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 Veterans Health Administration (VA) healthcare system has been significantly impacted by HIV, which has much to do with the demographic characteristics of the VA patient population. Veterans are at much higher HIV risk than the general population. The development of effective antiretroviral (ARV) therapy has transformed HIV into a treatable chronic disease, dramatically reducing the death rate for patients who access care. Although this is indeed a positive step forward, there continue to be significant problems with current HIV screening and testing methods, including: 1) identifying HIV-positive individuals, 2) providing them with knowledge of their HIV status; and 3) doing so early enough so they can be placed into care, new drug therapies can be effective, and the epidemic can be slowed and reversed. None of this can be accomplished, however, without innovative techniques and new ways of thinking about how, and in what domains, to screen and test for HIV. The Centers for Disease Control and Prevention (CDC) and VA have made recent strides in this regard, as they both now recommend routine HIV screening for all who present for care. Current testing methods have been shown to be highly ineffective however, due largely to the method itself. Conventional HIV testing requires both a blood draw and laboratory analysis, requiring a patient to return days or even weeks later to receive test results. Consequently, a significant number of people simply do not return for their results. This is vitally important, for research shows that when people are aware of their status, they tend to cease or at the very least, lessen their risk-related behaviors, which in turn works to reduce further spread of the epidemic. Current HIV prevalence estimates bear this out. CDC estimates that of the approximately 1.2 million persons in the United States currently infected with HIV, as many as 1/3 do not know they are infected. This is particularly concerning as these uninformed, but infected people are the main transmission route of HIV. The VA is no exception to this trend. A companion project by the VA HIV/Hepatitis Quality Enhancement Research Center (QUERI-HIV) found that less than 2 out of 10 Veterans that had been identified through the VA Computerized Patient Record System (CPRS) as being at high risk for HIV infection had ever had an HIV test.
One response to this challenge is to intensify efforts to identify Veterans with known HIV risk factors (e.g., intravenous drug use, general substance abuse) by focusing HIV screening efforts in substance use disorders (SUD) clinics where these at-risk Veterans present for care. The VA QUERI HIV-Hepatitis, in collaboration with our partners in QUERI SUD are in an excellent position to leverage their combined resources to do so.
As we collaboratively pursue implementation of enhanced HIV testing quality improvement initiatives, we must address the hard questions about what is required to disseminate HIV screening and testing programs more broadly throughout non-primary care VA settings like SUD clinics. In addition, the advent and use of novel HIV testing tools (i.e., HIV oral rapid testing), combined with novel HIV testing approaches (i.e., our nurse-initiated HIV rapid testing model, which we term NRT), although highly effective, provides many implementation challenges. For example, are the barriers and facilitators consistent across VA facilities and domains, or do they vary? Are there unintended adverse consequences to implementing NRT? How would this type of implementation effort be integrated (and supported) in non-traditional clinic settings where known HIV risk among patients is high, such as VA SUD clinics? Do regional issues pertaining to HIV stigma affect the uptake of HIV testing, and if so, how can these barriers be overcome? What implementation and uptake differences exist between more urban (and comprehensive) VA SUD clinic settings, and those that are more rural, that offer less comprehensive care? These issues are of paramount importance in reaching an evidence-based consensus as to what a 'best practices' approach to HIV testing in specialty domains like SUD clinics could look like within a national, decentralized healthcare organization like VA.
AIM 1: To expand the implementation of our recent pilot NRT in VA SUD strategy on a broader, regional
AIM 2: To qualitatively explore and document the barriers, facilitators, and unintended consequences of
implementing this HIV testing strategy into VA SUD clinics regionally;
AIM 3: To quantitatively evaluate the success and sustainability of this regional expansion effort in identifying
and linking new HIV infected Veterans to care.
AIM 4: To evaluate the budgetary impact pertaining to regional roll-out of this effort.
