Barriers and Facilitators to Routine HIV Testing: Perceptions from Massachusetts Community Health Center Personnel

Abstract

Since 2006, the Centers for Disease Control and Prevention (CDC) has recommended routine, voluntary HIV testing for persons aged 13–64 in all health care settings, including the elimination of separate informed consent, which remains in effect in five states including Massachusetts. Community health centers (CHCs) represent an important HIV testing site for at-risk populations. From April to December 2008 a qualitative interview was administered to one senior personnel from each of 30 CHCs in Massachusetts, to identify barriers and facilitators to implementing CDC recommendations and to elucidate strategies to improve routine HIV testing. The following themes emerged as routine HIV testing barriers: (1) provider time constraints, including time to administer counseling and separate informed consent; (2) lack of funding, staff, and space; (3) provider, patient, and community discomfort; (4) inconsistent levels of awareness regarding CDC recommendations; and (5) perceived incompatibility with Massachusetts HIV testing policy. Facilitators included designation of personnel to serve as organizational “champions” for routine testing and use of clinical reminders within electronic medical records to prompt HIV testing. Strategies identified to improve routine HIV testing rates among Massachusetts CHCs included more explicit state-level guidelines; organizational buy-in; collaborative analysis to integrate testing within existing activities; and provider, patient and community education.

Introduction

A ccording to the Centers for Disease Control and Prevention (CDC), more than 1 million Americans are estimated to be living with HIV; approximately 56,000 people become newly infected with HIV each year.^1
–3 Despite advances in HIV testing technologies, including rapid HIV testing, more than 1 in 5 (21%) people with HIV remain undiagnosed and/or unaware of their HIV infection.⁴ Moreover, more than one third (33%) of HIV diagnoses occur late in the course of infection, meaning that these persons are diagnosed with AIDS within 1 year of first testing positive for HIV.⁵ In Massachusetts, for example, between 2006 and 2008 30% of all individuals newly diagnosed with HIV were concurrently diagnosed with AIDS or progressed to an AIDS diagnosis within 2 months.⁶

In 2006, the CDC released revised HIV testing guidelines recommending routine, voluntary HIV testing as an opt-out procedure (meaning that patients are to be notified that an HIV test will be conducted unless the patient declines) for all persons aged 13 to 64 in all health care settings, including primary care practices and community clinics. The CDC further recommended separate, informed consent for HIV testing no longer be required, which remains legally mandated in 5 states.^7,8 This broad population-based strategy was designed to increase HIV testing, foster earlier detection of HIV infection, and identify and link persons with unrecognized disease to clinical and prevention services.⁷

Community health centers (CHCs) provide an important site for HIV testing. Many CHCs are a source of primary care for people who are low income, racial/ethnic and sexual minorities, immigrants, and those seeking mental health and substance abuse treatment services.⁹ These populations are also disproportionately affected by HIV, suggesting that CHCs serve as an important resource for HIV prevention and treatment services.¹⁰ While prior research has examined efforts to implement routine HIV testing within CHCs, little research to date has reported factors specific to the implementation of routine HIV testing from the perspective of CHC personnel.^11

–14

In particular, there are few qualitative studies that describe the perceived barriers and strategies to routine HIV testing implementation, including the specific barriers providers encounter in states with separate written informed consent policies such as those in Massachusetts.^15

–18 Using in-depth qualitative interviews, this study examined HIV testing experiences among individual personnel representing 30 Massachusetts CHCs, including 15 that received support from the Ryan White HIV/AIDS Program, the federal program primarily responsible for HIV-related health services.¹⁹ The goals were to evaluate the degree to which the 2006 CDC recommendations may have influenced routine HIV testing in these environments, to explore potential differences among Ryan White-funded and non-Ryan White–funded health centers, and to determine strategies to improve HIV testing rates. Identifying the perceived barriers, facilitators, and implementation strategies from the unique perspective of health center personnel may aid in enhancing acceptability and feasibility of interventions designed to improve routine testing procedures in these settings.

