Barriers to HIV Testing in Barriers to HIV Testing in Community Settings in the Community Settings in the

United States: Current United States: Current Issues and Issues and

RecommendationsRecommendationsLaura M. Bogart, Ph.D.Laura M. Bogart, Ph.D.

Associate Professor of PediatricsAssociate Professor of Pediatrics

Children’s Hospital BostonChildren’s Hospital Boston

Harvard Medical SchoolHarvard Medical School

Presentation Overview

Barriers to HIV testing in communities Policy barriers Organizational/provider barriers

Rapid HIV testing study of organizational and provider barriers

Policy recommendations

Policy Barriers to Policy Barriers to Community-Based TestingCommunity-Based Testing

CDC’s 2006 recommendations to CDC’s 2006 recommendations to increase routine HIV testing in increase routine HIV testing in health care settingshealth care settings No longer require:No longer require:

PPretest counseling HIV-specific written informed consent (vs.

general medical) Recommend rapid HIV testingRecommend rapid HIV testing

Do not apply to non-medical settingsDo not apply to non-medical settings

Policy Barriers to Policy Barriers to Community-Based TestingCommunity-Based Testing

3 states require pretest counseling3 states require pretest counseling MI, PA, WIMI, PA, WI

Required in 20 other states under certain Required in 20 other states under certain conditions (e.g., non-physician testing)conditions (e.g., non-physician testing)

6 states require HIV-specific written 6 states require HIV-specific written informed consentinformed consent MA, MI, NE, NY, PA, WIMA, MI, NE, NY, PA, WI

Required in 18 other states under certain Required in 18 other states under certain conditionsconditions

e.g., for community testing in CO, MDe.g., for community testing in CO, MD

Policy Barriers to Policy Barriers to Community-Based Community-Based

TestingTesting Laws in 48 states/DC allow modified Laws in 48 states/DC allow modified testing scenariostesting scenarios No pretest counseling (n=48)No pretest counseling (n=48)

13 require pretest explanation/information13 require pretest explanation/information Modified consent process (n=44)Modified consent process (n=44)

General medical consent for HIV testing General medical consent for HIV testing (n=22)(n=22)

HIV-specific written or oral informed consent HIV-specific written or oral informed consent (n=11)(n=11)

No specific provisions found regarding No specific provisions found regarding consent (n=7) or informed consent (n=4)consent (n=7) or informed consent (n=4)

Organizational/Provider Organizational/Provider Barriers to Community-Barriers to Community-

Based TestingBased Testing Lack of provider training Lack of provider training

On conducting testsOn conducting tests On integrating testing On integrating testing

Insufficient timeInsufficient time Perceived low patient riskPerceived low patient risk

Burke et al., Burke et al., 20072007

Organizational/Provider Organizational/Provider Barriers to Community-Barriers to Community-

Based TestingBased Testing CostCost

Routine and rapid testing expensive in Routine and rapid testing expensive in short-termshort-term If good linkage to treatment and prevalence If good linkage to treatment and prevalence

>0.1%, then cost of routine testing >0.1%, then cost of routine testing outweighed by increased serostatus outweighed by increased serostatus awareness awareness (Walensky et al., 2007)(Walensky et al., 2007)

Rapid HIV Testing Study

Aimed to determine scope of and barriers to rapid HIV testing in the U.S. across private nonprofit community settings Community health clinics (CHCs) Community-based organizations (CBOs)

Conducted in 2005-2006 Prior to release of most recent CDC

recommendationsBogart et al., 2008a,

2008b

Method: Multistage Method: Multistage SamplingSampling

12 Primary Metropolitan Statistical 12 Primary Metropolitan Statistical Areas (PMSAs) randomly selected Areas (PMSAs) randomly selected 3 per U.S. region 3 per U.S. region Sampling probabilities proportional to Sampling probabilities proportional to

AIDS prevalence in each PMSAAIDS prevalence in each PMSA West: West: Los Angeles-Long Beach, Oakland, Los Angeles-Long Beach, Oakland,

Riverside-San BernardinoRiverside-San Bernardino Northeast: New York, Boston, NewarkNortheast: New York, Boston, Newark South: South: Miami, Atlanta, Washington, DCMiami, Atlanta, Washington, DC Midwest: Chicago, Indianapolis, St. LouisMidwest: Chicago, Indianapolis, St. Louis