Mixed methods approach using qualitative formative and process interviews, and quantitative methods to evaluate the success of our testing and linkage to care initiative.
The number of unique patients seen at each clinic varied from 290 to 1238, with a total of 5,376 patients. Patients' age was similar across all clinics with a mean of 52 years and a standard deviation of 12.5 years. The majority of patients were male, comprising 88% of the study patients. Race and ethnicity varied greatly across the clinics; for example, the percentage of African American ranged from 14% to 78% across the clinics. Two-thirds of the patients were not married at most clinics. The most prevalent biological risk factor was drug use, ranging from 38% at a mental health clinic to 99% at the residential program. Hepatitis C infection was the second most prevalent biological risk factor, from 12% to 26% across the clinics. Among the social risk factors for HIV infection, alcohol use was most common, ranging from 43% to 97%; homelessness varied from 18% to 74%, and history of incarceration ranged from 4% to 27% across the clinics. Among the mental health problems, the prevalence of depression was 77% in total, anxiety 63%, and PTSD 58%. Last but not least, the prevalence of prior HIV infection was high, from 1.3% to 3.0% across the clinics.
Effectiveness, sustainability, and yield of the intervention
We also compared crude HIV testing rates and HIV positive rates in the pre-launch, post-launch, and sustainability periods among the three SUD/MH settings. With regard to the intervention effectiveness, HIV testing rates increased from 0% to 50.3% at the residential program, from 0% to 22.9% at the outpatient clinics in main facilities, and from 0% to 10.0% at the outpatient clinics in sub-facilities from the pre-launch to the post-launch periods. With regards to the intervention sustainability, HIV testing rates decreased from 50.3% to 26.1% at the residential program, from 22.9% to 21.1% at the outpatient clinics in main facilities, and from 10.0% to 3.8% at the outpatient clinics in sub-facilities. With regard to the intervention yield, only one patient was newly diagnosed with HIV infection at the residential program during the sustainability period. Correspondingly, the HIV new diagnosis rates were 0.6% at the residential program and 0.0% at the outpatient clinics in main and sub facilities.
We also adjusted HIV testing rates across the clinics and the settings. Overall, adjusted testing rates show the same trend from the pre-launch to the post-launch period as the crude rates: HIV testing increased the most at the residential program (0% to 39.1%), the second most at the main facilities (0% to 15.3%) and the least at the sub-facilities (0% to 10.0%). However, adjusted HIV testing rates show a different trend from the post-launch to the sustainability period than the crude rates: HIV testing decreased by half in the sustainability period at the residential program (39.1% to 18.8%) and sub-facilities (10.0% to 3.9%) but increased at the main facilities (15.3% to 19.6%). This result means that if the clinics in the main facilities were similar to Seattle, we could have seen a further increase in HIV testing in the sustainability period.
As a note, adjusted testing rates were lower than the corresponding crude rates at most clinics, indicating that the likelihood of receiving HIV testing varied greatly across patients and clinics; in the other words, some patients were much more likely to receive HIV testing because they had specific demographic and clinical characteristics in favor of HIV testing or because they were seen at the clinics which were much more proactive in HIV testing than other clinics.
In light of the longitudinal nature of our data collection in regard to budget impact analyses, these results are still being collated and will be presented in manuscript format at a future date.
Policy makers can use this information as the basis of implementing an HIV rapid testing program at their facilities.
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- Anaya HD, Butler JN, Knapp H, Chan K, Conners EE, Rumanes SF. Implementing an HIV Rapid Testing-Linkage-to-Care Project Among Homeless Individuals in Los Angeles County: A Collaborative Effort Between Federal, County, and City Government. American journal of public health. 2015 Jan 1; 105(1):85-90.
- Knapp H, Hagedorn H, Anaya HD. A five-year self-sustainability analysis of nurse-administered HIV rapid testing in Veterans Affairs primary care. International Journal of STD & AIDS. 2014 Oct 1; 25(12):837-43.