Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
HIV T
    ESTING IN                           
 
HRSA-F
  UNDED                          
 
H C S  
EALTH  ENTER  ITES
 
Daniel R. Levinson  
Inspector General 
 
January 2013 
OEI-06-10-00290   
   
EXECUTIVE SUMMARY:  HIV Testing in HRSA-Funded Health Center Sites 
OEI-06-10-00290 
 
WHY WE DID THIS STUDY  
Health center sites funded by the Health Resources and Services Administration (HRSA) provide 
primary health care to millions of patients each year and are critical to efforts to test patients for 
human immunodeficiency virus (HIV) and reduce its spread.  Since 2006, the Centers for 
Disease Control and Prevention (CDC) has recommended routine HIV testingi.e., that patients 
be tested as a routine part of care and be told they will be tested unless they decline.  This 
approach aims to expand testing to a wider patient population and increase testing rates.  We did 
this study to determine the extent to which HRSA-funded sites adopted four practices that CDC 
recommended:  (1) routine HIV testing of all patients 1364 years of age; (2) not requiring 
prevention counseling for all patients; (3) gaining patient consent for the HIV test in the same 
way as for other screening and diagnostic tests; and (4) providing HIV tests as standard, opt-out 
tests. 
 
HOW WE DID THIS STUDY 
We analyzed survey responses from 324 HRSA-funded sites; the results are projectable to the 
estimated population of 5,275 sites that provide primary care.  We determined the extent to 
which sites adopted the four practices and how Federal recommendations influenced their written 
HIV testing policies.  We also asked sites to describe factors that affected their adoption of these 
practices and their provision of HIV testing.    
 
WHAT WE FOUND 
Health center sites have not fully adopted all four practices recommended by CDC for routine 
HIV testing.  Regarding whom to test, for which CDCs recommendation varies according to the 
circumstances of individual health care providers, 20 percent of sites reported testing all patients 
1364 years of age; 1 percent tested all adults, but not teens; and 55 percent targeted testing to 
high-risk patients.  Regarding the other three practices, 29 percent adopted the practice regarding 
prevention counseling; 27 percent adopted the practice regarding gaining patient consent for the 
HIV test; and 15 percent adopted the practice regarding providing HIV tests as standard, opt-out 
tests.  Most sites had written HIV testing policies that were influenced by the recommendation.  
Factors that affected adoption of the practices and affected HIV testing at sites included the 
financial resources of sites and patients, existence of partnerships with other community 
organizations, patient and staff perceptions about patient risk of contracting HIV, and patient 
discomfort associated with HIV testing. 
 
WHAT WE RECOMMEND  
We recommend that HRSA require grantees to establish and report to HRSA two HIV testing 
metrics:  prevalence and positivity, as follows:  (1) grantees should establish and report the 
prevalence of undiagnosed HIV among their patient populations, and (2) grantees should report 
HIV positivity (the proportion of patients who test positive among all those tested).  We also 
recommend that HRSA continue to provide guidance and education to grantees and sites 
regarding the CDC-recommended practices and HIV testing.  HRSA concurred with our 
recommendations and described its activities to improve HIV testing in sites.  
   
   
   
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................7 
Findings......................................................................................................10 
Health center sites have not fully adopted all four                               
CDC-recommended practices ........................................................10 
The CDC recommendation influenced most health                                    
center sites written HIV testing policies .......................................12 
Health center sites reported that financial resources                                      
and other factors affected adoption of the                                                          
CDC-recommended practices and affected HIV testing ................12 
Conclusion and Recommendations ............................................................15 
Agency Comments and Office of Inspector General Response .....17 
Appendixes ................................................................................................18 
A:  CDCs Revised Recommendations for HIV Testing                                       
of Adults, Adolescents, and Pregnant Women in                                         
Health-Care Settings ......................................................................18 
B:  Point Estimates and Confidence Intervals................................22 
C:  Agency Comments ...................................................................26 
Acknowledgments......................................................................................31 
   
   
OBJECTIVES 
1.  To determine the extent to which health center sites funded by the 
Health Resources and Services Administration (HRSA) adopted 
practices recommended by the Centers for Disease Control and 
Prevention (CDC) for routine testing for human immunodeficiency 
virus (HIV).  
2.  To determine the extent to which Federal recommendations for HIV 
testing influenced health center sites written HIV testing policies. 
3.  To describe factors that affected adoption of the practices and affected 
HIV testing in health center sites.  
BACKGROUND  
HIV Epidemic 
HIV is the virus that causes acquired immune deficiency syndrome 
(AIDS).  In June 2012, CDC estimated that 1.2 million people in the 
United States were living with HIV.1  According to CDC, nearly one in 
five of those people does not know his or her HIV status.2  Traditionally, 
groups at high risk for HIV included men who have sex with men, those 
who have unprotected sex with people who have HIV, and those who 
share injection drug needles.3  However, according to CDC, the HIV 
epidemic has spread beyond these traditional high-risk groups.  CDC 
states, Since the 1980s, the demographics of the HIV epidemic in the 
U.S. have changed; increasing proportions of infected persons are aged 
[less than] 20 years, women, members of racial or ethnic minority 
populations, persons who reside outside metropolitan areas, and 
heterosexual men and women who frequently are unaware that they are at 
risk for HIV.4  The changes in the populations affected by HIV are such 
 
1 CDC, Monitoring Selected National HIV Prevention and Care Objectives By Using 
HIV Surveillance DataUnited States and 6 U.S. Dependent Areas2010.  HIV 
Surveillance Supplemental Report.  June 2012.  Accessed at 
http://www.cdc.gov/hiv/surveillance/resources/reports/2010supp_vol17no3/pdf/hssr_vol_
17_no_3.pdf   on September 6, 2012. 
2 CDC, HIV in the United States.  March 2012.  Accessed at 
http://www.cdc.gov/hiv/resources/factsheets/PDF/HIV_at_a_glance.pdf on September 5, 
2012. 
3 CDC, HIV Prevalence Among Selected Populations:  High Risk Populations.  Accessed 
at http://www.cdc.gov/hiv/topics/testing/resources/reports/hiv_prevalence/high-risk.htm 
on April 25, 2012.  
4 CDC, Revised Recommendations for HIV Testing of Adults, Adolescents, and 
Pregnant Women in Health Care Settings, Morbidity and Mortality Weekly Report, 
September 22, 2006.  Accessed at 
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm on June 19, 2012. 
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   1   
   