Methods

Design and setting

There are 52 CHCs in Massachusetts providing care for 1 of 9 state residents (>700,000) through more than 200 sites.²⁰ From April to December 2008, key staff from 30 Massachusetts CHCs were enrolled in the current study. CHCs were selected based on community rates of HIV/AIDS, geographic diversity, and sociodemographics indicative of health disparities, such as racial/ethnic composition and poverty levels. Using these criteria, 15 of the participating health centers that received Ryan White funding were matched with 15 health centers that did not receive this support. A confidential, semistructured, qualitative interview was administered to one senior personnel from each CHC enrolled (totaling 30 personnel). All study interviews took place at the CHC where data were obtained. The Fenway Health Institutional Review Board approved the study, and each study participant completed an informed consent process. The interview, including the informed consent process, took approximately 1.5 h.

Sample

In order to interview the personnel who would be most knowledgeable about current practices within their health center, individuals were eligible to participate if they were: (1) a senior-level administrator (e.g., the executive director or another high-level administrator knowledgeable of the agency's HIV/AIDS services); (2) the medical director; or (3) a senior medical provider (i.e., supervised medical staff and had been with the agency for a minimum of 3 years). Compensation for completion of an interview was $500, paid directly to the health center, not the participant.

Data collection and measures

The study team developed the qualitative interview guide in consultation with local HIV care providers and other stakeholders familiar with health centers and Massachusetts and CDC HIV testing policies. The interview addressed six topic areas for each respondent's CHC: (1) CHC patient population and services; (2) CHC HIV/AIDS services; (3) CHC HIV testing policies; (4) perceptions of the legal and regulatory environment regarding HIV testing; (5) attitudes regarding routine HIV testing, and; (6) personal and organizational awareness of the CDC revised recommendations for routine HIV testing and implementation barriers and facilitators. Administrators were instructed to respond from their understanding of overall health center operations and procedures; medical directors and senior medical providers responded from their individual practice and/or their understanding of operations and the medical procedures of others within their health centers.

Analytic approach

For this study, routine HIV testing was defined as, “Voluntary HIV testing performed for all patients in a setting unless the patient specifically declines HIV testing, i.e., ‘opt-out’ testing.”²¹ As Massachusetts law currently requires the administration of separate, written informed consent prior to administration of an HIV test,¹⁵ the definition was read to respondents during the informed consent process, the introduction portion of the interview, and at the beginning of the interview guide section specific to discussing routine HIV testing, in order to minimize the likelihood of misunderstanding the questions. For the question, “Have you or your community health center implemented routine HIV testing?” the study team accepted and analyzed responses as affirmative when respondents answered “yes” either from their individual or organizational perspective.

Qualitative data were analyzed using content analysis.^22

–27 An “emergent coding” approach was used to categorize the data where thematic categories were established following preliminary examination of the data.²⁶ Transcripts were reviewed for errors and omissions, and cleaned to focus on the content of what was said. NVivo® software, version 7.0 (QSR International [Americas], Inc., Cambridge, MA) was used to aid with the coding, organization, and searching of narrative sections from each interview, as well as to facilitate the systematic comparison and analysis of themes across interviews.²⁶ The following steps were implemented to systematically evaluate the content of the data: (1) two research staff independently reviewed the material to generate a checklist of preliminary codes; (2) the research team compared checklists and reconciled any differences; (3) a consolidated checklist was created and a structured codebook was developed that contained unique information to characterize each coding element^28,29; (4) the coding scheme was independently applied to several transcripts by research staff; (5) percent coder agreement (>90%) was checked to ensure acceptable reliability; (6) once reliability was established, the coding scheme was broadly applied to analyze all transcripts; (7) a quality control procedure was followed whereby coded transcripts were regularly reviewed by the research team, and ongoing discussion helped resolve coding inconsistencies. Analyses were focused on understanding the HIV testing services within the respondents' CHCs and whether CDC recommendations have influenced routine HIV testing in these environments, and to identify barriers and facilitators to implementing these recommendations.

