Need to improve routine HIV testing of U.S. Veterans in care: results of an Internet survey

"Oops! I forgot HIV": resident physician self-audits and universal HIV screening

BACKGROUND

Innovations are needed to increase universal HIV screening by primary care providers. One potential intervention is self-audit feedback, which describes the process of a clinician reviewing their own patient charts and reflecting on their performance.

METHODS

The effectiveness of self-audit feedback was investigated using a mixed methods approach. A total of 2111 patient charts were analyzed in a quantitative pre-post intervention study design, where the intervention was providing self-audit feedback to all internal medicine residents at one institution through an annual chart review. Qualitative data generated from the subsequent resident focus group discussions explored the motivation and mechanism for change using a knowledge-attitude-behavior framework.

RESULTS

The proportion of primary care patients screened for HIV increased from 17.9% (190/1060) to 40.3% (423/1051). The adjusted odds ratio of a patient being screened following resident self-audited feedback was 3.17 (95% CI 2.11, 4.76, p<0.001). Focus group participants attributed the improved performance to the self-audit feedback.

CONCLUSIONS

Self-audit feedback is a potentially effective intervention for increasing universal HIV screening in primary care. This strategy may be most useful in settings where (1) baseline performance is low, (2) behavioral change is provider-driven, and (3) resident trainees are targeted.

Are VA primary care providers aware of HIV testing recommendations for Veterans? Findings at an urban VA primary care clinic

Given the prevalence of human immunodeficiency virus (HIV) in veterans and that nearly 90% of veterans have not been HIV tested, the Veterans Affairs (VA) has recommended routine HIV testing of all veterans.The objective of this study carried out at an urban VA primary care clinic was to assess provider knowledge of recent U.S. Centers for Disease Control and Prevention (CDC) and VA HIV testing recommendations and policies. Fifty-six primary care providers completed a survey. Nearly 40% of providers were unaware of the CDC recommendation to test all persons ages 13 to 64 in health care settings or the VA policy to test veterans of all ages. Over 75% of providers were unaware of the latest requirements for pre- and posttest counseling, and many were unaware of the latest consent process requirements. Educating VA providers about recent HIV testing recommendations and policies may improve the low HIV testing prevalence in the VA.

Evaluating the implementation of nurse-initiated HIV rapid testing in three Veterans Health Administration substance use disorder clinics

Individuals with substance use disorders (SUDs) are at higher risk of HIV infection, yet recent studies show rates of HIV testing are low among this population. We implemented and evaluated a nurse-initiated HIV oral rapid testing (NRT) strategy at three Veterans Health Administration SUD clinics. Implementation of NRT includes streamlined nurse training and a computerized clinical reminder. The evaluation employed qualitative interviews with staff and a quantitative evaluation of HIV testing rates. Barriers to testing included lack of laboratory support and SUD nursing resistance to performing medical procedures. Facilitators included the ease of NRT integration into workflow, engaged management and an existing culture of disease prevention. Six-months post intervention, rapid testing rates at SUD clinics in sites 1, 2, and 3 were 5.0%, 1.1% and 24.0%, respectively. Findings indicate that NRT can be successfully incorporated into some types of SUD subclinics with minimal perceived impact on workflow and time.

Routine HIV testing among providers of HIV care in the United States, 2009

In 2006, CDC recommended HIV screening as part of routine medical care for all persons aged 13-64 years. We examined adherence to the recommendations among a sample of HIV care providers in the US to determine if known providers of HIV care are offering routine HIV testing in outpatient settings. Data were from the CDC's Medical Monitoring Project Provider Survey, administered to physicians, nurse practitioners and physician assistants from June-September 2009. We assessed bivariate associations between testing behaviors and provider and practice characteristics and used multivariate regression to determine factors associated with offering HIV screening to all patients aged 13-64 years. Sixty percent of providers reported offering HIV screening to all patients 13 to 64 years of age. Being a nurse practitioner (aOR = 5.6, 95% CI = 2.6-11.9) compared to physician, age<39 (aOR = 1.9, 95% CI = 1.0-3.5) or 39-49 (aOR = 2.1, 95% CI = 1.4-3.3) compared with ≥50 years, and black race (aOR = 2.6, 95% CI = 1.2-6.0) compared with white race was associated with offering testing to all patients. Providers with low (aOR = 0.2, 95% CI = 0.1-0.3) or medium (aOR = 0.4, 95% CI = 0.2-0.6) HIV-infected patient loads were less likely to offer HIV testing to all patients compared with providers with high patient loads. Many providers of HIV care are still conducting risk-based rather than routine testing. We found that provider profession, age, race, and HIV-infected patient load were associated with offering HIV testing. Health care providers should use patient encounters as an opportunity to offer routine HIV testing to patients as outlined in CDC's revised recommendations for HIV testing in health care settings.

Factors affecting clinician educator encouragement of routine HIV testing among trainees

BACKGROUND

Adoption of CDC recommendations for routine, voluntary HIV screening of all Americans age 13–64 years has been slow. One method to increase adherence to clinical practice guidelines is through medical school and residency training.

OBJECTIVE

To explore the attitudes, barriers, and behaviors of clinician educators (CEs) regarding advocating routine HIV testing to their trainees.

DESIGN/PARTICIPANTS

We analyzed CE responses to a 2009 survey of Society of General Internal Medicine members from community, VA, and university-affiliated clinics regarding HIV testing practices.

MAIN MEASURES

Clinician educators were asked about their outpatient practices, knowledge and attitudes regarding the revised CDC recommendations and whether they encouraged trainees to perform routine HIV testing. Associations between HIV testing knowledge and attitudes and encouraging trainees to perform routine HIV testing were estimated using bivariate and multivariable logistic regression.