that CDC no longer considers a traditional high-risk designation as the key 
determinant for who should receive an HIV test.   
CDCs Recommendation for Routine HIV Testing  
CDCs recommendations regarding HIV testing have changed in recent 
years.  Prior to 2005, CDC recommended a focused approach to HIV 
testing, including targeting high-risk groups, offering prevention 
counseling for all patients, and gaining patient consent for tests through 
HIV-specific consent forms.  In 2005, CDC released recommendations to 
certain settings and populations, including correctional facilities, 
emergency rooms, and obstetric patients (i.e., pregnant women).  The new 
recommendations called for routine testing of patients in these settings and 
groups, a departure from CDCs prior guidance.   
In 2006, CDC significantly changed its recommended approach for how 
primary care providers should provide HIV tests, releasing a new 
recommendation to expand routine testing to all health care settings.  CDC 
recommended that HIV testing be based, in part, on prevalence of 
undiagnosed HIV in the patient population, rather than on patient risk 
factors, and encouraged adopting four specific practices:   
  testing all patients aged 1364 unless the patient has previously been 
tested for HIV or the prevalence of undiagnosed HIV is less than 
0.1 percent, in which case routine testing is no longer warranted;   
  not requiring prevention counseling for all patients;  
  gaining patient consent for the HIV test in the same way as for other 
screening and diagnostic testsi.e., not requiring separate consent; 
and 
  providing HIV tests as standard, opt-out tests.5 
CDC recommended these practices to expand HIV testing to a wider 
patient population, reduce the stigma that surrounds testing, and increase 
the number of people who know their status.  CDC cited research 
indicating that those who know they have HIV are less likely to transmit 
the virus for two reasons:  first, the majority of patients who learn they 
have HIV substantially reduce sexual behaviors that may transmit the 
virus, and second, patients who know they have HIV typically begin 
medications that combat HIV, which lowers the amount of the virus in 
 
5 CDC, Revised Recommendations for HIV Testing of Adults, Adolescents, and 
Pregnant Women in Health Care Settings, Morbidity and Mortality Weekly Report, 
September 22, 2006.  Accessed at 
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm on June 19, 2012. 
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   2   
   
their bodies and consequently reduces their risk of transmitting HIV to 
others.6  See Appendix A for full text of the 2006 CDC recommendation. 
Determining Whom to Test.  Providers have historically targeted HIV tests 
specifically to high-risk patients.  Targeted testing focuses on populations 
that engage in high-risk behaviors, such as intravenous drug use and 
certain sexual activities.  Because HIV has reached a broader population, 
CDC now recommends that primary care providers test all patients aged 
1364, with two exceptions.  First, CDC notes that if the patient has 
previously been tested, HIV tests should be offered at clinicians 
discretion.  Second, CDC notes that if the prevalence of undiagnosed HIV 
infections in the patient population is known to be less than 0.1 percent, 
routine testing would no longer be recommended.7  According to the 
American College of Physicians and the HIV Medicine Association, a 
provider would need to test approximately 4,000 patients to establish a 
prevalence of undiagnosed HIV infection of less than 0.1 percent. 8 
Providing Prevention Counseling.  CDC formerly encouragedand some 
States requiredproviders to give all patients prevention counseling 
before administering an HIV test.9, 10  During such counseling, providers 
gave patients information about risk factors and how to prevent 
transmission of HIV; some providers offered personalized risk 
assessments.11  CDC now recommends that prevention counseling not be 
required as a part of HIV testing.  CDC cited research that found that 
providers perceived prevention counseling to be prohibitively time 
consuming, especially in busy health care settings, and that counseling 
 
6 CDC, Revised Recommendations for HIV Testing of Adults, Adolescents, and 
Pregnant Women in Health Care Settings, Morbidity and Mortality Weekly Report, 
September 22, 2006.  Accessed at 
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm on June 19, 2010. 
7 Ibid. 
8 A. Qaseem; V. Snow; P. Shekelle; R. Hopkins, Jr.; and D. Owens. Screening for HIV 
in Health Care Settings:  A Guidance Statement From the American College of 
Physicians and HIV Medicine Association.  Annals of Internal Medicine.                            
January 20, 2009. Accessed at 
http://annals.org/article.aspx?volume=150&issue=2&page=125 on September 5, 2012. 
9 CDC, Technical Guidance on HIV Counseling, Morbidity and Mortality Weekly 
Report, January 15, 1993.  Accessed at 
http://www.cdc.gov/mmwr/preview/mmwrhtml/00020645.htm on June 19, 2012.  
10  S. Neff and R. Goldschmidt, Compendium of State HIV Testing Laws.  
September 2011.  Accessed at http://www.nccc.ucsf.edu/docs/QRG.pdf  on May 17, 
2012. 
11 CDC, HIV Counseling with Rapid Tests.  Accessed at 
http://www.cdc.gov/hiv/topics/testing/resources/factsheets/rt_counseling.htm on                    
June 14, 2012.   
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   3   
   
may limit testing because some individual providers are uncomfortable 
discussing patients behaviors and risk factors.    
Gaining  Patient Consent.  CDC previously recommended gaining patient 
consent for HIV tests separately from consent for other medical care; this 
separate consent was thought to ensure that patients would be better 
informed about HIV tests and that the tests would be voluntary.  CDC now 
recommends that providers offer information about HIV and obtain 
consent for HIV tests in the same way as for other screening and 
diagnostic tests, which is expected to reduce the stigma associated with 
HIV testing and to increase the likelihood that patients will be tested.  
CDC specifically states that a separate consent form should not be 
required and is not recommended.  In changing the recommended practice, 
CDC cited a study of pregnant patients in which the use of HIV-specific 
consent forms reduced testing rates.12   
Offering Tests on an Opt-out Basis.  Historically, providers presented HIV 
testing to patients as an elective medical test, asking whether they wanted 
the test.  This practice is known as opt-in testing.  CDC now recommends 
that providers present HIV tests as a standard practice for all patients 
unless a patient specifically declines.  This practice is known as opt-out 
testing.  CDC cites research indicating that making HIV tests standard can 
increase the number of people who know their HIV status, identify 
HIV-infected persons earlier in the diseases development, reduce stigma 
associated with HIV testing, and lead to increased acceptance of HIV 
testing as a standard of care.    
Other Federal and State Guidelines 
Other entities, such as a Federal task force and some States, have 
requirements or recommendations that conflict with some                                            
CDC-recommended practices.  For example, the United States Preventive 
Services Task Force (USPSTF)an independent body that provides 
guidance on many health care matterscurrently recommends targeted 
HIV testing for high-risk groups, but released draft recommendations for 
widespread screening in November 2012.13  Additionally, research 
 
12 CDC, Revised Recommendations for HIV Testing of Adults, Adolescents, and 
Pregnant Women in Health Care Settings, Morbidity and Mortality Weekly Report, 
September 22, 2006.  Accessed at 
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm on June 19, 2010. 
13 USPSTF, Screening for HIV.  April 2007.  Accessed at 
http://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm on September 5, 2012.  
The USPSTF released draft recommendations on the topic November 20, 2012, 
recommending that clinicians screen patients ages 15 to 65 years for HIV infection.  
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   4   
   
indicates that as late as 2011, four States had laws requiring that patients 
sign a separate written consent form specifically for an HIV test.    
HRSA-Funded Health Center Sites 
HRSA funds grantees that administer four different types of health centers: 
community health, migrant health, health care for the homeless, and public 
housing primary care, collectively referred to as health center sites.  
Such health center sites provide primary health care to millions of patients 
each year and are critical to efforts to increase HIV testing.  Health center 
sites provide access to health care services for people who are uninsured 
or publicly insured; geographically isolated; or otherwise medically 
vulnerable, including populations that are disproportionately affected by 
HIV, such as homeless persons, African Americans, and 
Hispanics/Latinos.14, 15, 16, 17, 18, 19    
During 2011, health center sites provided services to more than 17 million 
patients.20  The American Recovery and Reinvestment Act of 2009 
(ARRA) and the Patient Protection and Affordable Care Act of 2010 
(ACA) increased health center funding.21, 22  Estimates indicate that 
combined, these additional funds will enable health centers to greatly 
increase the number of patients served.23, 24 
 