Quantitative data were derived from frequency counts and from estimates provided by respondents during interviews, and are integrated with the interview findings below. Descriptive statistics were conducted using SPSS® statistical software, version 15.0.1 (SPSS Inc., Chicago, IL). χ² and Fisher's exact tests were used to examine statistical differences between variables.

Results

Among 30 individuals who completed interviews, respondents included 9 administrators, 15 medical directors, and 6 senior medical providers from 15 Ryan White- and 15 non-Ryan White-funded health centers throughout Massachusetts. Twenty-two respondents represented health centers located within the Greater Boston metropolitan area, 4 respondents represented health centers from the southeast and Cape Cod, and 4 represented health centers from the state's central and western regions.

Health center characteristics and HIV testing

Per the study design, CHCs were selected for participation based on factors associated with health disparities, including racial/ethnic composition, socioeconomic indicators, and local rates of HIV/AIDS. Consequently, respondents described patient populations that were largely low income and included high proportions of blacks, Latinos, and immigrants. A few respondents described specialized services for patient populations who were homeless, incarcerated, and sexual or gender minorities.

In addition to wellness visits (100%), pediatrics (96%), and obstetrical care (76%), the most commonly reported health center services were chronic disease management for diabetes (70%), cardiovascular disease (47%), hypertension (40%), asthma (27%), and obesity (27%) and mental health services for depression (23%), anxiety (10%), and substance abuse/dependence (33%), including injection drug use (13%). Estimated annual patient visits ranged from 5000 to 300,000, with an average 14,340 (standard deviation [SD]=10,474) individual patients served by these CHCs.

All interview respondents reported that they or their health centers made some type of HIV testing available to their patients. HIV testing occurred within a variety of contexts and settings. In addition to mobile, community-based outreach programs, respondents described that HIV testing occurred within the primary care visit most frequently as a result of a patient's risk assessment or request, or for specific populations, such as pregnant women or those seeking treatment or presenting a history of injection drug use or sexually transmitted infections. A few respondents described their efforts to integrate HIV testing within routine clinical visits, such as during annual physical examinations.

Twenty-three (77%) of the respondents reported that their health centers made HIV testing available through a dedicated program, such as one funded by the Massachusetts Department of Public Health or another granting agency. Fourteen of 15 (93%) respondents from Ryan White-supported health centers indicated that their health centers hosted a dedicated HIV testing program, compared to 9 of 15 (60%) respondents from non-Ryan White health centers (p<0.04). Similarly, all Ryan White respondents were aware of the CDC 2006 revised recommendations regarding routine HIV testing, compared to 8 of 15 (53%) non-Ryan White respondents (p<0.004). When asked, “Have you or your community health center implemented routine HIV testing?” 9 of 15 (60%) Ryan White respondents compared to 7 of 15 (47%) non-Ryan White respondents indicated that they or their health centers had implemented routine HIV testing (NS). Thirteen of these 16 (81%) described implementation as a component of prenatal care. Interview respondents' self-reported frequencies of HIV testing services by Ryan White- versus non-Ryan White-funded health centers are presented in Table 1.

Table 1.

Provision of HIV Testing Services Among Respondents from Is Ryan White-Supported and Is Non-Ryan White–Supported Massachusetts Community Health Centers (n=30)

	Ryan White community health center respondents (n=15)^a				Non-Ryan White community health center respondents (n=15)^a
	All Ryan White (n=15)	Administrators (n=6)	Medical directors (n=5)	Providers (n=4)	All Non-Ryan White (n=15)	Administrators (n=3)	Medical directors (n=10)	Providers (n=2)	Total community health center ^a respondents (n=30)
Respondent or health center provides HIV testing	100% (15/15)	100% (6/6)	100% (5/5)	100% (4/4)	100% (15/15)	100% (3/3)	100% (10/10)	100% (2/2)	100% (30/30)
Health center has a dedicated HIV testing program	93% (14/15)	100% (6/6)	100% (5/5)	75% (3/4)	60% (9/15)	100% (3/3)	50% (5/10)	50% (1/2)	77% (23/30)
Aware of the CDC 2006 recommendations regarding routine HIV testing	100% (15/15)	100% (6/6)	100% (5/5)	100% (4/4)	53% (8/15)	67% (2/3)	50% (5/10)	50% (1/2)	77% (23/30)
Respondent or health center has implemented routine HIV testing ^b	60% (9/15)	67% (4/6)	60% (3/5)	50% (2/4)	47% (7/15)	100% (3/3)	30% (3/10)	50% (1/2)	53% (16/30)^c

