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.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. 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. [view]
2. Knapp H, Anaya HD, Goetz MB. Attributes of an independently self-sustaining implementation: nurse-administered HIV rapid testing in VA primary care. Quality management in health care. 2010 Oct 1; 19(4):292-7. [view]
3. Sanders GD, Anaya HD, Asch S, Hoang T, Golden JF, Bayoumi AM, Owens DK. Cost-effectiveness of strategies to improve HIV testing and receipt of results: economic analysis of a randomized controlled trial. Journal of general internal medicine. 2010 Jun 1; 25(6):556-63. [view]
4. Anaya HD, Butler JN, Solomon JL, Knapp H, Hoang T, Kan V, Rodriguez-Barradas MC, Hare KA, Kertz B, Bokhour B. Implementation of nurse-initiated rapid HIV testing at high-prevalence primary care sites within the U.S. Veterans Affairs Health Care System. Sexually Transmitted Diseases. 2013 Apr 1; 40(4):341-5. [view]
5. Knapp H, Anaya HD. Implementation science in the real world: a case study of HIV rapid testing. International Journal of STD & AIDS. 2013 May 6; 24(1):5-11. [view]
6. Knapp H, Anaya HD. Implementation science in the real world: a streamlined model. Journal for healthcare quality : official publication of the National Association for Healthcare Quality. 2012 Nov 1; 34(6):27-34; quiz 34-5. [view]
7. Knapp H, Anaya HD, Feld JE, Hoang T, Goetz MB. Launching nurse-initiated HIV rapid testing in Veterans Affairs primary care: a comprehensive overview of a self-sustaining implementation. International Journal of STD & AIDS. 2011 Dec 1; 22(12):734-7. [view]
8. Solomon JL, Bokhour BG, Butler J, Golden JF, Hare K, Kertz B, Kan V, Rodriguez-Barradas M, Knapp H, Anaya HD. Sustaining nurse-rapid HIV testing in the U.S. Department of Veterans Affairs: lessons learned from a comparative evaluation. Journal for healthcare quality : official publication of the National Association for Healthcare Quality. 2014 Sep 1; 36(5):26-31. [view]

Journal Other

1. Knapp H, Anaya HD. Facilitating HIV testing: exploring provider and patient-centered barriers. [Editorial]. Military medicine. 2010 Aug 1; 175(8):541-3. [view]

Center Products

1. Knapp H, Anaya H, Goetz MB. HIV Oral Rapid Test Implementation Toolkit. 2010 Apr 29. [view]

Conference Presentations

1. Solomon J, Butler J, Golden J, Bokhour BG, Hare K, Kertz B, Kan V, Rodriguez-Barradas M, Knapp H, Anaya H. Challenges and facilitators of implementing nurse initiated rapid HIV testing in high prevalence primary care settings within the US Department of Veterans Affairs. Poster session presented at: American Public Health Association Annual Meeting and Exposition; 2011 Oct 29; Washington, DC. [view]
2. Butler JN, Solomon JL, Golden JF, Bokhour BG, Rodriguez-Barradas M, Kan V, Anaya HD. Evaluation of readiness to implement nurse initiated rapid testing at high prevalence primary care setting within the VA. Poster session presented at: Forum for Collaborative HIV Research National Summit on HIV Diagnosis, Prevention, and Access to Care; 2010 Nov 18; National Harbor, MD. [view]
3. Butler JN, Solomon JL, Golden J, Bokhour BG, Rodriguez-Barradas M, Kan V, Anaya H. Evaluation of Readiness to Implement Nurse-Initiated Rapid Testing at High Prevalence Primary Care Settings within the VA. Poster session presented at: International AIDS Conference; 2010 Jul 18; Vienna, Austria. [view]
4. Bulter JN, Solomon J, Golden JF, Bokhour BG, Rodriguez-Barradas M, Kan V, Anaya HD. Evaluation of Readiness to Implement Nurse-Initiated Rapid Testing at High Prevalence Primary Care Settings within the VA. Poster session presented at: American Public Health Association Annual Meeting and Exposition; 2010 Oct 29; Denver, CO. [view]
5. Bokhour BG, Feld JE, Golden J, Asch SM, Knapp H, Anaya H. Implementation of Routine Rapid HIV Testing within the US Department of Veterans Affairs Healthcare System. Paper presented at: American Public Health Association Annual Meeting and Exposition; 2010 Nov 1; Denver, CO. [view]
6. Solomon JL, Butler JN, Golden JF, Bokhour BG, Hare KA, Kertz BL, Kan VL, Rodriguez-Barradas M, Knapp H, Anaya HD. The challenges and facilitators of implementing nurse initiated rapid HIV testing in high prevalence primary care settings within the U.S. Department of Veterans Affairs. Poster session presented at: International Conference on HIV Treatment and Prevention Adherence; 2011 May 22; Miami, FL. [view]
7. Solomon JL, Butler JN, Golden JF, Bokhour BG, Hare KA, Kertz BL, Kan VL, Rodriguez-Barradas M, Knapp H, Anaya HD. The challenges and facilitators of implementing nurse initiated rapid HIV testing in high prevalence primary care settings within the U.S. Department of Veterans Affairs. Poster session presented at: American Conference for the Treatment of HIV; 2011 Apr 7; Denver, CO. [view]
8. Solomon J, Bulter JN, Golden JF, Bokhour BG, Hare KA, Kertz BL, Rodrigues-Barradas MC, Kan VL, Knapp H, Anaya HD. The challenges and Facilitators of Implementing Nurse-Initiated Rapid HIV Testing in High Prevalence Primary Care Settings with the U.S. Department of Veterans Affairs. Poster session presented at: International AIDS Society on HIV Pathogenesis, Treatment and Prevention Annual Conference; 2011 Jul 5; Rome, Italy. [view]
9. Solomon J, Bulter JN, Golden JF, Bokhour BG, Hare KA, Kertz BL, Kan V, Rodrigues-Barradas M, Knapp H, Anaya HD. The challenges and Facilitators of Implementing Nurse-Initiated Rapid HIV Testing in High Prevalence Primary Care Settings with the U.S. Department of Veterans Affairs. Poster session presented at: National HIV Prevention Annual Conference; 2011 Aug 14; Atlanta, GA. [view]
10. Solomon JL, Butler J, Golden J, Bokhour B, Hare K, Kertz B, Kan V, Rodriguez-Barradas M, Knapp H, Anaya H. The Challenges and Facilitators of Implementing Nurse-Initiated Rapid HIV Testing in High Prevalence Primary Care Settings within the U.S. Department of Veterans Affairs. Poster session presented at: AcademyHealth Annual Research Meeting; 2011 Jun 12; Seattle, WA. [view]
11. Solomon J, Bulter JN, Golden JF, Bokhour BG, Hare KA, Kertz BL, Kan V, Rodrigues-Barradas M, Knapp H, Anaya HD. The Challenges and Facilitators of Implementing Nurse-Initiated Rapid HIV Testing in High Prevalence Primary Care Settings within the U.S. Department of Veterans Affairs. Poster session presented at: American Conference for the Treatment of HIV; 2011 Apr 7; Atlanta, GA. [view]
12. Anaya H, Chan K, Goetz MB, Karmarkar US, Asch SM. Using Capacity Planning Models to Estimate Organizational Costs of HIV Care within the United States Department of Veterans Affairs. Poster session presented at: International AIDS Conference; 2010 Jul 18; Vienna, Austria. [view]

DRA: Infectious Diseases
DRE: Diagnosis, Prevention
Keywords: HIV/AIDS, Homeless, Screening
MeSH Terms: none