RESULTS

Of 515 respondents, 367 (71.3%) indicated they supervised trainees in an outpatient general internal medicine clinic. These CEs demonstrated suboptimal knowledge of CDC guidelines and over a third reported continued risk-based testing. Among CEs, 196 (53.4%) reported that they encourage trainees to perform routine HIV testing. Higher knowledge scores (aOR 5.10 (2.16, 12.0)) and more positive attitudes toward testing (aOR 8.83 (4.21, 18.5)) were independently associated with encouraging trainees to screen for HIV. Reasons for not encouraging trainees to screen included perceived low local prevalence (37.2%), competing teaching priorities (34.6%), and a busy clinic environment (34.0%).

CONCLUSIONS

Clinician educators have a special role in the dissemination of the CDC recommendations as they impact the knowledge and attitudes of newly practicing physicians. Despite awareness of CDC recommendations, many CEs do not recommend universal HIV testing to trainees. Interventions that improve faculty knowledge of HIV testing recommendations and address barriers in resident clinics may enhance adoption of routine HIV testing.

Transfer of information from personal health records: a survey of veterans using My HealtheVet

OBJECTIVE

Personal health records provide patients with ownership of their health information and allow them to share information with multiple healthcare providers. However, the usefulness of these records relies on patients understanding and using their records appropriately. My HealtheVet is a Web-based patient portal containing a personal health record administered by the Veterans Health Administration. The goal of this study was to explore veterans' interest and use of My HealtheVet to transfer and share information as well as to identify opportunities to increase veteran use of the My HealtheVet functions.

MATERIALS AND METHODS

Two waves of data were collected in 2010 through an American Customer Satisfaction Index Web-based survey. A random sample of veterans using My HealtheVet was invited to participate in the survey conducted on the My HealtheVet portal through a Web-based pop-up browser window.

RESULTS

Wave One results (n=25,898) found that 41% of veterans reported printing information, 21% reported saving information electronically, and only 4% ever sent information from My HealtheVet to another person. In Wave Two (n=18,471), 30% reported self-entering medication information, with 18% sharing this information with their Veterans Affairs (VA) provider and 9.6% sharing with their non-VA provider.

CONCLUSION

Although veterans are transferring important medical information from their personal health records, increased education and awareness are needed to increase use. Personal health records have the potential to improve continuity of care. However, more research is needed on both the barriers to adoption as well as the actual impact on patient health outcomes and well-being.

Commentary: thirty years of AIDS in America: a story of infinite hope

The year 2011 marks the thirtieth anniversary of the first case reports in the United States of what we now know to be end-stage HIV disease. This chronological milestone provides an opportunity to reflect upon the changing context of the American HIV/AIDS epidemic. Using two seminal documents as a framework, the 1986 Institute of Medicine Report, "Confronting AIDS," and the 2010 National HIV/AIDS Strategy, this descriptive analysis details our accomplishments in addressing the domestic U.S. epidemic and outlines what remains to be done on the long road to eradication of HIV disease. The past three decades have witnessed tremendous biomedical and behavioral advances in preventing, diagnosing, and treating HIV disease. However, to fully realize the promise of these scientific advances, such that we achieve the vision of the National HIV/AIDS Strategy, we must develop effective strategies to surmount a number of salient challenges, including: unbalanced combinations of prevention interventions; programs that are not of adequate scale to achieve population-level results; systems of service delivery that do not function in an integrated fashion; and social and economic structures that increase the vulnerability of populations who are at risk for or living with HIV disease.

Impact of a kiosk educational module on HIV screening rates and patient knowledge

We assessed the effect of a kiosk educational module on HIV screening rates and patient knowledge about HIV testing. The evaluation was performed in a walk-in clinic offering routine HIV screening. During alternating two-week periods, patients were referred either to view a kiosk-based, educational module prior to receiving usual care, or the kiosk module was turned off and no alterations to care processes were made. The primary outcome was HIV testing rate. The secondary outcome was knowledge about HIV rapid screening, as measured with a questionnaire. There were 71 patients in the kiosk periods and 79 patients in the usual-care periods. The overall HIV testing rate was 41%. The kiosk period was not associated with greater odds of HIV testing (OR 0.7; 95% CI: 0.4-1.4). In 44 patients who completed the knowledge survey, the kiosk group was strongly associated with increased knowledge (predicted increase in knowledge score: 1.3; 95% CI: 036-2.1). The brief kiosk educational module did not improve HIV screening rates, but it increased overall patient knowledge about HIV testing.

General internists' beliefs, behaviors, and perceived barriers to routine HIV screening in primary care

The Centers for Disease Control and Prevention (CDC) recommends routine HIV screening in primary care but little is known about general internists' views of this practice. We conducted a national, cross-sectional, Internet-based survey of 446 general internists in 2009 regarding their HIV screening behaviors, beliefs, and perceived barriers to routine HIV screening in outpatient internal medicine practices. Internists' awareness of revised CDC guidelines was high (88%), but only 52% had increased HIV testing, 61% offered HIV screening regardless of risk, and a median 2% (range 0-67%) of their patients were tested in the past month. Internists practicing in perceived higher risk communities reported greater HIV screening. Consent requirements were a barrier to screening, particularly for VA providers and those practicing in states with HIV consent statutes inconsistent with CDC guidelines. Interventions that promote HIV screening regardless of risk and streamlined consent requirements will likely increase adoption of routine HIV screening in general medicine practices.