Administrators responded from their understanding of overall health center operations and procedures; medical directors and senior medical providers responded from their individual practice and/or their understanding of operations and the medical procedures of others within their health centers.

For the question, “Have you or your community health center implemented routine HIV testing?” responses were counted as affirmative when respondents answered “yes” either from their individual or organizational perspective.

Thirteen of these 16 (81%) described implementation as a component of prenatal care.

Perceived barriers to the implementation of routine HIV testing

Thematic barriers identified from individual interviews included perceptions of: (1) limited time; (2) resource constraints, including funding, staffing, and space; (3) provider, patient, and community discomfort; (4) inconsistent levels of awareness and implementation of CDC recommendations; and (5) concerns regarding incompatibility with state HIV testing policies.

Time

Twenty-four interview respondents (80%) described that constraints on providers' time limited their ability to conduct routine HIV testing:

That's the big issue. I think time. Time is it…The 30-minute visit, the 15-minute visit—it's crazy. You have to try and get everything in…Whenever you walk in with a patient, you have your own agenda; they have theirs. And it takes more than 15 minutes, even more—you know—more than 30 minutes, sometimes, to get through both of your agendas.—Ryan White clinical director who has implemented routine HIV testing throughout health center

Massachusetts law currently requires the administration of separate, written informed consent prior to administration of an HIV test.¹⁵ All respondents were aware of this obligation, and many interview respondents considered the time to separately consent patients as a potential barrier to testing:

I think the act of having to sign a consent is a barrier to doing the test. Instead of being treated like an ordinary blood test like any other, it has now become something that is somehow different than every other blood test and requires special approval, which makes the patients think twice about it—and makes the doctor think twice about it, because now you have to take the time to pull out this form and have the patient read it and have the patient sign it. And I don't understand the logic for the need to do that anymore.—Non-Ryan White medical director who has not implemented routine HIV testing

Additionally, while individual counseling in the context of HIV testing is only required by state law for those diagnosed with HIV infection, most respondents seemed unaware of this singular mandate and instead perceived counseling as a prerequisite to HIV testing. While most respondents considered routine HIV testing of patients to be a good idea, several medical providers expressed frustration at the prospect that they were expected to integrate another procedure within a clinical visit without additional resources, including time:

I mean, there's just a lot expected to be accomplished…[patients are] coming in complaining of a sore neck, or for a physical exam, numerous complaints, and only a certain amount of time to do it. We're asking providers to do a whole lot of screening, in addition to addressing the current problems…but there's no new resources put into doing it.…I think, all of these things plus patients' own issues make it a real demand on those primary care encounters so that whether you're going to take time to talk about getting HIV counseling, or HIV testing—this would be a good idea too. It just gets put down somewhere on the priority list unless it seems to be an at-risk individual, [then] it goes up.—Non-Ryan White medical director who has not implemented routine HIV testing

Resource constraints

In addition to the perceived limitations of time to provide routine testing, several respondents expressed concerns regarding the anticipated demands on their health centers' financial, human, and physical resources to accommodate increased testing rates:

Do we have the resources, the financial resources, to hire the people to do the counseling, to do the follow-up, to do the support?—Non-Ryan White senior administrator whose health center conducts routine prenatal HIV testing

These concerns were often qualified, however, by respondents' understanding of their health centers' current testing protocols. For example, respondents from health centers that provided a dedicated HIV testing program often considered implementation issues from existing practice:

Who's going to do the testing? You know, we have two people here on site who do the testing, and are they going to be flooded all of the sudden by all of these people that are going to want to get tested?—Ryan White medical director who has not implemented routine HIV testing

