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IIR 04-023 – HSR&D Study

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IIR 04-023
Improving HIV Screening by Nurse Rapid Testing, Streamlined Counseling
Steven M. Asch MD MPH
VA Greater Los Angeles Healthcare System, West Los Angeles, CA
West Los Angeles, CA
Funding Period: January 2005 - June 2007

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 plan to incorporate 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.

PUBLICATIONS:

Journal Articles

  1. Pinkerton SD, Bogart LM, Howerton D, Snyder S, Becker K, Asch SM. Cost of OraQuick oral fluid rapid HIV testing at 35 community clinics and community-based organizations in the USA. AIDS Care. 2009 Sep 1; 21(9):1157-62.
  2. Anaya HD, Hoang T, Golden JF, Goetz MB, Gifford A, Bowman C, Osborn T, Owens DK, Sanders GD, Asch SM. Improving HIV screening and receipt of results by nurse-initiated streamlined counseling and rapid testing. Journal of general internal medicine. 2008 Jun 1; 23(6):800-7.
Conference Presentations

  1. Anaya H, Chan K, Goetz MB, Karmarkar US, Asch SM. Using Capacity Planning Models to Estimate Organizational Costs of HIV Care Within the United States Department of Veterans Affairs. Poster session presented at: American Conference for the Treatment of HIV; 2011 Apr 7; Denver, CO.
  2. Anaya H, Goetz MB, Karmarkar U, Asch SM. Using Capacity Planning Models to Estimate Organizational Costs of HIV Care Within the United States Department of Veterans Affairs. Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL.
  3. Anaya H, Goetz MB, Asch SM, Karmarkar US. Using Capacity Planning Models to Estimate Organizational Costs of HIV Care within the United States Department of Veterans Affairs. Paper presented at: VA QUERI National Meeting; 2008 Dec 11; Phoenix, AZ.
  4. Anaya HD, Goetz MB, Asch SM, Karmarkar U. Using Capacity Planning Models to Estimate Organizational Costs of HIV Care within the United States Department of Veterans Affairs. Paper presented at: HIV Diagnosis, Prevention, and Access to Care National Annual Summit; 2008 Nov 20; Washington, DC.
  5. Anaya H, Asch S, Hoang T, Goetz M, Bowman C, Gifford AL. Improving HIV screening with nurse-initiated rapid testing and streamlined counseling. Paper presented at: International AIDS Society on HIV Pathogenesis, Treatment and Prevention Annual Conference; 2007 Jul 23; Sydney, Australia.
  6. Sanders GD, Anaya H, Asch S, Hoang T, Golden J, Gifford AL, Bowman C, Owens DK. Cost effectiveness of rapid HIV testing with streamlined counseling. Presented at: International AIDS Society on HIV Pathogenesis, Treatment and Prevention Annual Conference; 2007 Jul 22; Sydney, Australia.
  7. Anaya HD, Hoang T, Golden JA, Asch SM. Improving HIV screening with Nurse-Based referral and streamlined counseling. Poster session presented at: AcademyHealth Annual Research Meeting; 2007 Jun 4; Washington, DC.
  8. Anaya HD, Hoang T, Golden JA, Asch SM. Improving HIV screening with Nurse-Based Referral and streamlined counseling. Paper presented at: American Conference for the Treatment of HIV; 2007 Jun 1; Dallas, TX.
  9. Anaya HD, Asch SM, Hoang T, Goetz MB, Gifford AL, Bowman C, Golden JF, Knapp H. Improving HIV Screening with Nurse-Based Rapid Testing and Streamlined Counseling. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA.
  10. Anaya HD, Hoang T, Golden J, Asch SM. Improving HIV screening with nurse-based referral and streamlined counseling. Paper presented at: International AIDS Conference; 2006 Aug 1; Toronto, Canada.
  11. Asch SM. Use of rapid HIV testing in hospitals, community clinics, and community-based organizations in the United States. Paper presented at: International AIDS Conference; 2006 Aug 1; Toronto, Canada.
  12. Anaya H. Improving HIV screening with rapid testing and streamlined counseling. Paper presented at: AcademyHealth Annual Research Meeting; 2006 Jun 1; Seattle, WA.
  13. Anaya HD, Hoang T, Golden J, Asch SM. Improving HIV Screening with Rapid Testing and Streamlined Counseling. Paper presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA.
  14. Asch SM. Improving HIV testing rates in VISN 22. Paper presented at: Society of General Internal Medicine Clinical Practice Committee Annual Meeting; 2005 Mar 1; Los Angeles, CA.


DRA: Health Systems
DRE: Treatment - Observational
Keywords: Communication -- doctor-patient, HIV/AIDS, Screening
MeSH Terms: none

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