14 National Alliance to End Homelessness (NAEH), Fact Sheet:  Homelessness and 
HIV/AIDS.  Accessed at http://www.endhomelessness.org/content/article/detail/1073 on 
June 12, 2012.   
15 United States Census Bureau, State and County Quick Facts.  Accessed at 
http://quickfacts.census.gov/qfd/states/00000.html on June 12, 2012.   
16 NACHC, Americas Health Centers (fact sheet).  Accessed at 
http://www.nachc.com/client/documents/America's%20Health%20Centers%20Fact%20S
heet%20August%202011.pdf  on June 12, 2012.   
17 CDC, HIV/AIDS Among African Americans.  Accessed at 
http://www.cdc.gov/hiv/topics/aa/resources/factsheets/aa.htm on June 12, 2012.   
18 CDC, HIV/AIDS Among Hispanics/Latinos.  Accessed at 
http://www.cdc.gov/hiv/hispanics/resources/factsheets/hispanic.htm on June 12, 2012.   
19 HRSA, About HRSA, Accessed at http://www.hrsa.gov/about/index.html on                                      
June 19, 2012.   
20 Office of Inspector General discussion with HRSA officials, June 26, 2012. 
21 ARRA, P.L. 111-5, Division A, Title VIII.  In 2009, Congress appropriated a one-time 
direct investment of $2 billion in supplemental funding specifically for health centers. 
22 ACA, P.L. 111-148  10503, Public Health Service Act  330.  The ACA created the 
Community Health Centers Trust Fund and appropriated $11 billion in funding over 
5 years for the health center program. 
23 NACHC, Community Health Centers and Health Reform.  Accessed at 
http://www.nachc.com/client/Summary%20of%20Final%20Health%20Reform%20Packa
ge.pdf on June 12, 2012. 
24 U.S. Department of Health and Human Services (HHS), Fiscal Year 2013, Budget in 
Brief. Accessed at http://www.hhs.gov/budget/budget-brief-fy2013.pdf on September 27, 
2012. 
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   5   
   
 
HIV Testing in Health Center Sites 
The rates of HIV testing reported by health center sites have increased 
slightly in recent years.  In 2006, CDC found that HIV tests conducted in 
community clinics (which include HRSA-funded health center sites 
examined in this report) diagnosed 21 percent of all new HIV infections, 
yet only 5 percent of community clinic patients were tested that year.25  In 
2011, 5 years after CDC released its recommendation for routine HIV 
testing, HRSA reported slightly higher annual testing rates.  Specifically, 
in 2011, 7.4 percent of health center grantee patients aged 1364 years
the age group that CDC recommends for routine HIV testingreceived 
HIV tests at health center sites, up from 5.8 percent in 2010.26 
Federal regulations do not require HRSA-funded health centers to offer 
HIV tests at each site.  Rather, HRSA requires that a grantee either offer 
HIV testing in some or all of its health center sites or refer patients to 
other health care providers for HIV tests.  Additionally, HRSA requires 
each grantee to report into the Uniform Data System (UDS) the number of 
HIV tests provided in its health center sites each year.27  HRSA also 
requires those grantees that receive funding through the Ryan White 
HIV/AIDS Program (about 14 percent of health center grantees) to track 
certain performance measures regarding HIV testing and care.28  However, 
this requirement does not cover health center grantees that do not receive 
such funding.  Additionally, HRSA has indicated plans to require that 
grantees report HIV positivity, which is one of the core indicators for  
   
 
25 The Forum for Collaborative HIV Research, Metrics and Evaluation Measures for 
Monitoring the Implementation of Routine HIV Testing in the U.S., April 23, 2009.  
Accessed at 
http://www.hivforum.org/storage/hivforum/documents/metrics/hiv_testing_metrics_repor
t_12.14.09.pdf  on May 23, 2012.   
26 Office of Inspector General Staff discussion with HRSA officials, June 26, 2012.  
Patients may have also received HIV tests before or after the 2011 time period included 
in this 7.4-percent statistic or may have received HIV tests in other health care settings.  
27 HRSA, Health Center Data. Accessed at 
http://bphc.hrsa.gov/healthcenterdatastatistics/reporting/index.html on May 3, 2012.  
28  HRSA, HAB [HIV/AIDS Bureau], HIV Performance Measures.  Accessed at 
http://hab.hrsa.gov/deliverhivaidscare/habperformmeasures.html on May 17, 2012.  The 
Ryan White HIV/AIDS Program provides HIV-related services to people who do not 
have the financial resources or sufficient health care coverage for coping with the disease. 
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   6   
   
monitoring HHS-funded HIV prevention, treatment, and care services.29, 30   
HRSA has promoted the CDC recommendation for routine HIV testing as 
well as other initiatives that encourage HIV testing.  In September 2010, 
HRSA released a Program Assistance Letter summarizing current                 
CDC-recommended practices for HIV testing and providing additional 
resources for health centers that seek to increase HIV testing.  In 
January 2011, HRSA hosted a technical assistance call with health center 
grantees to discuss the Office of National AIDS Policys (ONAP) National 
HIV/AIDS Strategy and HRSAs plans to enhance HIV care at health 
center sites.31   
Some HRSA-funded health centers receive HIV-related guidance and 
funding from other organizations.  For example, NACHC provides health 
centers with guidance on routine HIV testing.32  Additionally, health 
centers may receive special funding for HIV testing under CDCs 
Expanded HIV Testing for Disproportionately Affected Populations 
Initiative; the Enhanced Comprehensive HIV Prevention Plan (ECHPP), a 
project that supports HIV services for health centers in the 12 cities most 
affected by the HIV epidemic; and the Ryan White HIV Program for early 
intervention services, which include HIV testing. 33, 34, 35   
METHODOLOGY 
Scope 
This report provides information about HIV testing practices at                       
HRSA-funded health center sites as reported in 2011.  We examined the 
health center sites adoption of the four testing-related practices specified 
in CDCs 2006 recommendation for routine HIV testing, the reported 
 