For health centers that did not have a dedicated testing program, the reimbursement cost structure for routine HIV testing was an outstanding issue for several respondents:

Who is going to pay for it? Even though the insurance will pay for it for the patient, does that mean premiums are going to go up? So somebody's paying for it, but how do we all pay for it?—Non-Ryan White senior medical provider who has not implemented routine HIV testing

Discomfort

Discomfort with various aspects of routine HIV testing was a commonly expressed theme and resulted in being a barrier to conducting routine testing. Several respondents described either their own personal discomfort with broaching the subject of HIV testing with their patients, or the perceived discomfort of other providers, patients, or communities served by their respective health centers:

The barriers include provider discomfort with testing, partly because we were always trained that it's such a terrible disease that if you could keep it out of your brain, you were going to be happier. You know, you can't admit this in public, but the patients' providers, just like everybody else, don't think about the terrible stuff.—Ryan White medical director who has implemented HIV testing during routine physicals

A few respondents described their discomfort conducting frank discussions of sexual behaviors with their patients:

Part of the intake is also asking about the possible risk that you may have put yourself at…There's a couple that are just very, very personal questions: what kind of sex you've had, whether it was vaginal sex, rectal sex. And that's always a difficult question even to ask unless you get—you never really get totally comfortable with it, but you do.—Non-Ryan White administrator whose health center conducts routine prenatal HIV testing

More commonly, respondents described the perception that other providers, either health center colleagues or providers in general, were insufficiently trained to conduct a thorough sexual history with patients, which contributed to provider discomfort regarding routine HIV testing:

Doctors aren't that trained on asking about sexual behavior…And so that might be a barrier to people broaching an HIV test, is just taking a sexual history.—Ryan White senior medical provider who has not implemented routine HIV testing

Approximately half of the interview respondents expressed concerns about routine testing based on perceived patient and community attitudes towards HIV, including denial, fear, stigma, and discrimination. Some respondents were concerned about possible negative reactions from patients, such as patient denial of risk or fear of a positive diagnosis:

We have many patients who express fear of knowing their HIV status and refuse to be tested. We see that a lot. So we know there's a lot of fear out there, being tested.—Ryan White senior medical provider who has not implemented routine HIV testing

Consequently, respondents described the possibility that patients' fears of routine testing might cause them to delay care or to seek alternate services, or in the event of testing positive, their sense of loss of confidentiality in that setting could affect their willingness to engage in care. Half of the respondents felt that HIV-related stigma remained an important concern for those who were racial/ethnic minorities, immigrants, or older and ongoing discrimination could affect community members' willingness to accept and utilize routine HIV testing:

As an example, if we were going to say, “OK, we're going to do routine testing” and…we just kind of ran down that with…an immigrant [who] was feeling like HIV had a lot of stigma attached, there are already cultural barriers that we're trying to overcome to reach some of those immigrant populations and we could intensify those barriers if it became more…routine. It actually could make it harder for people to seek health care in general, I think.—Ryan White administrator whose health center conducts routine prenatal HIV testing

However, some respondents felt that making HIV testing a more routine component of health care would reduce HIV-related stigma:

I think that we can reach more people if we take the stigma out and just test everybody—just offer everybody an HIV test—as you would do a cholesterol test.—Ryan White administrator whose health center has implemented routine testing

Inconsistent levels of awareness and implementation of CDC recommendations

While 23 (77%) interview respondents were aware of the CDC 2006 recommendations and 16 (53%) self-reported that they or their health centers had implemented routine HIV testing, respondents described varying levels of awareness, understanding, and implementation of the guidelines:

So I know that the recommendations have been revised, that the testing now is more recommended to be done. I don't know the details.—Non-Ryan White medical director whose health center conducts routine prenatal HIV testing

Respondents reported learning of the guidelines from a variety of sources, including newspaper and scientific journal articles, health center e-mail, in-service trainings, and provider team meetings. A few respondents described specific individual staff, such as infectious disease specialists or HIV program managers, as having educated personnel and advocated for adoption of the recommendations.

