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SDP 07-318
Implementation of an Opt-Out HIV Rapid Testing Intervention at High Prevalence Primary and Urgent Care Settings within the VA
Henry Anaya, PhD VA Greater Los Angeles Healthcare System, West Los Angeles, CA West Los Angeles, CA Virginia Kan MD Washington DC VA Medical Center, Washington, DC Washington, DC Funding Period: October 2009 - September 2012 |
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BACKGROUND/RATIONALE:
As the largest provider of HIV care in the US, the aforementioned problems with current HIV testing methods are especially salient problems for the VA, as HIV risk is elevated for many VA patient groups (e.g., minority, homeless and mentally ill vets, drug abusers, etc. Our research has shown that more than 25% of VA patients engage in HIV-related risk behaviors; additional research has shown that the HIV prevalence in VA outpatient settings is high and varied from 1% to 9%. Perhaps the most recently identified group at high risk for undetected HIV infection are OEF/OIF veterans. Large proportions of returning vets have significantly higher diagnoses of mental illness and substance abuse than the general VA population, both of which have been linked to increased HIV risk. Coupled with this is research showing that approximately 60% of active duty personnel did not use condoms at last sexual encounter, and also have high rates of binge drinking (42% of all personnel), both of which have been associated as significant co-factors with HIV infection. These patterns put returning vets at higher risk of HIV infection post-discharge, making investigation of effective means of implementing proven HIV testing programs all the more salient. OBJECTIVE(S): The specific aims of this project are: AIM 1: To implement a variant of our previously successful nurse-initiated HIV rapid testing (NRT) strategy in VA PC clinics; AIM 2: To explore and document barriers, facilitators, and unintended consequences of the alternative strategies for spreading NRT into PC clinics; AIM 3: To quantitatively evaluate the success of our implementation efforts; AIM 4: To evaluate the organizational cost-effectiveness of implementing NRT. METHODS: The investigators used a mixed methods approach to evaluate qualitative and quantatative issues regarding the uptake of nurse-initiated HIV rapid testing. The intervention was be designed as a two-year program. After careful consideration, we selected 3 intervention sites: the downtown Los Angeles Outpatient Clinic (OPC), the Washington DC VAMC (VISN 5), and Houston VAMC (VISN 16). Sites were selected not only for their combined HIV prevalence and number of returning OEF/OIF veterans, but also for the appropriate contrast in "social systems" (i.e., 2 sites with strong "opinion leadership" (LA/DC) and one that lacks any identified elements or primary care champions (Houston). This purposeful dissimilarity in facility type and geography, as well as the presence, activation and engagement by local champions will allow for a more comprehensive understanding of the qualitative issues involved in implementing NRT within VA FINDINGS/RESULTS: At site 1, nurses were concerned about delivering patient test results. Therefore, a collective decision was made for nurses to communicate test results to providers who would deliver results during the visit. At Site 2, the nurses delivered the majority of negative results. There were 8,265 patients seen in PC study clinics during the 6-month intervention period at site 1, and 27,771 patients seen during the 4-month period at site 2. In regard to our patient demographic profile, both sites were similar in patient age and gender: mean age was 60 years (s.d.=14 years) and 90% of the patients were male. Sites 1 and 2 were different in the distribution of patients' marital status (single: 23% versus 12%, respectively), race (Caucasian: 21% versus 51% respectively), and homelessness (8% versus 4% respectively); all comparisons are statistically significant at p-values<.05. The two most prevalent HIV risk factors at both sites were HCV infection (8-10%) and illicit drug use (9-10%). The two most prevalent medical problems were mental health (39-40%) and diabetes (28-35%). At site 1, 2,364 (28.6%) patients received a rapid test during the intervention period as compared to only 101 (1.2%) patients during the 6-month pre-intervention period. At site 2, 2,522 (9.1%) patients received a rapid test during the 4-month intervention period as compared to only 10 (0.04%) patients tested during the 4-month pre-intervention period. Younger patients were more likely to be tested at both intervention sites: rapid test rates were 17-34% among patients younger than 50 years as compared to 0-15% among patients older than 70 years. African Americans were more likely to be tested than Caucasians (12-31% versus 7-20%). Single patients were more likely to be tested than married patients (12-29% versus 8-26%; all comparisons are statistically significant at p-values<.05). IMPACT: Nurse-initiated HIV rapid testing has the ability to improve identification of HIV-infected patients with the added advantage of timely notification, which mitigates the linkage-to-care gaps evident with traditional venipuncture testing. This work is additional evidence that nurse-initiated HIV testing can be integrated into a variety of clinical domains, specifically in this instance, primary care clinics. External Links for this ProjectDimensions for VA Dimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects. Learn more about Dimensions for VA. VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address. Search Dimensions for this project PUBLICATIONS:Journal Articles
DRA:
Infectious Diseases
DRE: Diagnosis, Prevention Keywords: HIV/AIDS, Homeless, Screening MeSH Terms: none |