29 HIV positivity is the number of positive HIV tests divided by the number of all HIV 
tests administered. 
30 The White House Office of National AIDS Policy Blog.  Secretary Sebelius Approves 
Indicators for Monitoring HHS-Funded HIV Services.  Accessed at 
http://blog.aids.gov/2012/08/secretary-sebelius-approves-indicators-for-monitoring-hhs-
funded-hiv-services.html on September 18, 2012. 
31 ONAP, National HIV/AIDS Strategy for the United States, July 2010.  Accessed at 
www.whitehouse.gov on May 17, 2011. 
32 NACHC, HIV Screening Model for Primary Care.  Accessed at 
http://www.nachc.com/hivmodel.cfm on May 16, 2012.  
33 The 12 ECHPP cities are Atlanta; Baltimore; Chicago; Dallas; Houston; Los Angeles; 
Miami; New York City; Philadelphia; San Francisco; San Juan; and Washington, D.C.  
34 CDC, Funding Opportunity Announcement PS10-10138:  Expanded HIV Testing for 
Disproportionately Affected Populations. Accessed at 
http://www.cdc.gov/hiv/topics/funding/ps10-10138/index.htm on May 16, 2012.   
35 HRSA, The Ryan White HIV/AIDS Program, Part C. Accessed at 
http://hab.hrsa.gov/livinghistory/programs/Part-C.htm on May 16, 2012.  
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   7   
   
influence of Federal recommendations on health center sites written HIV 
testing policies and practices, and factors that affected the adoption of the 
practices and affected HIV testing.  The health center site responses 
regarding testing practices are projectable to all HRSA-funded health 
center sites providing primary care in 2010.    
Sample 
HRSA data indicate that 8,144 health center sites received funding in 
November 2010.  We selected a simple random sample of 500 health 
center sites from these.   
Data Collection  
To determine the extent to which HRSA-funded health center sites that 
provide primary care adopted the CDC-recommended practices for routine 
HIV testing, we surveyed 500 health center sites about their HIV testing 
practices during MayNovember 2011.  During data collection, we 
excluded 149 of the 500 sampled health center sites because they did not 
provide primary care, they were no longer in operation, or their associated 
health center grantees did not respond to our inquiries.  For example, some 
health center sites provided only dental or gynecological services and 
other health center sites had closed.  We received responses from 324 of 
the eligible 351 health center sites, a 92-percent response rate.  To 
encourage responses, we sent emails and postcards to health center sites 
and made a minimum of three phone calls.  The study results are 
projectable to the estimated population of 5,275 HRSA-funded health 
center sites that provide primary health care.   
Data Analysis   
We analyzed survey responses to determine HRSA-funded health center 
sites HIV testing practices.  We used the following criteria to calculate 
adoption rates for each of the four CDC-recommended practices for 
routine HIV testing:   
Determining Whom To Test.  On the basis of the wording of the CDC 
recommendation regarding determining which patients to offer HIV tests, 
we categorized health center sites into three groups: 
1)  The first group consists of health center sites that provided HIV 
tests only to patients who requested a test and/or patients who 
showed symptoms of HIV. This group is too limited to be aligned 
with the CDC recommendation for routine testing. 
2)  We identified a second group of health center sites that offered 
tests to patients with certain risk factors, which CDC recommends 
is appropriate only for patients who have previously been tested for 
HIV and in health care facilities that have established a prevalence 
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   8   
   
of undiagnosed HIV of less than 0.1 percent among their patient 
populations. 
3)  The third group consists of health center sites that tested all 
patients 1364 years of age, without taking into account 
patient-specific risk factors.  CDC recommends that most health 
care facilities follow this testing pattern.   
Providing Prevention Counseling.  Regarding prevention counseling, we 
considered all health center site responses to be in alignment with the 
CDC recommendation unless the health center site indicated that it 
provided prevention counseling to all patients, which CDC specifically 
does not recommend.   
Gaining Patient Consent.  Regarding gaining patient consent, we 
considered all health center site responses to be in alignment with the 
CDC recommendation unless the health center site indicated that it used a 
separate written consent form, which CDC specifically does not 
recommend.    
Offering Tests on an Opt-out Basis.  Regarding offering tests on an opt-out 
basis, we considered all health center site responses to be in alignment 
with the CDC recommendation unless the health center site indicated that 
it required some or all patients to specifically indicate that they wanted an 
HIV test, which CDC refers to as opt-in testing.   
We also determined whether health center sites had written HIV testing 
policies and examined factors that affected the adoption of each 
recommended practice, such as whether health center sites received 
funding specific to HIV testing or partnered with other organizations in the 
community.  See Appendix B for estimates and confidence intervals. 
Limitations 
We did not verify the accuracy of the information provided by health 
center sites.  However, we attempted to identify inconsistencies, unclear 
responses, abbreviated responses, and indications that the respondent may 
have misunderstood the question.  We resolved these issues when possible 
and in some cases followed up with respondents to clarify.  Additionally, 
respondents often described patient perceptions and behaviors.  However, 
we did not verify with patients that the respondents descriptions of their 
perceptions or behaviors were accurate.  
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   9   
   
FINDINGS 
Health center sites have not fully adopted all four 
CDC-recommended practices.   
Ninety percent of HRSA-funded health center sites offered HIV testing 
but had not fully adopted all four of CDCs recommended practices.  The 
remaining 10 percent, which did not offer HIV testing, typically referred 
patients to other providers, such as local health departments, for HIV tests.   
Determining Whom To Test.  Twenty percent of health center sites that 
offered HIV tests reported testing all patients 1364 years of age.  CDC 
recommends this approach in health center sites that have not established a 
prevalence of undiagnosed HIV of less than 0.1 percent in their patient 
populations and for patients not previously tested for HIV.  An additional 
1 percent reported testing all adults, but not teens.  Fifty-five percent 
targeted high-risk patients, such as those with histories of injection drug 
use.  This approach aligns with the USPSTF recommendation and is 
consistent with the CDC-recommended practice if patients have 
previously been tested for HIV or if health center sites have established a 
prevalence of undiagnosed HIV of less than 0.1 percent in their patient 
populations.  However, few health center sites in our sample reported 
testing enough patients to establish their prevalence of undiagnosed HIV.36  
The remaining 24 percent of sites offered HIV tests only when patients 
requested a test or had symptoms of HIV or took some other approach.   
Health center sites that reported testing all patients aged 1364 also 
reported additional practices that suggest they have a greater focus on HIV 
prevention and care than other health center sites.  For example, these 
health center sites were more likely to report that they have written HIV 
testing policies regarding who should receive an HIV test.37  They were 
 
