Patients' attitudes toward and factors predictive of human immunodeficiency virus testing of academic medical clinics

The moderating effects of alcohol use on the association between sexual orientation and HIV testing: results from the 2013-2018 National Health Interview Study

Routine screening and testing for HIV are recommended for all adolescents and adults. However, only one-third of the U.S. population has been tested for HIV. Women, sexual minorities, and people who use alcohol are more likely to be tested for HIV, but less is known about how alcohol use and sexual orientation impact the likelihood of HIV testing synergistically. Examining both alcohol use and sexual orientation is especially relevant, because sexual minorities are at increased risk for alcohol use, including heavy drinking. This study tested an alcohol x sexual orientation interaction effect on HIV testing through logistic regression modeling with a nationally representative sample. Results of the significant interaction identify demographic groups that are particularly at-risk for not being tested for HIV. These groups include lesbian women who currently use alcohol or previously used alcohol; bisexual men who have not used or previously used alcohol; and gay men who previously used alcohol. Although efforts to test all adolescents and adults are warranted, these findings highlight the importance of assessing alcohol and sexual orientation and augmenting testing efforts for highrisk groups.

Patient acceptance of HIV rapid testing in the dental care setting

Dental settings are untapped venues to identify patients with undiagnosed HIV who may otherwise lack testing opportunities. Perceived lack of patient acceptance has been a significant barrier limiting dentists' willingness to offer HIV testing. This study implemented rapid HIV testing in dental settings located in an HIV prevalent region to evaluate patient acceptance. Two South Florida community health centers implemented routine oral rapid HIV testing as part of clinical practice, followed by exit interviews with patients immediately after to determine patient acceptance. The binary primary outcome was patient's acceptance of the rapid HIV test. Multivariable logistic regression assessed associations between patient characteristics and acceptance. Overall acceptance by dental patients (N = 600) was 84.5%. Patients who were more likely to participate in other medical screenings in dental settings were more than twice as likely to accept the test compared to those who were neutral/less likely (OR: 2.373; 95% CI: 1.406-4.004). Study findings highlight the high patient acceptance of HIV testing in dental settings. Widespread implementation of such testing will require an expanded societal view of the traditional role of the dentist that will embrace the potentially valuable role of dentistry in preventive health screenings and population health.

Enlaces Por La Salud: A Personal Health Navigator Intervention Grounded in the Transnational Framework

Despite the disproportionate burden of HIV among Latinxs, there is a paucity of culturally appropriate interventions that have shown efficacy at increasing their engagement and retention in HIV care. We describe the development and implementation of Enlaces, a six-session, individual-level intervention, guided by the transnational framework, to improve HIV care outcomes for newly diagnosed and out-of-care Mexican men and transgender women (TW). Descriptive statistics summarizing baseline data and implementation outcomes are provided. 91 participants enrolled between October 2014 and August 2017. Intervention engagement and satisfaction was high; 81.3% completed all six sessions and 100% were very satisfied/satisfied with their experience. Successful implementation of the ENLACES intervention was the result of establishing client trust and maintaining a flexible, supportive approach to intervention delivery. Use of the transnational framework provided a contextualized approach to engaging with Mexican men and TW living with HIV that can be adapted to other Latino populations.

Missed Opportunities for HIV Testing Among STD Clinic Patients

Current HIV testing guidelines recommend that all adolescents and adults aged 13-64 be routinely screened for HIV in healthcare settings. Sexually transmitted disease (STD) clinic patients represent a population at increased risk for HIV, justifying more frequent risk assessment and testing. This analysis describes missed opportunities for HIV testing among a sample of STD clinic patients to identify areas where HIV testing services may be improved. Secondary analysis was conducted using data from Project AWARE, a randomized trial of 5012 adult patients from 9 STD clinics in the United States, enrolled April-December 2010. HIV testing history, healthcare service utilization, and behavioral risks were obtained through audio computer-assisted self-interview. Missed opportunities for HIV testing, defined as having a healthcare visit but no HIV test in the last 12 months, were characterized by location and frequency. Of 2315 (46.2%) participants not tested for HIV in the last 12 months, 1715 (74.1%) had a missed opportunity for HIV testing. These missed opportunities occurred in both traditional (54.9% at family doctor, 20.3% at other medical doctor visits) and non-traditional (28.5% at dental, 19.0% at eye doctor, 13.9% at correctional facility, and 13.3% at psychology visits) testing settings. Of 53 participants positive for HIV at baseline, 16 (30.2%) had a missed testing opportunity. Missed opportunities for HIV testing were common in this population of STD clinic patients. There is a need to increase routinized HIV screening and expand testing services to a broader range of healthcare settings.