In practice, when asked if they or their health centers had implemented routine HIV testing, respondents most frequently described implementation as a component of prenatal care. Thirteen respondents (43%) explained that pregnant women were routinely voluntarily tested for HIV within their health centers either through a primary care visit or in conjunction with a dedicated HIV testing program following administration of separate informed consent. Among respondents who identified as having implemented routine testing, patients who presented specific risk factors such as injection drug use or a sexually transmitted infection were “routinely recommended” to be tested for HIV. Efforts to implement the CDC 2006 recommendations ranged from single providers acting alone to an organizational process that involved senior management and interdepartmental collaborations to integrate testing within other patient services. Among respondents who described organizational-level efforts, implementation activities included provider trainings, testing protocol changes that de-emphasized pretest counseling, the use of prompts to HIV test within the patient electronic medical record, and a poster campaign educating patients about routine testing.

Perceived incompatibility with state HIV testing policies

Respondents from both Ryan White- and non-Ryan White supported health centers perceived various aspects of the CDC recommendations to be incompatible with current Massachusetts HIV testing policy:

What we do here in the health center—it's the opposite of what the CDC is saying that they want done. But we don't do that here in Massachusetts. We don't do opt-out, we do opt-in.—Non-Ryan White administrator whose health center features an MDPH-sponsored HIV testing program

Many respondents found the legal requirement for separate, written informed consent to be a barrier to routine HIV testing, both in the time needed to consent and the potentially stigmatizing message it communicated to patients. Additionally, respondents from health centers that hosted state-funded HIV testing programs described testing protocols that featured counseling, laboratory and reporting procedures, as well as testing quotas for targeted populations that factored into program monitoring, evaluation, and future state funding decisions:

[The provider] can ask the patient if he wants to have an HIV test. If the patient says yes, the provider then needs to move that patient to see an HIV counselor…At that point in time, the HIV coordinator will come down to the clinic, find an empty clinic room, or use that same room—the provider can go to another patient—and go through the protocol that we are required to through the Department of Public Health in order for us to do our counseling and testing.—Non-Ryan White administrator whose health center features an MDPH-sponsored HIV testing program

So [a provider] said, “Can I just consent them in my office and send them to the lab? Because your testing and counseling is too time-consuming or whatever, and can I just do it?”…So we said no. We have grants to pay for this.—Ryan White senior provider whose health center features an MDPH-sponsored HIV testing program

At the time of the study, the state had recently converted from a code-based to a federally required name-based reporting system for HIV diagnoses. A few respondents expressed concerns regarding routine testing in light of this revised reporting policy and seemed to require clarification:

I spoke with different providers. They're not quite sure what routine testing entails…It sounds like a mandate and the mandate is attached to [name-based] reporting, and that's what scares people, the reporting aspect of it.—Ryan White administrator whose health center features an MDPH-sponsored HIV testing program

Facilitators and recommended strategies to improve implementation of routine HIV testing

Interview respondents described several factors that either facilitated adoption of routine HIV testing in current practice or would contribute to improved implementation within Massachusetts CHCs. Among respondents who identified as having implemented routine HIV testing, five respondents specifically discussed efforts to implement the CDC 2006 recommendations at the organizational level.

Release of state-level guidelines, accompanied by resources and an accountability mechanism

Several respondents requested stronger state-level guidance regarding the CDC 2006 recommendations, including clarification of current Massachusetts regulations and procedures regarding written informed consent, counseling, and the reporting of test results both to individual patients and to state and federal governments. Some respondents felt that the CDC recommendations were too removed from their daily experience to motivate implementation:

Because it's a recommendation from the CDC, like OK, great, one more thing to do…I think certainly if it comes from the state level and if you understand what the implications are…and why it's important, and who it affects…The more personal, the better.—Non-Ryan White medical director who has not implemented routine testing

As resource constraints were identified as a barrier to routine testing implementation, some respondents suggested that the policy should be accompanied by funding and an accountability mechanism such as those for other health screening procedures:

