Department of Health and Human Services

OFFICE OF

INSPECTOR GENERAL

HIV TESTING IN 

HRSA-FUNDED 

HEALTH CENTER SITES

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 testing—i.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 13–64 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 CDC’s recommendation varies according to the 

circumstances of individual health care providers, 20 percent of sites reported testing all patients

13–64 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: CDC’s 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
HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290) 1

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 Data—United States and 6 U.S. Dependent Areas—2010.” 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) 2

that CDC no longer considers a traditional high-risk designation as the key 

determinant for who should receive an HIV test. 

CDC’s Recommendation for Routine HIV Testing 

CDC’s 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 CDC’s 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 13–64 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 tests—i.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) 3

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 

13–64, with two exceptions. First, CDC notes that if the patient has 

previously been tested, HIV tests should be offered at clinician’s 

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 encouraged—and some 

States required—providers 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) 4

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 disease’s 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 matters—currently 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) 5

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, America’s 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) 6

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 13–64 years—

the age group that CDC recommends for routine HIV testing—received 

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) 7

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 Policy’s (ONAP) National 

HIV/AIDS Strategy and HRSA’s 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 CDC’s 

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 CDC’s 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-hhsfunded-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) 8

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 May–November 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) 9

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 13–64 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) 10

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 CDC’s 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 13–64 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 13–64 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 13–64 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 54.0–78.2 percent. 
 

HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290) 11

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 13–64 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 41.6–66.9 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) 12

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 sites—76 percent—reported 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 CDC’s 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 13–64 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 58.6–85.6 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) 13

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 13–64.44 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 13–64 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 55.9–79.7 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 48.2–77.4 percent. 44 Sixty-one percent of health center sites that tested all patients 13–64 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 

48.6–73.4 percent. 
 

HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290) 14

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) 15

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 CDC’s recommended 

practices. Most had written HIV testing policies influenced by CDC’s 

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 positivity—the 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 

grantee’s health center sites each year. However, HRSA does not collect 
 

HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290) 16

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) 17

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 HRSA’s

comments. For the full text of HRSA’s comments, see Appendix C. 
 

HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290) 18

APPENDIX A

Centers for Disease Control and Prevention’s 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 patient’s 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 13–64 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) 19

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 patient’s 

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 patient’s 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) 20

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 patient’s 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 patient’s 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) 21

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) 22

APPENDIX B

Table B-1: Point Estimates and Confidence Intervals

Estimate Characteristic Sample 

Size

Point 

Estimate

95-percent

Confidence Interval

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 13–64* 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 13–64** 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 

consent form 287 19.2% 14.8% 24.2% 

Gained patient consent through a separate HIV-specific written consent 

along with other methods 287 54.0% 48.4% 59.6% 

* 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
 

HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290) 23

Estimate Characteristic Sample 

Size

Point 

Estimate

95-percent

Confidence Interval

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 

 Services Task Force 245 15.1% 10.9% 20.2% 

 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 13–64 years of age 140 67.8% 55.9% 79.7% 

 Did not test all patients 13–64 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

tests affected HIV testing 331 31.7% 26.8% 36.6% 

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 13–64 years of age 137 61.0% 48.6% 73.4% 

 Did not test patients 13–64 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) 24

Estimate Characteristic Sample 

Size

Point 

Estimate

95-percent

Confidence Interval

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) 25

Table B-2: Comparison of Site Characteristics

Comparison of Site Characteristics Sample 

Size Z Value P Value* 

Sixty-six percent of health center sites that tested all patients 13–64 years of age 

had written HIV testing policies, whereas 38 percent of health center sites that did 

not test all such patients had written HIV testing policies. 

125 16.97 <0.0001

Fifty-four percent of health center sites that tested all patients 13–64 years of age 

provided HIV care, whereas 23 percent of health center sites that did not test all 

such patients provided HIV care. 

84 8.81 <0.0001

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 

patients before or after an HIV test also reported that providers spent 5 minutes or 

more counseling patients. 

132 34.4 <0.0001

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 

health center sites reported increased testing over the past 5 years. 

149 28.76 <0.0001

Sixty-eight percent of health center sites that tested all patients aged 13–64 also 

reported that they received funding specifically for HIV testing, whereas 37 percent 

of health center sites that did not test all such patients received such funding. 

125 16.24 <0.0001

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 

sites that required patients to request an HIV test received such funding. 

127 16.24 <0.0001

Sixty-one percent of health center sites that tested all patients 13–64 years of age 

partnered with organizations in their communities to promote HIV awareness, 

whereas versus 40 percent of health center sites that did not test all such patients

had such partnerships. 

127 19.7 <0.0001

*A p value of less than 0.01 indicates a statistically significant difference. 
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 

HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290) 26 
 

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
 

HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290) 30
 

HIV Testing in HRSA-Funded Health Center Sites (OEI-06-10-00290) 31

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. 
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 OIG’s 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.