Multimodal Intervention Increases HIV Testing in VA Primary Care

BACKGROUND:
The CDC recommends that providers routinely offer HIV testing to patients under the age of 65, but barriers exist (i.e., stigma, time constraints). Investigators with VA/HSR&D's HIV/Hepatitis Quality Enhancement Research Initiative (QUERI) previously developed, implemented, and evaluated a multimodal program to promote HIV testing, which more than doubled testing among at-risk Veterans. These results prompted the current study that scaled up this intervention in a large number of diverse VA facilities providing primary care to nearly 200,000 Veterans previously untested for HIV between 6/09 and 9/11. Investigators examined the effectiveness of promoting routine as well as risk-based HIV testing, and the effect of providing different levels of organizational support at study sites comprising three study arms: 1) Central (intervention with ongoing support from Project Management Team), 2) Local (no ongoing support after intervention implementation), and 3) Control (no intervention). Intervention components included: real-time electronic clinical reminder, quarterly audit-feedback system, removal of organizational barriers to testing, and a provider activation program (i.e., social marketing, patient/provider educational materials). Frequency of HIV testing in the six months prior to the intervention was then compared to the six months following the intervention.

FINDINGS:

• The use of clinical reminders, provider feedback, education, and social marketing in this HIV-testing intervention significantly increased the frequency at which HIV testing was offered and performed within the VA healthcare system. Implementation of this intervention increased the rate of risk-based HIV testing two- to three-fold, and increased routine testing three- to four-fold.
• The adjusted rate of risk-based testing increased by 0.4%, 6%, and 10% in the Control, Local, and Central arms, respectively. Similarly, the adjusted rate of routine testing of all patients, regardless of risk status, increased by 0.5%, 5%, and 9% in the Control, Local, and Central arms, respectively.
• At the end of the 6-month interventions, the proportion of all Veterans who were documented to have ever had an HIV test increased from 10% to 12% in the Control arm, from 13% to 25% in the Local arm, and from 10% to 28% in the Central arm.
• Authors note that the larger increases in both routine and risk-based testing among the Central arm vs. the Local arm suggest that centralization of resources is a more successful implementation strategy within VA's integrated system setting.
• Risk-based and routine HIV testing increased in all facility-, provider-, and patient-level groups.

LIMITATIONS:

• Investigators could not ascertain which component of the multimodal approach was most effective at increasing HIV testing rates.
• Modifications of this primary care-oriented intervention would be necessary to accommodate work flow patterns in other settings, i.e., substance abuse clinics and emergency departments.

AUTHOR/FUNDING INFORMATION: This study was funded through HIV/Hepatitis-QUERI (SDP 08-002). All authors are part of HIV/Hepatitis-QUERI.

Goetz M, Hoang T, Knapp H, Burgess J, Fletcher M, Gifford A, Asch S, and the HIV/Hepatitis-QUERI Center. Central Implementation Strategies Outperform Local Ones in Improving HIV Testing in Veterans Healthcare Administration Facilities. Journal of General Internal Medicine April 19, 2013;e-pub ahead of print.