Analysis of HIV testing refusal among patients aged less than 21 years in the Pediatric Emergency Department

HIV testing in the Pediatric Emergency Department (PED) is a novel concept as adolescents, and young adults, use the PED as point of care or first point of contact with the health care system. Our objective was to study the HIV nontesting data and factors that influenced testing decision among patients receiving care in our PED. We designed a survey that inquired about testing acceptance, reasons for rejection, satisfaction with testing conditions, and understanding of the consequence of HIV test results. We approached 500 patients across all shifts in the PED; for analysis, categorical variables were created using demographic data (race, age, ethnicity, marital status, level of education). Forward conditional binary logistic regression was used to explore the effect of various independent predictors on HIV testing rejection with the strength of association measured with adjusted odds ratio (OR), and their 95% CIs. We conducted model fitting by plotting residuals, Hosmer and Lemeshow test statistic, and area under the curve completed using predicted probabilities. We used SPSS Version 25^™, Microsoft Excel 2016^™ for data preparation and analysis. Of the 500 patients approached, 423 (84.6%) completed the survey, median (interquartile) age of survey participants was 19 (17–20) years, 158 (37.4%) rejected HIV testing, 284 (67.1%) were older than 18 years of age, 200 (47.3%) were males, 154 (36.4%) were white, and 127 (30%) were of Hispanic origin. The most common reason for rejecting HIV was low risk perception declared by 79 (50%) respondents. In multivariate analysis, age <18 years (OR, 3.5; 95% CI, 2.3–5.5, P<0.00) and being Hispanic (OR, 2.5; 95% CI, 1.6–3.8, P<0.00) were significant predictors for respondent nontesting. Hosmer and Lemeshow test was not significant, P=0.42, and area under the curve was 0.67 (95% CI, 0.61–0.76). Respondents, <18 years were more likely to reject HIV testing because of low perception of risk. Program addressing risk perception which emphasizes safe health practices should be developed to reduce HIV transmission.

An overview of recent evidence on barriers and facilitators to HIV testing

BACKGROUND

To address the issue of undiagnosed HIV infections, the Public Health Agency of Canada released the Human Immunodeficiency Virus-HIV Screening and Testing Guide in 2012, which identified several barriers and facilitators for HIV testing.

OBJECTIVE

The objective of this overview is to summarize the most recent evidence regarding barriers and facilitators to HIV testing, to expand upon the research conducted for the HIV Screening and Testing Guide.

METHODS

A review of the literature published between 2010 and 2014 was conducted using Scopus, PubMed (MEDLINE), and the Cochrane Library; websites of groups such as the Centers for Disease Control and Prevention, European Centre for Disease Prevention and Control, Australian Department of Health, and New Zealand Ministry of Health were searched for recent reports. Studies were categorized based on the barrier or facilitator identified, and the results were summarized.

RESULTS

In addition to the known barriers of lack of perceived risk, lack of comfort or knowledge, provider time constraints, and fear of the diagnosis, stigma and discrimination, new studies have identified additional barriers including: fear regarding disclosure or lack of confidentiality, lack of access, lack of compensation of providers, and lack of human resources to carry out testing. In addition to the known facilitators of increased awareness and normalization of HIV screening and testing, opt-out testing was identified as a facilitator in recent studies.

CONCLUSION

Since 2010, research has advanced our knowledge of barriers and facilitators and can be applied to help decrease the number of undiagnosed HIV infections.

Detecting HIV among persons accompanying patients to an infectious diseases clinic

BACKGROUND

Infectious diseases (ID) clinics are locations where members of at risk social networks, including sex partners of HIV-infected patients, make contact with a medical care setting when they accompany HIV-positive patients to appointments.

