Improving HIV Screening With Nurse-Based Rapid Testing/Streamlined Counseling
Condition: Health Care Quality, Access, and Evaluation; Delivery of Health Care; Immune System Diseases; HIV Infections
MeSH terms: Immune System Diseases
Study type: Interventional

Summary: 
      Background: HIV testing is cost-effective in unselected general medical populations, yet
      testing rates among those at-risk remain low, even among those with regular primary care. HIV
      rapid testing is effective in many healthcare settings but scant research has been done
      within primary care settings, nor within the US Department of Veteran's Affairs Healthcare
      System.

      Objectives: We evaluated three methods proven effective in other diseases/settings: Nurse
      standing orders for testing, streamlined counseling, and HIV rapid testing.

      Design: Randomized, controlled trial with three intervention models: Model A (traditional
      counseling/testing); Model B (nurse-initiated screening, traditional counseling/testing);
      Model C (nurse-initiated screening, streamlined counseling/rapid testing).

      Participants: 251 patients with primary/urgent care appointments in two VA clinics in the
      same city (one large urban hospital, one freestanding outpatient clinic in a high HIV
      prevalence area)

      Measurements: Rates of HIV testing and receipt of results; sexual risk reduction; HIV
      knowledge improvement.

      Results: Testing rates were 40.2% (Model A), 84.5% (Model B), and 89.3% (Model C) (p=<.01).
      Test receipt rates were 14.6% (Model A), 31.0% (Model B), 79.8% (Model C) (all p=<.01).
      Sexual risk reduction and knowledge improvement did not differ significantly between
      counseling methods.

      Conclusions: Streamlined counseling with rapid testing significantly increased testing and
      receipt rates over current practice without changes in risk behavior or post-test knowledge.
      Increased testing and receipt of results could lead to earlier disease identification,
      increased treatment and reduced morbidity/mortality. Policymakers should consider streamlined
      counseling/rapid testing when implementing routine HIV testing into primary/urgent care.
    

Detailed description: 
      BACKGROUND/RATIONALE:

      HIV testing is cost-effective in unselected general medical populations, yet testing rates
      among those at-risk remain low, even among those with regular primary care. HIV rapid testing
      is effective in many healthcare settings but scant research has been done within primary care
      settings, nor within the US Department of Veteran's Affairs Healthcare System.

      The cumbersome nature and complexity of current counseling and testing procedures have been
      suggested as reasons that rates of receipt of HIV test results are so low. Because the
      standard screening test results are unavailable on the same day, many persons do not return
      for the results. Up to 30% of persons who tested HIV-positive during 2000 and 39% of persons
      who tested HIV-negative did not return (1). The CDC has recommended that alternate
      streamlined counseling and testing methods may increase the receipt rates of HIV tests. To
      address the problems of failing to return for screening results, we incorporated rapid HIV
      testing into the proposed screening trial.

      OBJECTIVE(S):

      The specific aims of this project were:

      To determine whether nurse-based referral for traditional HIV testing and counseling will
      improve screening rates compared to current testing procedures.

      To determine whether nurse-based rapid testing with streamlined counseling improves screening
      rates more than nurse-based referral for traditional testing and counseling alone.

      To assess the cost-effectiveness of these alternative strategies for HIV testing and
      counseling.

      Secondary aims were to compare patient knowledge of HIV testing prevention practices and
      their views of the procedures' acceptability after traditional and rapid testing/streamlined
      counseling. To achieve these aims, we proposed a robust three-arm randomized controlled
      trial.

      METHODS:

      We planned a parallel-group randomized controlled trial set in the general medicine and
      urgent care clinics of the West Los Angeles VA Medical Center (VAMC). All participants
      underwent an interview collecting information about HIV risk factors and other predictors of
      HIV screening, as well as knowledge of HIV test characteristics and prevention. All patients
      were randomized to one of three models of screening: Model A: Traditional counseling/testing;
      Model B: Nurse-based screening + traditional counseling/testing; Model C: Nurse-based
      screening + streamlined counseling/ rapid testing

      The analysis focused on differences between the three models in rates of screening, receipt
      of results, knowledge, acceptability and cost-effectiveness.

      FINDINGS/RESULTS:

      Testing rates were 40.2% (Model A), 84.5% (Model B), and 89.3% (Model C) (p=<.01). Rates of
      receipt of test results were 14.6% (Model A), 31.0% (Model B), 79.8% (Model C) (all p=<.01).
      Reduction in sexual risk and HIV knowledge improvement did not differ significantly between
      traditional versus streamlined counseling.

      IMPACT:

      Streamlined counseling with rapid testing significantly increased testing and receipt rates
      over current practice without changes in risk behavior or post-test knowledge. Increased
      testing and receipt of results could lead to earlier disease identification, increased
      treatment and reduced morbidity/mortality. Policymakers should consider streamlined
      counseling/rapid testing when implementing routine HIV testing into primary/urgent care.

      Widespread implementation would lead to critically important health benefits for veterans: 1)
      Increased rates of testing, which would lead to earlier identification of disease, increased
      treatment and decreased HIV transmission, morbidity and mortality; 2) Lower screening costs
      without decrements in either patient knowledge or acceptability.

      The CDC has made identification of people with HIV a national priority. The VA has an
      opportunity to provide national leadership in elucidating how best to identify people living
      with HIV and ensure access to state-of-the-art care.
    

Intervention name(s): Rates of HIV testing and receipt of results; Sexual risk reduction; HIV knowledge improvement; Rates of HIV testing and receipt of results; Sexual risk reduction; HIV knowledge improvement; Rates of HIV testing and receipt of results; Sexual risk reduction; HIV knowledge improvement
Intervention type(s): Other; Other; Other; Other; Other; Other
Intervention description(s): Rates of HIV testing and receipt of results; Sexual risk reduction; HIV knowledge improvement; Rates of HIV testing and receipt of results; Sexual risk reduction; HIV knowledge improvement; Rates of HIV testing and receipt of results; Sexual risk reduction; HIV knowledge improvement
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Diagnostic
Keywords: HIV Rapid Testing; Cost-effectiveness; HIV Seronegativity