36 Many health center sites in this group likely are not aligned with this 
CDC-recommended practice because they have not tested enough patients to establish a 
prevalence of undiagnosed HIV of less than 0.1 percent in their patient populations. CDC 
recommends this practice if the HIV-positive diagnostic yield is less than 1 per 
1,000 patients tested.  In our sample, 216 health center sites reported the number of HIV 
tests they had conducted; only 15 had performed at least 1,000 tests during our review 
period. 
37 Sixty-six percent of health center sites that tested all patients 1364 years of age had 
written HIV testing policies, whereas only 38 percent of health center sites that did not 
test all such patients had written HIV testing policies.  This difference is statistically 
significant (p < 0.0001).  The 95-percent confidence interval for the 66-percent estimate 
is 54.078.2 percent.  
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   10   
   
also more likely than other health center sites to report offering care to 
patients already infected with HIV.38   
Providing Prevention Counseling.  Twenty-nine percent of health center 
sites that offered HIV testing adopted the CDC recommendation of not 
requiring prevention counseling for every patient.  The remaining                               
71 percent provided prevention counseling to all patients either before or 
after their HIV tests.  CDC recommends that prevention counseling not be 
required as a part of HIV screening programs.  A goal of this 
recommended practice is to reduce counseling time and thereby reduce the 
time required to provide HIV tests in busy health care settings.  
Accordingly, providers in health center sites that encourage providers to 
determine appropriate prevention counseling spent less time providing 
counseling to patients than providers in other health center sites.39   
Gaining Patient Consent.  Twenty-seven percent of health center sites that 
offered HIV testing gained consent for such tests in the same way as for 
other screening and diagnostic tests, a practice that CDC recommends to 
reduce the stigma associated with HIV tests.  The remaining 73 percent 
used a separate form to gain consent for HIV tests as either one method for 
gaining consent (54 percent) or as the only method for gaining consent 
(19 percent).  CDC recommends that providers gain patient consent for an 
HIV test through general consent for medical care, regardless of whether 
consent is written or verbal, and specifies that it does not recommend a 
separate consent form for HIV testing. 
Offering Tests on an Opt-out Basis.  Fifteen percent of health center sites 
that offered HIV testing provided HIV tests as standard, opt-out tests.  The 
remaining 85 percent did not adopt opt-out HIV testing.  Specifically, 
49 percent offered only opt-in testing, which required patients to indicate 
that they wanted an HIV test.  The other 36 percent offered HIV testing 
using a combination of the two approaches, allowing individual providers 
to determine whether to provide HIV testing on an opt-in or opt-out basis.  
Health center sites that offered HIV tests as standard, opt-out tests were 
 
38 Fifty-four percent of health center sites that tested all patients 1364 years of age 
provided HIV care, whereas 23 percent of health center sites that did not test all such 
patients provided HIV care.   This difference is statistically significant (p < 0.0001).  The 
95-percent confidence interval for the 54-percent estimate is 41.666.9 percent.  
39 Of health center sites that did not require prevention counseling for all patients, 
25 percent reported that providers spent 5 minutes or more counseling patients.  By 
comparison, 57 percent of health center sites that provided prevention counseling to all 
patients before or after an HIV test also reported that providers spent 5 minutes or more 
counseling patients.  This difference is statistically significant (p < 0.0001).   
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   11   
   
more likely than other health center sites to report increases in HIV testing 
over the last 5 years.40   
The CDC recommendation influenced most health 
center sites written HIV testing policies 
Most health center sites76 percentreported having written HIV testing 
policies.  Their written policies covered topics such as gaining consent, 
prevention counseling, and patients who should be tested.41  Even though 
health center sites had not fully adopted all four CDC-recommended 
practices, 84 percent reported that CDCs recommendation influenced 
their written HIV testing policies.  Ninety percent reported updating their 
policies since 2006, the year CDC released its routine testing 
recommendation.  Health center sites with written HIV testing policies 
reported that their policies were also influenced by Federal 
recommendations issued by the USPSTF (15 percent) and by other 
organizations, including the American Medical Association (7 percent) 
and the World Health Organization (2 percent).  
Health center sites reported that financial resources 
and other factors affected adoption of the                                    
CDC-recommended practices and affected HIV testing 
Health center sites reported factors that affected their adoption of the                  
CDC-recommended practices and that more generally affected their HIV 
testing.  
Financial resources.  Forty-three percent of health center sites reported 
that they received funding specifically for HIV testing, from sources such 
as CDC and the Ryan White program.  Health center sites that received 
funding for HIV testing were more likely to adopt two of the four 
CDC-recommended practices for HIV testing.  These health center sites 
were more likely to adopt the practice of testing all patients 1364 years of 
 
40 Seventy-two percent of health center sites that offered opt-out HIV tests reported that 
HIV testing had increased over the past 5 years.  In comparison, 48 percent of other 
health center sites reported increased testing over the past 5 years.  This difference is 
statistically significant (p < 0.0001).  The 95-percent confidence interval for the 72-percent 
estimate is 58.685.6 percent. 
41 The remaining 24 percent of health center sites reported that they did not have written 
policies or other written guidance regarding HIV testing.   
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   12   
   
age and to offer tests on an opt-out basis than those that did not receive 
HIV-specific funding.42, 43    
Further, health center sites also reported that lack of resources on the part 
of both patients and health center sites limited HIV testing.  For example, 
32 percent of health center sites reported that they can offer only a limited 
number of free or reduced-cost tests, and 24 percent reported that patients 
often could not afford to pay for testing themselves.  Respondents from 
one health center site reported that patients who were not eligible for free 
HIV tests were unlikely to pay for tests, and respondents from another 
health center site reported that patients had difficulty paying even the 
small office visit fee, let alone an additional testing fee. 
Existence of Partnerships.  Forty-three percent of health center sites 
reported working with other organizations in their communities to combat 
HIV.  This activity was associated with the practice of testing all patients 
aged 1364.44  Partner organizations worked with health center sites on 
efforts such as providing testing, increasing community awareness of HIV, 
improving community planning for HIV prevention, and reducing HIV 
transmission in the community.  Health center sites reported partnering 
with other organizations including State and local health departments, 
local Ryan White programs, universities, churches, and homeless clinics 
on yearly events, such as National HIV Testing Day, and at seasonal 
events, such as local health fairs, as well as on collaborating on long-term 
planning through HIV reduction task forces and consortiums.  
Perception of Risk.  Health center sites reported that patient and staff 
perception of low patient risk for HIV limited HIV testing.  Although 
some patients may accurately perceive themselves to be at low risk, the 
 
42 Sixty-eight percent of health center sites that tested all patients aged 1364 also 
reported that they received funding specifically for HIV testing.  In comparison, 
37 percent of health center sites that did not test all such patients received funding.  This 
difference was statistically significant (p < 0.0001).  The 95-percent confidence interval 
for the 68-percent estimate is 55.979.7 percent.  
43 Health center sites that offered HIV testing on an opt-out basis reported receiving 
funding specifically for HIV testing, a resource that may allow for greater adoption of 
this recommended practice.  Specifically, 63 percent of health center sites that offered 
tests on an opt-out basis received HIV-specific funds.  In comparison, 40 percent of 
health center sites that required patients to request an HIV test also received HIV-specific 
funds.  This difference was statistically significant (p < 0.0001).  The 95-percent 
confidence interval for the 63-percent estimate is 48.277.4 percent.  
44 Sixty-one percent of health center sites that tested all patients 1364 years of age also 
partnered with organizations in their communities to promote HIV awareness.  In 
comparison, 40 percent of health center sites that did not test all such patients partnered 
with others in their communities.  This difference was statistically significant 
(p < 0.0001).   The 95-percent confidence interval for the 61-percent estimate is  
48.673.4 percent.  
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   13   
   