METHODS

We implemented a free point-of-care rapid HIV testing program for anyone accompanying a patient to the University of North Carolina ID clinic. Acceptability of the program among the general clinic population was assessed via an anonymous survey 1 year after program implementation. Basic frequencies of those who underwent and received results of rapid HIV testing, the proportion of positive rapid tests and confirmatory HIV tests performed, and the level of University of North Carolina ID clinic patient satisfaction with the HIV testing program were calculated.

RESULTS

Between October 2007 and June 2013, 450 (99.6%) of 452 individuals tested in the program received their results on the same day as testing. Twenty-two individuals (4.9%) tested HIV positive, of which 16 (72.7%) were newly positive, including 3 never previously tested. Excluding previously diagnosed individuals, HIV prevalence was 3.6% (16/446). Among those testing positive by rapid testing, 19 (86.4%) had confirmatory testing and immediately entered into HIV care at the clinic.

CONCLUSIONS

The high positivity and confirmatory HIV rates in our program confirm that the provision of rapid HIV testing in an ID clinic capitalizes on missed opportunities among an at-risk population and allows immediate linkage to care.

HIV testing experience in New York City: offer of and willingness to test in the context of new legal support of routine testing

BACKGROUND

In the United States, routine HIV testing is recommended for persons aged 13-64 years. In 2010, New York State passed a law mandating offer of testing in most health-care settings. We report on the consumer perspective in New York City (NYC) shortly after the law's enactment.

METHODS

We analyzed data from a 2011 telephone survey representative of NYC adults aged 18-64 years (n = 1,846). This analysis focused on respondents' report of HIV test offer at last clinical visit and of willingness to test if recommended by their doctor. Offer and willingness were estimated by age, gender, race/ethnicity, education, income, marital status, sexual identity, partner number, and HIV testing history; associations were examined using multivariable regression.

RESULTS

Among NYC adults, 35.7% reported an HIV test in the past year and 31.8% had never tested. Among 86.7% with a clinical visit in the past year, 31.4% reported being offered a test at last visit. Offer was associated with younger age, race/ethnicity other than white, non-Hispanic, lower income, and previous testing. Only 6.7% of never-testers were offered a test at last clinical visit. Willingness to test if recommended was high overall (90.2%) and across factors examined.

CONCLUSIONS

After a new law was enacted in support of routine HIV testing, approximately 1 in 3 New Yorkers aged 18-64 years were offered a test at last clinical visit; 9 in 10 were willing to test if recommended by their doctor. This suggests that patient attitudes will not be a barrier to complete implementation of the law.

In the routine HIV testing era, primary care physicians in community health centers remain unaware of HIV testing recommendations

BACKGROUND

Despite the 2006 U.S. Centers for Disease Control and Prevention (CDC) recommendations for routine HIV testing in health care settings, many persons remain untested.

PURPOSE

To determine physician barriers to HIV testing, we surveyed primary care physicians in community health centers in a high HIV prevalence city.

METHODS

Primary care physicians were invited via e-mail to participate in a Web-based survey. One hundred and thirty-seven physicians participated (response rate: 43.9%).

RESULTS

Fifty-five physicians (41.0%) were unaware of updated CDC HIV testing recommendations. Physicians were unaware that testing should be routinely offered in primary care settings caring for adolescents (62 physicians, 45.6%) and primary care settings caring for adults (33, 24.3%). Physicians were also unaware that teenage years patients aged 13 to 17 years (68, 49.6%) and adult patients aged 18 to 64 years (40, 29.2%) should be routinely HIV tested.

CONCLUSION

With the new 2013 US Preventive Services Task Force recommendations to support routine HIV testing, it is critical to address ongoing physician HIV testing barriers to mitigate the HIV epidemic.