Method: Multistage Method: Multistage SamplingSampling

Random sample of 746 clinics and CBOs in PMSAs Created comprehensive list of

clinics/CBOs from existing lists of clinic and HIV-related organizations

Method: EligibilityMethod: Eligibility

Eligible if:Eligible if: Non-profitNon-profit Direct provider of medical or social Direct provider of medical or social

servicesservices HIV test providerHIV test provider

Method: Final SampleMethod: Final Sample

575 (77%) of 746 sites contacted 575 (77%) of 746 sites contacted 375 eligible and interviewed (56% 375 eligible and interviewed (56%

community clinics, 44% CBOs)community clinics, 44% CBOs) Of those, 111 randomly selected and Of those, 111 randomly selected and

surveyed on provider barrierssurveyed on provider barriers

Method: SurveyMethod: Survey

Respondents asked:Respondents asked: If and when rapid testing implemented If and when rapid testing implemented Perceived barriers scalePerceived barriers scale

19 translational barriers: difficulty 19 translational barriers: difficulty translating policy into practice (e.g., quality translating policy into practice (e.g., quality assurance concerns)assurance concerns)

12 staffing barriers: difficulty meeting 12 staffing barriers: difficulty meeting staffing requirements, training concernsstaffing requirements, training concerns

Method: SurveyMethod: Survey

Organizational size and resourcesOrganizational size and resources Number of unique clients servedNumber of unique clients served Onsite laboratoryOnsite laboratory Mobile testing sitesMobile testing sites Other branches, locations, officesOther branches, locations, offices Other diagnostic tests provided (in Other diagnostic tests provided (in

addition to HIV)addition to HIV)

Method: Regional and Method: Regional and Community CharacteristicsCommunity Characteristics Need for HIV testing: Need for HIV testing:

AIDS prevalence of PMSAAIDS prevalence of PMSA Neighborhood proportion of African Neighborhood proportion of African

Americans and LatinosAmericans and Latinos

Results: Rapid Test UseResults: Rapid Test Use

17% (22% CHCs, 10% CBOs) were 17% (22% CHCs, 10% CBOs) were using rapid HIV testsusing rapid HIV tests

Of those not using rapid tests:Of those not using rapid tests: 14% (20% CHCs, 8% CBOs) had plans to 14% (20% CHCs, 8% CBOs) had plans to

startstart 53% (26% CHCs, 82% CBOs) provided 53% (26% CHCs, 82% CBOs) provided

referralsreferrals To health department (51%), clinic (31%), CBO To health department (51%), clinic (31%), CBO

(31%), hospital (29%)(31%), hospital (29%) 39% had formal agreements with other 39% had formal agreements with other

organizationsorganizations

0

5

10

15

20

25

30

2003 2004 2005 early 2006(projected)

Overall CC CBO

Cumulative Prevalence of U.S. Community Health Settings Offering Rapid HIV Tests from 2003-2006 (N = 373)

Clinic

Overall

CBO

Results: Predictors of Rapid Results: Predictors of Rapid TestingTesting

In multivariate model, rapid testing more In multivariate model, rapid testing more likely:likely: In areas of greater needIn areas of greater need

PMSAs with higher AIDS prevalence, PMSAs with higher AIDS prevalence, OR=1.7, OR=1.7, CI=1.2-2.3, p<.01CI=1.2-2.3, p<.01

In larger sites with more resources:In larger sites with more resources: On-site laboratory, On-site laboratory, OR=3.1,CI=1.8-5.4, p<.001OR=3.1,CI=1.8-5.4, p<.001

Multiple locations, Multiple locations, OR=1.9, CI=1.1-3.5, p<.05OR=1.9, CI=1.1-3.5, p<.05

Other diagnostic tests offered, Other diagnostic tests offered, OR=13.4, CI=1.8-OR=13.4, CI=1.8-101.0 p<.05101.0 p<.05

Mobile units, Mobile units, OR=1.60, CI=0.9-2.8, p<.10OR=1.60, CI=0.9-2.8, p<.10

In South vs. West, In South vs. West, OR=2.9, CI=1.2-6.8, p<.05OR=2.9, CI=1.2-6.8, p<.05OR = odds ratio; 95% CI = confidence interval

Results: Predictors Results: Predictors of Testing Referralof Testing Referral

In multivariate model, referral more likely In multivariate model, referral more likely in sites with:in sites with:

With no on-site laboratory, With no on-site laboratory, OR=0.3,CI=0.1-0.9, OR=0.3,CI=0.1-0.9, p<.05p<.05

That did not provide other diagnostic tests, That did not provide other diagnostic tests, OR=0.4, CI=0.1-0.9 p<.05OR=0.4, CI=0.1-0.9 p<.05

In CBOs vs. CHCs,In CBOs vs. CHCs, OR=3.9, CI=1.6-9.5 p<.01 OR=3.9, CI=1.6-9.5 p<.01