HIV epidemic has broadened and patients not considered high risk may 
still be infected.  However, 60 percent of health center sites reported that 
they believed their patients did not perceive themselves to be at risk, and 
most of these health center sites also reported that their staffs did not 
perceive the centers patient populations to be at high risk.  Health center 
sites that do not perceive their patient populations to be at high risk may 
not believe that routine testing is appropriate.  In many cases, health center 
site respondents attributed staff and patient perception of HIV risk to a 
lack of education about HIV and lack of awareness that the effectiveness 
of testing on the basis of patient risk factors has diminished.   
Patient comfort.  Health center sites also reported that they perceive 
patients as being uncomfortable requesting an HIV test or receiving test 
results.  Specifically, 38 percent of health center sites reported that 
patients were not comfortable requesting an HIV test and that this limited 
testing in the health center sites.  Respondents from several health center 
sites explained that patients often appeared concerned that their requests 
for HIV testing or their test results would not remain confidential.  For 
example, respondents from a health center site in a small community 
reported that patients might be inhibited from discussing HIV testing 
because the office staff know most people in the community.  Another 
20 percent of health center sites reported that patients were not willing to 
wait or return for HIV test results.  Several health center sites reported that 
patients do not wait or return because they are afraid to learn that they may 
be infected.  For example, respondents from one health center site reported 
that some patients would rather not know their HIV status and that they 
were likely unaware of the treatments available and the extended life 
expectancy once treatment begins. 
   
   
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   14   
   
CONCLUSION AND RECOMMENDATIONS 
HRSA-funded health center sites provide primary health care to millions 
of patients each year and are critical to efforts to test patients and reduce 
the spread of HIV.   CDC estimates that one in five people in the United 
States who are living with HIV do not know their HIV status and, 
therefore, are more likely to transmit the disease to others.  CDC 
recommends that health care facilities determine their HIV testing 
approaches on the basis of data and evidence about the prevalence of 
undiagnosed HIV in the patient population.  CDC also recommends four 
key practices for HIV testing.   
Health center sites have not fully adopted all four of CDCs recommended 
practices.  Most had written HIV testing policies influenced by CDCs 
routine testing recommendation.  Health center sites reported that several 
factors influenced their adoption of the recommended practices and 
affected their HIV testing, such as financial resources, existence of 
partnerships with others in their communities, patient and staff perception 
of patient risk of contracting HIV, and patient comfort in requesting tests 
and hearing test results.  
We recommend that HRSA: 
Require health center grantees to establish and report to 
HRSA two relevant HIV testing metrics:  prevalence and 
positivity 
CDC recommends HIV testing that is based, in part, on prevalence of 
undiagnosed HIV in the patient population.  HRSA should require health 
center grantees to determine the prevalence of undiagnosed HIV in their 
patient populations and report this to HRSA.  Additionally, recognizing 
that some grantees will establish prevalence more quickly than others, 
HRSA should require grantees to report to it regarding their progress 
toward establishing prevalence.  CDC indicates that once a grantee tests 
enough patients to establish a prevalence of less than 0.1 percent, routine 
testing is no longer warranted.  However, few health center sites in our 
sample reported testing enough patients to establish their prevalence of 
undiagnosed HIV, suggesting that a HRSA requirement is needed to make 
progress toward identifying which health center sites should routinely 
perform HIV tests.  
As health center grantees work toward establishing the prevalence of 
undiagnosed HIV in their patient populations, they should also report to 
HRSA their HIV positivitythe number of positive HIV tests divided by 
the number of all HIV tests administered.  HRSA already requires each 
grantee to enter into the UDS the number of HIV tests provided in the 
grantees health center sites each year.  However, HRSA does not collect 
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   15   
   
information about how many of those HIV tests resulted in HIV-positive 
diagnoses.  Recently, HHS released seven core indicators for monitoring 
HHS-funded HIV prevention, treatment, and care, including HIV 
positivity.  Required reporting of HIV positivity would align data 
collection by HRSA health center grantees with that of other HHS-funded 
HIV programs and services.  Further, required reporting would raise 
awareness of HIV testing among health center sites that are critical to 
reducing the spread of HIV. 
Provide additional guidance and education regarding the                      
CDC-recommended practices and HIV testing 
HRSA provided guidance regarding the CDC-recommended practices 
through AIDS Education and Training Centers and a Program Assistance 
Letter and provided education about HIV testing through a technical 
assistance call with health center grantees.  However, our findings suggest 
that more guidance and education regarding these practices and HIV 
testing is needed.  HRSA could provide guidance and education by 
making additional technical assistance calls, issuing program assistance 
letters, and offering additional training sessions and educational 
opportunities to health center grantees and sites.  Guidance should include 
methods for establishing prevalence and for determining HIV positivity.  
The guidance should include strategies regarding how to incorporate the 
recommended practices into written HIV testing policies and into primary 
care services.  HRSA guidance should also encourage health center sites to 
partner with other organizations in their communities and to raise 
awareness among patients and staff about patient risk for HIV infection. 
   
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   16   
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
HRSA concurred with our recommendations and described past and 
current activities to improve HIV testing in health centers.  Regarding the 
first recommendation to establish and report metrics for HIV testing, 
HRSA stated that it will begin collecting HIV positivity rates as part of 
health centers annual UDS reports.  HRSA also stated that it will work 
with CDC to assess HIV prevalence rates in health center service areas.  
Regarding the second recommendation to provide additional guidance and 
education, HRSA stated it that it will continue to support health centers by 
developing new resources and enhancing existing resources.  
We did not make any changes to the report on the basis of HRSAs 
comments.  For the full text of HRSAs comments, see Appendix C.  
   
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   17   
   
APPENDIX A 
Centers for Disease Control and Preventions Revised Recommendations 
for HIV Testing of Adults, Adolescents, and Pregnant Women in                           
Health-Care Settings45 
Recommendations for Adults and Adolescents 
CDC recommends that diagnostic HIV testing and opt out HIV screening 
be a part of routine clinical care in all health-care settings while also 
preserving the patients option to decline HIV testing and ensuring a 
provider-patient relationship conducive to optimal clinical and preventive 
care.  The recommendations are intended for providers in all health-care 
settings, including hospital EDs [emergency departments], urgent-care 
clinics, inpatient services, STD [sexually transmitted disease] clinics or 
other venues offering clinical STD services, tuberculosis (TB) clinics, 
substance abuse treatment clinics, other public health clinics, community 
clinics, correctional health-care facilities, and primary care settings.  The 
guidelines address HIV testing in health-care settings only; they do not 
modify existing guidelines concerning HIV counseling, testing, and 
referral for persons at high risk for HIV who seek or receive HIV testing 
in nonclinical settings (e.g., community based organizations, outreach 
settings, or mobile vans). 
Screening for HIV Infection 
 In all health-care settings, screening for HIV infection should be 
performed routinely for all patients aged 1364 years.  Health-care 
providers should initiate screening unless prevalence of undiagnosed HIV 
infection in their patients has been documented to be <0.1%.  In the 
absence of existing data for HIV prevalence, health-care providers should 
initiate voluntary HIV screening until they establish that the diagnostic 
yield is <1 per 1,000 patients screened, at which point such screening is no 
longer warranted. 
 All patients initiating treatment for TB should be screened routinely for 
HIV infection. 
 All patients seeking treatment for STDs, including all patients attending 
STD clinics, should be screened routinely for HIV during each visit for a 
 
