There are significant problems with current HIV screening and testing methods, including: 1) identifying HIV-positive individuals, 2) providing them with the knowledge of their HIV-positive status; and 3) doing so early enough in the disease so that patients can be placed into care, new drug therapies can be effective, and the HIV epidemic can be slowed and reversed. None of this can be done, however, without innovative techniques and new ways of thinking about how to screen and test difficult to reach populations.
Because substance use increases HIV transmission risk, Substance Use Disorder (SUD) clinics can be an important location for identifying HIV-infected patients. Using knowledge from a previously successful primary/urgent care HIV testing implementation project, the purpose of this developmental formative evaluation was to assess organizational readiness to implement a nurse-based HIV rapid test program (NRT) that combines a routine nurse offer, streamlined counseling, and rapid HIV testing in two geographically disparate VA SUD clinics.
Our mixed-methods approach utilized qualitative staff interviews (Phase One) and quantitative surveys (Phase Two) to generate information on barriers and facilitators to NRT at two sites with QUERI centers (one low prevalence and one high prevalence) as well as conduct an assessment of each clinic's readiness to change. We collected 50 structured surveys from staff in order to assess agreement with the evidence-base supporting NRT. We used this quantitative methodology to benefit from the evidence-based organizational readiness to change survey. In addition, we conducted 28 qualitative interviews with SUD management and staff NRT in two VA SUD Clinics (Site 1 and Site 2). We used this qualitative methodology to gain added insight into discrepant attitudes regarding implementation.
Staff at both sites agreed that NRT in SUD clinics is supported by research evidence, clinical experience, and patient needs. Site 2 staff were significantly more likely than Site 1 staff to agree that NRT fit within the SUD clinic mission. Site 1 staff scored significantly higher on scales which assessed the shared understanding of the clinic mission, perceived openness of clinic communication channels, and positive attitude toward new technology compared to the Site 2 staff. Site 1 staff scored significantly lower on job-related stress. Overall Site 1 was more organizationally ready for NRT. Overall our interviews identified surmountable barriers to the adoption of these innovative strategies, including limited resources (i.e. time/staff), staff resistance to new additional tasks, and anxiety about communicating positive test results. However, a majority of SUD management and staff expressed support for implementing NRT in SUD clinics.
Despite commonly identified barriers to implementation including resource limitations (i.e. lack of time and/or increases in nursing workload), concerns of organizational readiness (i.e. lack of resources), and scope (i.e. HIV identification as a primary care clinic responsibility), in these two VA SUD clinics, staff are willing to adopt NRT if supported by appropriate modifications in organizational structure, HIV ordering policies and specific changes in clinical practices.
Both sites concur that NRT and HIV screening and testing in general is within the scope of the SUD clinic mission and that NRT has particular benefits for the SUD patients. Implementation of NRT in SUD clinics would likely result in increased detection of HIV among a high risk patient group, improved access to beneficial, life-saving treatments, and reductions in HIV/AIDS related health disparities. Future steps include tailoring the implementation strategy to address staff concerns, policy barriers, and the need to develop linkages between SUD clinics and HIV/AIDS clinics.
- Henry SR, Hagedorn HJ, Feld JE, Golden JF, Horns HL, Knapp HE, Anaya HD. A formative evaluation of organizational readiness to implement nurse-initiated HIV rapid testing in two veterans health administration substance use disorders clinics. Journal of HIV/AIDS and Social Services. 2010 Jan 1; 9(1):7-26.
- Henry SR, Anaya H, Butler JN, Knapp H, Hagedorn H. Evaluation of Readiness to Implement HIV Rapid Testing in SUD Clinics. Paper presented at: International Association of Physicians in AIDS Care International Conference on HIV Treatment and Prevention Adherence; 2009 Nov 29; New Orleans, LA.
- Hagedorn HJ, Henry SR, Horns H, Feld J, Golden J, Anaya H. Assessing Organizational Readiness to Implement Nurse-Based HIV Rapid Testing in SUD Clinics. Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL.
- Hagedorn HJ, Henry SR, Horns H, Feld JE, Golden JF, Anaya H. Assessing Organizational Readiness to Implement Nurse-Based HIV Rapid Testing in SUD Clinics. Paper presented at: American Conference for the Treatment of HIV; 2009 May 15; Denver, CO.
- Henry S, Cargill V, Justice A, Wright S, Zickmund S, Hagedorn HJ, Anaya H. Treatment Challenges and Collaborative Opportunities to Improve Care for Veterans with HIV/AIDS or Hepatitis. Presented at: VA QUERI National Meeting; 2008 Dec 10; Phoenix, AZ.
- Golden JF, Feld JE, Henry SR, Hagedorn HJ, Knapp H, Anaya H. Evaluation of Readiness to Implement HIV Rapid Testing in Substance Use Disorder (SUD) Clinics. Paper presented at: HIV Diagnosis, Prevention, and Access to Care National Annual Summit; 2008 Nov 19; Arlington, VA.
Substance Abuse and Addiction
Addictive Disorders, HIV/AIDS, Screening