Mitigating HIV health disparities: the promise of mobile health for a patient-initiated solution

The HIV epidemic is an ongoing public health problem fueled, in part, by undertesting for HIV. When HIV-infected people learn their status, many of them decrease risky behaviors and begin therapy to decrease viral load, both of which prevent ongoing spread of HIV in the community. Some physicians face barriers to testing their patients for HIV and would rather their patients ask them for the HIV test. A campaign prompting patients to ask their physicians about HIV testing could increase testing. A mobile health (mHealth) campaign would be a low-cost, accessible solution to activate patients to take greater control of their health, especially populations at risk for HIV. This campaign could achieve Healthy People 2020 objectives: improve patient-physician communication, improve HIV testing, and increase use of mHealth.

Racial and ethnic disparities in future testing intentions for HIV: United States, 2007-2010: results from the National Health Interview Survey

This study examined racial/ethnic differences in rationale for intending to test for HIV. Data were analyzed from 98,971 adults from the 2007-2010 National Health Interview Survey. An estimated 38.5 % of respondents previously tested for HIV. Testing as part of a medical checkup or procedure was the most common reason for being tested among studied racial/ethnic groups. Non-Hispanic whites (80.7 %) and non-Hispanic Asians (71.2 %) had higher proportions (p < 0.001) of respondents that have not been tested for HIV due to believing they were unlikely exposed. Non-Hispanic blacks (ARR: 2.55; 95 % CI 2.39-2.72) and Hispanics (ARR: 1.81; 95 % CI 1.68-1.95) who ever tested for HIV were significantly more likely to report positive future testing intentions compared to non-Hispanic whites. Additional efforts to increase the availability of HIV tests by making HIV testing a routine part of medical care and increasing knowledge of HIV transmission, risk-perception, and treatment may reduce racial/ethnic disparities in HIV testing.

Physician barriers to successful implementation of US Preventive Services Task Force routine HIV testing recommendations

In 2006, the US Centers for Disease Control and Prevention issued recommendations supporting routine HIV testing in health care settings for all persons aged 13 to 64 years. Despite these recommendations, physicians are not offering HIV testing routinely. We apply a model that has previously identified 3 central, inter-related factors (knowledge-, attitude-, and behavior-related barriers) for why physicians do not follow practice guidelines in order to better understand why physicians are not offering HIV testing routinely. This model frames our review of the existing literature on physician barriers to routine HIV testing. Within the model, knowledge barriers include lack of familiarity or awareness of clinical recommendations, attitude barriers include lack of agreement with guidelines, while behavioral barriers include external barriers related to the guidelines themselves, to patients, or to environmental factors. Our review reveals that many physicians face these barriers with regards to implementing routine HIV testing. Several factors underscore the importance of determining how to best address physician barriers to HIV testing, including: provisions of the Affordable Care Act that are likely to require or incentivize major payers to cover HIV testing, evidence which suggests that a physician's recommendation to test for HIV is a strong predictor of patient testing behavior, and data which reveals that nearly 20% of HIV-positive individuals may be unaware of their status. In April 2013, the US Preventive Services Task Force released a recommendation supporting routine HIV testing; strategies are needed to help address ongoing physician barriers to testing.

African-American patients' preferences for a health center campaign promoting HIV testing: an exploratory study and future directions

OBJECTIVE

In 2006, the US Centers for Disease Control and Prevention recommended routine HIV testing in health care settings and called for HIV testing campaigns targeting African Americans. In a 2011 national survey, 63% of African Americans wanted information on HIV testing.

METHODS

In our study, 176 African Americans were surveyed to determine channels and spokespersons for an HIV testing campaign.

RESULTS

Among 9 media channels, the top 3 ranked as "very likely" to convince them to get HIV tested were television, poster, and brochure. Among 10 spokespersons, the top 3 were doctor, nurse, and "real person like me."

CONCLUSION

The media are a cost-effective strategy to promote HIV prevention. Posters and brochures are inexpensive and easy to reproduce for clinical settings. Television campaigns may be feasible in clinics with closed-circuit televisions. Research is needed on campaign messages. An effective health center HIV testing campaign may help mitigate the disproportionate toll HIV is having on African Americans.

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.

HIV testing beliefs in a predominantly Hispanic community health center during the routine HIV testing era: does English language ability matter?