45 The material in this appendix is quoted directly from Centers for Disease Control and 
Prevention (CDC), Revised Recommendations for HIV Testing of Adults, Adolescents, 
and Pregnant Women in Health-Care Settings, Morbidity and Mortality Weekly Report, 
September 22, 2006.  Accessed at 
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm on June 19, 2012. 
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   18   
   
new complaint, regardless of whether the patient is known or suspected to 
have specific behavior risks for HIV infection. 
Repeat Screening 
 Health-care providers should subsequently test all persons likely to be at 
high risk for HIV at least annually.  Persons likely to be at high risk 
include injection-drug users and their sex partners, persons who exchange 
sex for money or drugs, sex partners of HIV-infected persons, and MSM 
[men who have sex with men] or heterosexual persons who themselves or 
whose sex partners have had more than one sex partner since their most 
recent HIV test.  
 Health-care providers should encourage patients and their prospective 
sex partners to be tested before initiating a new sexual relationship. 
 Repeat screening of persons not likely to be at high risk for HIV should 
be performed on the basis of clinical judgment.  
 Unless recent HIV test results are immediately available, any person 
whose blood or body fluid is the source of an occupational exposure for a 
health-care provider should be informed of the incident and tested for HIV 
infection at the time the exposure occurs.   
Consent and Pretest Information 
 Screening should be voluntary and undertaken only with the patients 
knowledge and understanding that HIV testing is planned. 
 Patients should be informed orally or in writing that HIV testing will be 
performed unless they decline (opt out screening).  Oral or written 
information should include an explanation of HIV infection and the patient 
should be offered an opportunity to ask questions and to decline testing.  
With such notification, consent for HIV screening should be incorporated 
into the patients general informed consent for medical care on the same 
basis as are other screening or diagnostic tests; a separate consent form for 
HIV testing is not recommended. 
 Easily understood informational materials should be made available in 
the languages of the commonly encountered populations within the service 
area.  The competence of interpreters and bilingual staff to provide 
language assistance to patients with limited English proficiency must be 
ensured. 
 If a patient declines an HIV test, this decision should be documented in 
the medical record. 
 
 
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   19   
   
Diagnostic Testing for HIV Infection 
 All patients with signs or symptoms consistent with HIV infection or an 
opportunistic illness characteristic of AIDS should be tested for HIV. 
 Clinicians should maintain a high level of suspicion for acute HIV 
infection in all patients who have a compatible clinical syndrome and who 
report recent high-risk behavior.  When acute retroviral syndrome is a 
possibility, a plasma RNA test should be used in conjunction with an HIV 
antibody test to diagnose acute HIV infection. 
 Patients or persons responsible for the patients care should be notified 
orally that testing is planned, advised of the indication for testing and the 
implications of positive and negative test results, and offered an 
opportunity to ask questions and to decline testing.  With such 
notification, the patients general consent for medical care is considered 
sufficient for diagnostic HIV testing. 
Similarities and Differences Between Current and Previous 
Recommendations for Adults and Adolescents 
Aspects of these recommendations that remain unchanged from previous 
recommendations are as follows: 
 HIV testing must be voluntary and free from coercion. Patients must not 
be tested without their knowledge.  
 HIV testing is recommended and should be routine for persons attending 
STD clinics and those seeking treatment for STDs in other clinical 
settings. 
 Access to clinical care, prevention counseling, and support services is 
essential for persons with positive HIV test results. 
Aspects of these recommendations that differ from previous 
recommendations are as follows: 
 Screening after notifying the patient that an HIV test will be performed 
unless the patient declines (opt-out screening) is recommended in all 
health-care settings.  Specific signed consent for HIV testing should not be 
required. General informed consent for medical care should be considered 
sufficient to encompass informed consent for HIV testing. 
 Persons at high risk for HIV should be screened for HIV at least 
annually. 
 HIV test results should be provided in the same manner as results of 
other diagnostic or screening tests 
 Prevention counseling should not be required as a part of HIV screening 
programs in health-care settings.  Prevention counseling is strongly 
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   20   
   
encouraged for persons at high risk for HIV in settings in which risk 
behaviors are assessed routinely (e.g., STD clinics) but should not have to 
be linked to HIV testing. 
 HIV diagnostic testing or screening to detect HIV infection earlier 
should be considered distinct from HIV counseling and testing conducted 
primarily as a prevention intervention for uninfected persons at high risk.  
   
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   21   
   
APPENDIX B 
Table B-1:  Point Estimates and Confidence Intervals 
95-percent 
Sample  Point  Confidence Interval 
Estimate Characteristic 
Size  Estimate 
Lower  Upper 
Offered HIV tests  324  89.8%  85.9%  92.9% 
Rates of Adoption of Routine HIV Testing Practices Among Health Center Sites That Offered Testing  
Determining Whom To Test 
Tested all patients aged 1364*  289  20.4%  15.9%  25.5% 
     Had a written HIV testing policy  59  66.1%  54.0%  78.2% 
     Offered HIV care  59  54.2%  41.6%  66.9% 
Tested all adults  289  1.0%  0.2%  3.0% 
Tested and targeted high-risk patients *  289  54.7%  49.1%  60.3% 
Tested only when patients requested or had symptoms  289  22.8%  18.1%  28.1% 
Tested on the basis of some other approach  289  1.0%  0.2%  3.0% 
Did not test all patients aged 1364**  289  79.6%  74.5%  84.1% 
     Had a written HIV testing policy  230  37.6%  31.4%  43.7% 
     Offered HIV care   230  23.0%  17.7%  29.1% 
Providing Prevention Counseling 
Did not require prevention counseling for all patients *  286  28.7%  23.6%  33.8% 
     Spent 5 minutes or more counseling  67  25.4%  15.0%  35.7% 
Provided prevention counseling for all patients before or after HIV tests  286  71.3%  66.2%  76.4% 
     Spent 5 minutes or more counseling  202  56.9%  50.3%  63.6% 
Gaining Patient Consent 
Gained patient consent with consent for all medical care *  287  26.8%  21.8%  31.8% 
Gained patient consent only through a separate HIV-specific written 
287  19.2%  14.8%  24.2% 
consent form 
Gained patient consent through a separate HIV-specific written consent 
287  54.0%  48.4%  59.6% 
along with other methods 
* Indicates a practice recommended by the Centers for Disease Control and Prevention (CDC). 
** Indicates a practice recommended by CDC if patients have previously been tested for HIV or if prevalence of undiagnosed 
HIV infection is less than 0.1 percent. 
Continued on next page 
  
 
 