OR = odds ratio; 95% CI = confidence interval

Results: Translational Results: Translational BarriersBarriers

Greater agreement among non-users Greater agreement among non-users vs. users:vs. users: Rapid tests are difficult to integrate into Rapid tests are difficult to integrate into

my organization (14.9% vs. 0%**)my organization (14.9% vs. 0%**) My organization does not have enough My organization does not have enough

space to confidentially conduct rapid space to confidentially conduct rapid tests (34.3% vs. 10.5%*)tests (34.3% vs. 10.5%*)

Regulations for rapid testing are Regulations for rapid testing are difficult to understand (27.7% vs. 7.7%difficult to understand (27.7% vs. 7.7%+)+)

**p<.001; *p<.05; +p<.10

Results: Translational Results: Translational BarriersBarriers

Greater agreement among non-Greater agreement among non-users vs. users:users vs. users: Rapid testing does not allow more Rapid testing does not allow more

people to know their HIV status (3.1% people to know their HIV status (3.1% vs. 0%**)vs. 0%**)

The procedures for running rapid The procedures for running rapid tests are difficult to learn (0.5% vs. tests are difficult to learn (0.5% vs. 0%**)0%**)

**p<.001; *p<.05; +p<.10

Results: Staffing BarriersResults: Staffing Barriers

Greater agreement among non-Greater agreement among non-users vs. users:users vs. users: My organization is unable to employ My organization is unable to employ

dedicated staff members to perform dedicated staff members to perform rapid testing (32.1% vs. 5.2%*)rapid testing (32.1% vs. 5.2%*)

My organization does not have a My organization does not have a sufficient number of staff to provide sufficient number of staff to provide rapid tests (34.2% vs. 15.7%+)rapid tests (34.2% vs. 15.7%+)

*p<.05; +p<.10

Association of Perceived Association of Perceived Barriers to Rapid Test UseBarriers to Rapid Test Use

Multivariate OR Multivariate OR (95% CI)(95% CI)

Clinics/CBOsClinics/CBOs 0.18 (0.07, 0.52)**0.18 (0.07, 0.52)**

** p < .01

SummarySummary Prior to 2006 CDC Prior to 2006 CDC

recommendations and policy recommendations and policy changes, rapid tests used changes, rapid tests used infrequentlyinfrequently in community settings in community settings

Many CBOs refer out for HIV Many CBOs refer out for HIV testing, possibly due to capacity testing, possibly due to capacity barriersbarriers

Updated survey neededUpdated survey needed

RecommendationsRecommendations

Identify barriers to policy change in Identify barriers to policy change in remaining states, especially for remaining states, especially for community settingscommunity settings Natural experiments show increased Natural experiments show increased

testing with revised counseling/consent testing with revised counseling/consent procedures procedures (Weis et al 2009, Wing 2009, Zetola et (Weis et al 2009, Wing 2009, Zetola et al 2008)al 2008)

However, effect of reduced or no However, effect of reduced or no counseling on risk behavior unknown counseling on risk behavior unknown (Holtgrave & McGuire 2007)(Holtgrave & McGuire 2007)

RecommendationsRecommendations

Build community capacityBuild community capacity Provide education, training, ongoing Provide education, training, ongoing

technical assistance tailored to each technical assistance tailored to each settingsetting

If funding available, invest in If funding available, invest in infrastructure (e.g., mobile units) and infrastructure (e.g., mobile units) and rapid test kitsrapid test kits

RecommendationsRecommendations

Increase community awareness and Increase community awareness and supportsupport Partner with communities to identify Partner with communities to identify

feasible testing venues and key social feasible testing venues and key social marketing messagesmarketing messages

Prior community-based participatory Prior community-based participatory research suggests promising research suggests promising interventions for high risk groups interventions for high risk groups (Bucher (Bucher et al 2007; Erausquin et al 2009; Galvan et al 2006; Olshefsky et al 2007; Erausquin et al 2009; Galvan et al 2006; Olshefsky et al 2008; Rhodes et al 2009)et al 2008; Rhodes et al 2009)

AcknowledgementsAcknowledgements

Funded by Grant #U65/CCU924523-01 Funded by Grant #U65/CCU924523-01 from the Centers for Disease Control from the Centers for Disease Control and Prevention (CDC)and Prevention (CDC)

ContributorsContributors CDC: Devery Howerton, James LangeCDC: Devery Howerton, James Lange RAND: Steven Asch, Kirsten Becker, RAND: Steven Asch, Kirsten Becker,

Claude Messan Setodji, David KleinClaude Messan Setodji, David Klein Center for AIDS Intervention Center for AIDS Intervention

Research/Medical College of Wisconsin: Research/Medical College of Wisconsin: Steven PinkertonSteven Pinkerton