ante‐natal services where, for example, as a routine part of care, pregnant women will be offered an HIV test.16 In many countries, HIV guidelines recommend that anyone presenting to health facilities for any reason, should be offered an HIV test.9,17,18 In reality, most health services have interpreted the guidelines more selectively due to resource implications. Currently, in addition to antenatal services, the most common settings for PITC are TB clinics, emergency departments or primary care facilities. Within a PITC model, the time allocated to counselling and patient support is greatly reduced; brief information giving is recommended instead.9 Likewise, there is no requirement to record written consent, with brief verbal consent considered sufficient.9 Other models of HIV testing are being implemented or piloted in countries around the world, including community initiatives to enable home‐based testing, self‐testing and community/mobile outreach testing to target hard to reach groups.8 Nonetheless, PITC remains a key model that arguably has the greatest potential to reach the largest numbers.8 The PITC policy has challenged health services to develop care pathways that incorporate testing into routine procedures, with minimal additional resource requirements. In reality, the implementation of PITC relies heavily on nursing/midwifery staff.14,19‐23 Research and anecdotal evidence suggests that many nurses, especially non‐specialists, remain hesitant about their HIV‐related knowledge, about adopting a diagnostic role and about their ability to provide adequate support to clients through the process.19,24‐26 This seems to be particularly the case in lower prevalence countries, e.g. the UK, where non‐specialist nurses have traditionally had limited involvement with HIV care.26‐28 In addition, concerns have been raised about the ability of nurses to provide patients with the level of information, education, care and support required during HIV testing, in contexts where there may be a high throughput of patients, limited time and limited access to specialist back‐up.19,29,30 Other studies suggest that even where specialist training is provided, nurses may still struggle to incorporate HIV testing effectively into routine care.25,27 The reasons for this are unclear, but may relate to heavy workloads, staff shortages or poorly designed care pathways.31 Training on PITC for nurses is often primarily orientated to information giving to fill a perceived gap in HIV‐related knowledge.32 However, the on‐going hesitancy expressed by nurses, suggests it may be useful to undertake a review of the existing literature on nurses’ views and experiences of routine HIV testing, to identify more clearly other key areas of concern and perceived issues that affect practice.33‐35 The results of such a review can then be used to further develop innovative training materials and methodologies and to make recommendations for improvements to service delivery processes.36 There have been several systematic reviews of factors influencing uptake of HIV testing from a client perspective,37‐39 but none to date that have synthesized the nursing/midwifery perspective in relation to PITC. The recent client‐orientated meta‐syntheses have shown that perceived trust in and quality of health services have a major impact on HIV testing uptake and subsequent retention in care.40,41 It is essential therefore that the clients’ experience of HIV testing is a positive one; but this hinges to a large extent on nurses’ attitudes, confidence and competence.42