HIV Infections Clinical Trial
Official title:
Improving HIV Screening by Nurse Rapid Testing, Streamlined Counseling
Background: HIV testing is cost-effective in unselected general medical populations, yet
testing rates among those at-risk remain low, even among those with regular primary care.
HIV rapid testing is effective in many healthcare settings but scant research has been done
within primary care settings, nor within the US Department of Veteran's Affairs Healthcare
System.
Objectives: We evaluated three methods proven effective in other diseases/settings: Nurse
standing orders for testing, streamlined counseling, and HIV rapid testing.
Design: Randomized, controlled trial with three intervention models: Model A (traditional
counseling/testing); Model B (nurse-initiated screening, traditional counseling/testing);
Model C (nurse-initiated screening, streamlined counseling/rapid testing).
Participants: 251 patients with primary/urgent care appointments in two VA clinics in the
same city (one large urban hospital, one freestanding outpatient clinic in a high HIV
prevalence area)
Measurements: Rates of HIV testing and receipt of results; sexual risk reduction; HIV
knowledge improvement.
Results: Testing rates were 40.2% (Model A), 84.5% (Model B), and 89.3% (Model C) (p=<.01).
Test receipt rates were 14.6% (Model A), 31.0% (Model B), 79.8% (Model C) (all p=<.01).
Sexual risk reduction and knowledge improvement did not differ significantly between
counseling methods.
Conclusions: Streamlined counseling with rapid testing significantly increased testing and
receipt rates over current practice without changes in risk behavior or post-test knowledge.
Increased testing and receipt of results could lead to earlier disease identification,
increased treatment and reduced morbidity/mortality. Policymakers should consider
streamlined counseling/rapid testing when implementing routine HIV testing into
primary/urgent care.
BACKGROUND/RATIONALE:
HIV testing is cost-effective in unselected general medical populations, yet testing rates
among those at-risk remain low, even among those with regular primary care. HIV rapid
testing is effective in many healthcare settings but scant research has been done within
primary care settings, nor within the US Department of Veteran's Affairs Healthcare System.
The cumbersome nature and complexity of current counseling and testing procedures have been
suggested as reasons that rates of receipt of HIV test results are so low. Because the
standard screening test results are unavailable on the same day, many persons do not return
for the results. Up to 30% of persons who tested HIV-positive during 2000 and 39% of persons
who tested HIV-negative did not return (1). The CDC has recommended that alternate
streamlined counseling and testing methods may increase the receipt rates of HIV tests. To
address the problems of failing to return for screening results, we incorporated rapid HIV
testing into the proposed screening trial.
OBJECTIVE(S):
The specific aims of this project were:
To determine whether nurse-based referral for traditional HIV testing and counseling will
improve screening rates compared to current testing procedures.
To determine whether nurse-based rapid testing with streamlined counseling improves
screening rates more than nurse-based referral for traditional testing and counseling alone.
To assess the cost-effectiveness of these alternative strategies for HIV testing and
counseling.
Secondary aims were to compare patient knowledge of HIV testing prevention practices and
their views of the procedures' acceptability after traditional and rapid testing/streamlined
counseling. To achieve these aims, we proposed a robust three-arm randomized controlled
trial.
METHODS:
We planned a parallel-group randomized controlled trial set in the general medicine and
urgent care clinics of the West Los Angeles VA Medical Center (VAMC). All participants
underwent an interview collecting information about HIV risk factors and other predictors of
HIV screening, as well as knowledge of HIV test characteristics and prevention. All patients
were randomized to one of three models of screening: Model A: Traditional
counseling/testing; Model B: Nurse-based screening + traditional counseling/testing; Model
C: Nurse-based screening + streamlined counseling/ rapid testing
The analysis focused on differences between the three models in rates of screening, receipt
of results, knowledge, acceptability and cost-effectiveness.
FINDINGS/RESULTS:
Testing rates were 40.2% (Model A), 84.5% (Model B), and 89.3% (Model C) (p=<.01). Rates of
receipt of test results were 14.6% (Model A), 31.0% (Model B), 79.8% (Model C) (all p=<.01).
Reduction in sexual risk and HIV knowledge improvement did not differ significantly between
traditional versus streamlined counseling.
IMPACT:
Streamlined counseling with rapid testing significantly increased testing and receipt rates
over current practice without changes in risk behavior or post-test knowledge. Increased
testing and receipt of results could lead to earlier disease identification, increased
treatment and reduced morbidity/mortality. Policymakers should consider streamlined
counseling/rapid testing when implementing routine HIV testing into primary/urgent care.
Widespread implementation would lead to critically important health benefits for veterans:
1) Increased rates of testing, which would lead to earlier identification of disease,
increased treatment and decreased HIV transmission, morbidity and mortality; 2) Lower
screening costs without decrements in either patient knowledge or acceptability.
The CDC has made identification of people with HIV a national priority. The VA has an
opportunity to provide national leadership in elucidating how best to identify people living
with HIV and ensure access to state-of-the-art care.
;
Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Single Blind (Subject), Primary Purpose: Diagnostic
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