Now if JCAHO [Joint Commission on Accreditation of Healthcare Organizations] developed a standard, let's say to have a policy on [routine HIV testing], we probably would. I mean sometimes…as much as we rebel against people from the outside telling us what to do, it works.—Ryan White senior administrator who has not implemented routine testing

Organizational buy-in

A few respondents described the role of health center “champions,” such as infectious disease specialists and HIV program managers, who facilitated adoption of routine testing at the organizational level through staff education and the commitment of senior-level management:

If it is a policy that the health center is going to adopt and it's going to be health center-wide, then it goes to the board. If it's a guideline that doesn't necessarily have to go through all this process, then sometimes the department manager of HIV who gets the guidelines, let's say, discusses with the adult medicine providers, and they amongst themselves say, “We can do this, this, and this at the health center”…and there may be a discussion of senior management or may not be. That gets pretty much implemented right there.—Ryan White medical director whose health center has implemented routine testing

Collaborative analysis of patient and resource flow

As several respondents had expressed concerns regarding resource demands with increased testing, a few respondents suggested health centers engage in an analysis among staff and management of the process by which patients currently test, accompanied by recommended changes to patient and resource flows:

If you're now going to be testing more people chances are they're going to be finding more positive cases, so then providing education to the providers, how to approach that, and then having this kind of support network with HIV counselors or whatever to work with the providers, and having these workflows established of what to do with those patients. We went through the same thing with the depression here at the health center.—Non-Ryan White medical director whose health center has not implemented routine testing

Patient, provider, and community education and marketing

Considering concerns regarding patient and community discomfort, several respondents suggested education and marketing campaigns among patients, providers, and community members before and during routine testing implementation:

I'd talk to providers about why we were doing this. I'd make sure everybody read the CDC article…We'd talk to our outreach people, we'd put posters up in the waiting rooms that said, “[name omitted] Health Center is proud to announce that we're implementing the CDC recommendations for routine testing. You will be offered…” We would do this in different languages…We would do some kind of an education campaign because I find that helps a lot with the patients feeling comfortable, and that it's something the health center's doing for everybody.—Non-Ryan White medical director whose health center has not implemented routine testing

Provider training

Among those interviewed, there were inconsistent levels of awareness of the CDC 2006 recommendations; 10 interview respondents specifically identified as having had participated in any type of in-service or training regarding routine testing. Several respondents identified the need for provider trainings both to increase an understanding of the recommendations and to address implementation concerns. For example, one respondent who had participated in an in-service expressed having additional unanswered questions:

Most of the people were wondering about consent and what would that mean for consent? Do you still consent people? What about for follow-up? Do you arrange follow-up visits? And it's her talking about it that made us realize…[HIV is] treatable and that we should be screening and catching people early and just telling patients that we're going to test.—Non-Ryan White medical director who has implemented routine testing

Clinical reminders

Two respondents described the use of clinical reminders within the patients' electronic medical record that prompted a provider to ask a patient about HIV testing:

We work with computerized electronic medical records. We have listed HIV testing as a recommendation for all patients…So I see if that's something that needs to be attended to, then I'll generally try and address it.—Ryan White medical director who has implemented routine testing

Discussion

This study demonstrates that routine HIV testing is not currently being implemented uniformly among Massachusetts CHCs, despite the fact that many health centers serve populations at high risk for HIV. While all interview respondents indicated that HIV testing was made available within their organizations, little more than half (53%) reported that either they or their health centers provided routine HIV testing. This was most commonly reported as a component of prenatal screening or for those determined to be at increased risk, suggesting that routine HIV testing in CHC settings was inconsistently applied and, due to the state's legal requirement for separate, written informed consent, not as an opt-out procedure intended by the 2006 CDC recommendations. Additionally, compared to those participating health centers that did not receive Ryan White funding support, a significantly higher proportion of Ryan White-supported health centers hosted a dedicated HIV testing program and all Ryan White respondents were aware of the 2006 CDC revised recommendations. However, there was no significant difference in the reported frequency of routine testing between Ryan White and non-Ryan White respondents, suggesting that factors other than the presence of supported HIV services affected the implementation of routine HIV testing.

