During the past three decades, human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) have caused extensive illness and death in the United States. Since the advent of the HIV epidemic, the VA healthcare system has been significantly impacted. Veterans are at much higher HIV risk than the general population. In addition, a significant proportion of VA patients are members of minority groups, and are homeless, both patient categories which have also been linked to high HIV prevalence. Because the VA is the largest provider of HIV treatment in the US, it is imperative that researchers develop innovative methods to 1) identify HIV-positive individuals, 2) provide them with the knowledge of their HIV-positive status; 3) do so early enough in the disease so that patients can be placed into care, so that antiretroviral therapies can be effective, and the HIV epidemic can be slowed and reversed.
Current HIV testing methods have been highly ineffective in this regard, due in large measure to the method itself. Conventional HIV testing requires both a blood draw and laboratory analysis, requiring a patient to schedule a future visit to receive results. Consequently, a significant number of people simply do not return for their test results. Current HIV prevalence figures bear this out. The Centers for Disease Control and Prevention (CDC) estimates that of the 1.2 million HIV infected persons in the US, as many as 1/3 are unaware of their infection. Indeed, the CDC now recommends routine HIV testing for all Americans. This recommendation was predicated on the evidence that moving from a risk-based, to a routine testing model is one of the most effective ways to significantly increase testing rates. As better HIV identification systems begin to spread through the VHA, the VHA must determine the proper place for broader routine HIV rapid testing programs in their delivery systems. Demonstrating effectiveness is only the first step. To make policy recommendations, we must better understand the challenges of implementing a testing system that would apply to all, not just at-risk patients.
The move toward routine HIV testing, combined with a novel diagnostic tool (rapid testing) although highly effective, provides many implementation challenges. For example, what are the unintended adverse consequences in implementing NRT? What are the barriers and facilitators to implementation? How important are local nursing and physician champions and opinion leaders? These issues are of paramount importance in reaching an evidence-based consensus as to what a 'best practices' approach could look like within a large, decentralized healthcare organization like VA.
The specific aims of this project then, are:
1.To develop generalized qualitative methods and instruments which can be used to evaluate VA HIV rapid testing implementation efforts;
2.To employ these developed instruments to qualitatively document the implementation of our previously successful NRT strategy for spreading NRT to VA primary/urgent care practice at our downtown Los Angeles Outpatient Clinic (OPC);
3. To explore and document barriers, facilitators, and unintended consequences of implementing our NRT model of HIV testing at LAOPC.
We used qualitative methods to conduct formative and process evaluations which allowed us to fully assess our research objective, which were:
A thorough examination, exploration and description of the barriers and facilitators to implementing NRT at the Los Angeles Outpatient Clinic (OPC).
Barriers included: clinical workload/staffing as insufficient for uptake of routine versus risk-based testing; lack of congruence with perceived roles/responsibilities in administrating NRT; bureaucratic delay for including NRT in nursing scope of practice; MD preference for blood draws. Facilitators included: Tailored staff trainings, patient education activities/publicity; identification of local champions dedicated to NRT; and potential expansion of RT training to include LVNs/LVPs. Findings also indicate staff concern regarding adequacy of training and incorporating NRT into workflow. Process findings indicate 1) concerns regarding training could be alleviated, but that workload/staffing concerns remained a barrier 2) expanding training to include LVNs/LVPs may mitigate this constraint 3) post-implementation administration of NRT was highly variable by provider motivation and service area. Community care, substance abuse and walk-in were identified as preferred clinics for NRT.
We have used the qualitative results from this project as a foundation for a larger, multi-site implementation grant
- Anaya HD, Bokhour B, Feld J, Golden JF, Asch SM, Knapp H. Implementation of routine rapid HIV testing within the U.S. Department of Veterans Affairs Healthcare System. Journal for healthcare quality : official publication of the National Association for Healthcare Quality. 2012 Sep 1; 34(5):7-14.
- Anaya H, Anaya H, Feld JE, Hoang T, Golden J, Knapp H, Bokhour BG, Asch SM, Knapp H. Qualitative Assessment of Implementing Routine Rapid HIV Testing. Paper presented at: International Association of Physicians in AIDS Care International Conference on HIV Treatment and Prevention Adherence; 2010 Nov 29; New Orleans, LA.
- Anaya H, Bokhour B, Feld J, Golden J, Knapp H. Qualitative Assessment of Implementing Routine Rapid HIV Testing. Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL.
- Anaya H, Bokhour BG, Feld JE, Golden JF, Knapp H. Qualitative Assessment of Implementing Routine Rapid HIV Testing Within the US Department of Veteran’s Affairs. Poster session presented at: American Conference for the Treatment of HIV; 2009 May 16; Denver, CO.
- Anaya H, Hagedorn H, Henry SR, Feld JE, Golden JF, Knapp H. Evaluation of Readiness to Implement HIV Rapid Testing in Substance Use Disorder (SUD) Clinics. Poster session presented at: American Conference for the Treatment of HIV; 2009 May 16; Denver, CO.
- Anaya H, Feld JE, Golden JF, Bokhour BG, Knapp H. Qualitative Assessment of Implementing Routine Rapid HIV Testing. Poster session presented at: VA HSR&D National Meeting; 2009 Feb 13; Baltimore, MD.
- Anaya H, Feld JE, Golden JF, Bokhour B. Qualitative Assessment of Implementing Routine Rapid HIV Testing. Poster session presented at: VA QUERI National Meeting; 2008 Dec 10; Phoenix, AZ.