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95-percent 
Sample  Point  Confidence Interval 
Estimate Characteristic 
Size  Estimate 
Lower  Upper 
Offering Tests on an Opt-Out Basis 
Provided HIV tests as standard, opt-out tests *  288  14.9%  11.0%  19.6% 
     Reported increased testing  43  72.1%  58.6%  85.6% 
Did not provide HIV tests as standard, opt-out tests  288  85.1%  82.5%  90.2% 
     Offered tests on an opt-in basis  288  48.9%  43.3%  54.6% 
     Used a combination of opt-out and opt-in approaches  288  35.8%  30.4%  41.2% 
     Reported  increased testing  245  47.8%  41.7%  53.9% 
Health Center Site HIV Testing Policies 
Health center site had a written HIV testing policy  324  75.6%  70.6%  80.2% 
     HIV testing policy was influenced by CDC recommendation  245  83.7%  78.4%  88.1% 
     HIV testing policy had been updated since 2006  245  89.8%  85.3%  93.3% 
     HIV testing policy was influenced by the United States Preventive  
245  15.1%  10.9%  20.2% 
          Services Task Force  
     HIV testing policy was influenced by the American Medical Association  245  6.9%  4.1%  10.9% 
     HIV testing policy was influenced by the World Health Organization  245  1.6%  0.5%  4.1% 
Health center site did not have a written HIV testing policy  324  24.4%  19.8%  29.4% 
Health Center Site-Identified Factors That Affected Adoption of CDC-Recommended Practices and HIV Testing 
Received HIV-specific funding  324  43.2%  37.9%  48.5% 
     Tested all patients 1364 years of age   140  67.8%  55.9%  79.7% 
     Did not test all patients 1364 years of age   140  36.9%  30.8%  43.0% 
     Offered HIV tests as standard, opt-out  140  62.8%  48.2%  77.4% 
     Did not offer HIV tests as standard, opt-out  140  40.3%  34.4%  46.3% 
Reported that ability to offer only a limited number of free or reduced-cost 
331  31.7%  26.8%  36.6% 
tests affected HIV testing 
Reported that patients often could not afford to pay for an HIV test  329  24.0%  19.5%  29.0% 
Partnered with others in the community  321  42.6%  37.4%  47.9% 
     Tested all patients 1364 years of age   137  61.0%  48.6%  73.4% 
     Did not test patients 1364 years of age   137  40.1%  33.9%  46.3% 
* Indicates a practice recommended by CDC. 
Continued on next page 
 
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   23   
   
95-percent 
Sample  Point  Confidence Interval 
Estimate Characteristic 
Size  Estimate 
Lower  Upper 
Identified perception of risk as a factor  324  59.7%  54.6%  64.8% 
     Patients not comfortable requesting an HIV test  324  37.7%  32.7%  42.8% 
     Patients not willing to wait or return for test  results  324  20.2%  16.0%  25.0% 
Source: Office of Inspector General (OIG) analysis of responses from Health Resources and Services Administration (HRSA)-funded health 
center sites, 2012. 
 
 
   
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   24   
   
Table B-2:  Comparison of Site Characteristics 
Sample 
Comparison of Site Characteristics  Z Value  P Value* 
Size 
Sixty-six percent of health center sites that tested all patients 1364 years of age 
had written HIV testing policies, whereas 38 percent of health center sites that did  125  16.97  <0.0001 
not test all such patients had written HIV testing policies.   
Fifty-four percent of health center sites that tested all patients 1364 years of age 
provided HIV care, whereas 23 percent of health center sites that did not test all  84  8.81  <0.0001 
such patients provided HIV care.   
Of health center sites that did not require prevention counseling for all patients, 
25 percent reported that providers spent 5 minutes or more counseling patients, 
whereas 57 percent of health center sites that provided prevention counseling to all  132  34.4  <0.0001 
patients before or after an HIV test also reported that providers spent 5 minutes or 
more counseling patients.   
Seventy-two percent of health center sites that offered opt-out HIV tests reported 
that HIV testing had increased over the past 5 years, whereas 48 percent of other  149  28.76  <0.0001 
health center sites reported increased testing over the past 5 years.   
Sixty-eight percent of health center sites that tested all patients aged 1364 also 
reported that they received funding specifically for HIV testing, whereas 37 percent  125  16.24  <0.0001 
of health center sites that did not test all such patients received such funding.   
Sixty-three percent of health center sites that offered tests on an opt-out basis 
received funding specifically for HIV testing, whereas 40 percent of health center  127  16.24  <0.0001 
sites that required patients to request an HIV test received such funding.   
Sixty-one percent of health center sites that tested all patients 1364 years of age  
partnered with organizations in their communities to promote HIV awareness, 
127  19.7  <0.0001 
whereas versus 40 percent of health center sites that did not test all such patients 
had such partnerships.   
*A p value of less than 0.01 indicates a statistically significant difference.  
 
 
 
 
 
 
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   25  APPENDIXC 
Agency Comments 
DEPARTMENT OF HEALTH&. HUMAN SERVICES  Health Resources and Services 
Administration 
Rockville MD 20857 
TO: 	 Daniel R. Levinson 
Inspector General, HHS 010 
FROM: 	 Administrator, HRSA 
SUBJECT: 	 OIG Draft Report Comments: HIV Testing in HRSA-Funded Health Center Sites, 
OEI-06-l 0-00290 
In response to OIG's request for comments on the draft report, "HIV Testing in HRSA-Funded 
Health Center Sites," OEI-06-10-00290, attached are the Health Resources and Services 
Administration's (HRSA) remarks with actions to OIG's recommendations. 
If you have any questions, please contact Angela Landeen in HRSA's Office of Planning, 
Analysis, and Evaluation at 301-443-1550. 
Mary K. Wakefield, Ph.D., R.N. 
Attachments 
Tab A: HRSA Response to Draft Report 
Tab B: OIG Draft Report 
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HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   27   
   
 
 
 
 
 
 
 
 
 
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   28   
   
 
 
 
 
 
 
 
 
 
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   29   
   
 
 
 
 
 
 
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ACKNOWLEDGMENTS 
This report was prepared under the direction of Kevin Golladay, Regional 
Inspector General for Evaluation and Inspections in the Dallas regional 
office; Blaine Collins, Deputy Regional Inspector General; and                
Ruth Ann Dorrill, Deputy Regional Inspector General.   
Amy Ashcraft served as the team leader for this study, and Lyndsay Patty 
served as the project leader.  Other principal Office of Evaluation and 
Inspections staff from the Dallas regional office who conducted this study 
include Leah Bostick, Tom Browning, Ben Gaddis, Jennifer Gist, and 
Malinda Hicks.  Central office staff who provided support include                   
Heather Barton, Kevin Farber, and Christine Moritz.  
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290)   31   
Office of Inspector General 
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs.  This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrying 
out their respective responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and 
mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud, waste, or abuse and promoting 
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 
of fraud and misconduct related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI utilizes its resources 
by actively coordinating with the Department of Justice and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to criminal 
convictions, administrative sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support for OIGs internal operations.  OCIG represents OIG in all civil and 
administrative fraud and abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
guidance to the health care industry concerning the anti-kickback statute and other OIG 
enforcement authorities.