Corroborating findings from settings other than CHCs,^30

–33 the barriers identified from this study included constraints on providers' time; the need to administer separate, written informed consent; concerns regarding funding, staffing and space; provider, patient and community discomfort; inconsistent levels of awareness and implementation of the CDC 2006 recommendations; and perceived incompatibility with state testing policies, especially for those health centers receiving state funding for dedicated HIV testing programs.

Respondents recommended a number of facilitators and strategies to improve routine HIV testing implementation within their health centers, including the release of state-level guidelines. For example, at the time of this study, the Massachusetts Department of Public Health released a clinical advisory in June 2008 which recommended routine HIV counseling and testing of all pregnant women in prenatal care and clarified the state's “opt-in” policy regarding HIV testing.³⁴ Many interview responses seem to reflect the perspective of this advisory and illustrate the role that state departments of health play in the adoption and implementation of policy. While Massachusetts law continues to require separate, written informed consent, a 2009 Massachusetts Department of Public Health clinical advisory supports the inclusion of this written consent on a patient's consent form for general medical care. Additionally, the advisory clarifies language regarding the provision of counseling and laboratory requisition forms, addressing several of the barriers identified by this study.¹⁷ However, if routine HIV testing is to become the norm in Massachusetts, a revised statewide testing protocol is warranted. This may include clarification and delineation of the terms, conditions, and settings in which HIV testing is to be routinely administered, compared to dedicated programs which may target specific populations.

Additional facilitators and strategies recommended by respondents to improve routine HIV testing implementation were organizational buy-in, including the commitment of senior-level management and identification of one or more “champions” of routine HIV testing at each health center; collaborative analyses of patient and resource flows to integrate routine HIV testing into existing activities; provider training; and clinical reminders, such as the use of prompts within the electronic medical record. Considering concerns regarding patient, provider, and community discomfort and inconsistent levels of awareness of the 2006 guidelines, respondents further recommended patient, provider, and community education and marketing, such as media campaigns targeting high-risk populations often served by health centers.^35,36 The National Association of Community Health Centers has developed a model for the integration of rapid HIV testing into routine primary care for patients age 13–64 years.³⁷ A pilot of this program among six health centers in three states increased the number of HIV tests performed more than 300%.¹³ Additional implementation and evaluation of this model program is warranted in other states and contexts, including CHCs specifically.

Although respondents represented 30 of the state's 52 CHCs, it is important to note that this study was a convenience sample and interview responses reflect the perceptions and experiences of a single individual from each agency. Consequently, generalizability of findings may be limited. Additionally, as interviews were administered face-to-face, there may have been social desirability bias, particularly in response to questions regarding awareness and implementation of the 2006 CDC recommendations, which would have overestimated these frequencies. Similarly, while routine HIV testing was defined for respondents throughout the study and interview, several factors that have been described in this article, including inconsistent awareness of the CDC recommendations and perceived incompatibility with state policy, may have contributed to inaccurate responses regarding actual routine testing implementation. This highlights the need for provider education and stronger state-level guidance regarding the testing recommendations.

The 2006 CDC revised recommendations offer an additional opportunity to mobilize health care providers and organizations to diagnose and treat the more than 200,000 Americans who are unaware of their HIV infection.⁴ The opportunity to detect these new diagnoses and integrate patients into timely treatment, in turn, can prevent subsequent morbidity, mortality, and additional infections. However, as indicated by this study's findings, CHC personnel, who are often at the vanguard of primary care for those most at risk for HIV and AIDS, require additional guidance, leadership, and resources to fully realize the goals of the recommendations.

Footnotes

Acknowledgments

This project was supported by a Testing and Linkage to Care grant (#2691) from Gilead Science, Inc. awarded to Drs. Mayer and Mimiaga, who exercised full control over the project. The content is solely the responsibility of the authors and does not necessarily represent the official view of Gilead Science, Inc.

Author Disclosure Statement

No competing financial interests exist.

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