The Hispanic population in the U.S. carries a disproportionate burden of HIV. Despite the high prevalence of HIV, many Hispanics remain untested for HIV. The purpose of this study conducted in a predominantly Hispanic-serving community health center in a high HIV prevalence area was to understand patient beliefs of who should be tested for HIV in the routine HIV testing era. Survey participants were presented with nine populations of people that should be tested for HIV based on CDC HIV testing recommendations. Of the 90 participants (67.1% Hispanic) who answered the HIV testing beliefs question, only approximately 45% were aware that all adults and teenagers should be HIV tested. Only 30% correctly identified all nine populations of people that should be tested for HIV based on CDC HIV testing recommendations. Our study suggests that Hispanics are either unaware of or disagree with the latest CDC recommendations for routine HIV testing of all persons ages 13-64 in high HIV prevalence areas. Improving knowledge of the current HIV epidemiologic profile in the U.S. and the most recent routine HIV testing recommendations may improve HIV testing rates in Hispanic communities.

Healthcare-related correlates of recent HIV testing in New York City

OBJECTIVE

To examine healthcare-related correlates of recent HIV testing among New York City (NYC) residents, controlling for socio-demographic and HIV-related risk factors.

METHODS

Using the NYC 2007 Community Health Survey (population-based telephone survey, n=8911), recent HIV testing was examined for its association with healthcare-related variables, including medical screening for other conditions, controlling for other HIV testing correlates using multiple logistic regression.

RESULTS

Factors associated with a recent HIV test included: provider recommendation for an HIV test (adjusted odds ratio [AOR]: 10.1, 95% confidence interval [CI]:7.6-13.5), Medicaid versus private insurance (AOR: 1.6, 95% CI: 1.2-2.1), and having a personal doctor (AOR: 1.6, 95% CI: 1.3-2.1). The proportion of HIV tests attributed to each factor (attributable-fraction [AF]) was 49% for provider recommendation, 33% for having a personal doctor, and 8.3% for Medicaid insurance. Among subgroups eligible for other medical screening, factors associated with recent HIV testing included recent receipt of blood lipid testing (AOR: 2.2, 95% CI: 1.6-3.0; AF: 45%), and Pap smear (AOR: 2.7, 95% CI: 2.1-3.5; AF: 52%). Recent receipt of mammography and colonoscopy was not associated with recent HIV testing.

CONCLUSIONS

A substantial proportion of recent HIV testing coverage among New Yorkers may be attributable to healthcare-related factors. Joint medical screening may provide opportunities to increase population HIV testing coverage.

Sociocultural and structural barriers to care among undocumented Latino immigrants with HIV infection

Timely entry into HIV care is critical for early initiation of therapy, immunologic recovery and improved survival. However, undocumented Latinos are more likely to enter HIV care late in the disease course and with concurrent AIDS. We conducted a qualitative study to examine the circumstantial, situational and social factors that uniquely affect entry and retention in care for this population. Between June and August 2006, we conducted semi-structured, in-depth, individual interviews with 22 undocumented Latino immigrants living with HIV infection. The interviews were audiotaped, transcribed and reviewed for accuracy. Data was analyzed using a grounded theory approach. Word content was coded and sorted by themes using AnSWR software. Emergent themes related to health care barriers include (1) the challenges of dealing with HIV stigma and rejection from family and community; and (2) the experienced and perceived structural barriers of accessing care as an undocumented individual. Societal intolerance of HIV and stigma-related experiences result in feelings of secrecy and shame. In addition, the undocumented state complicates the situation even further. These unique barriers include fear of deportation, work restrictions, inadequate translation services and difficulties meeting paperwork requirements. This study offers insight into the unique sociocultural and structural barriers faced by undocumented Latinos with HIV infection. Understanding and addressing these barriers will prove vital in the development and implementation of strategies to promote early entry into HIV care.

A Qualitative Study of Patients' Attitudes toward HIV Testing in the Dental Setting

An estimated 1.1 million people in the USA are living with HIV/AIDS. Nearly 200,000 of these individuals do not know that they are infected. In 2006, the CDC recommended that all healthcare providers routinely offer HIV screening to adolescent and adult patients. Nurse-dentist collaborations present unique opportunities to provide rapid oral HIV screening to patients in dental clinic settings and reach the many adults who lack primary medical providers. However, little is known about the feasibility and acceptability of this type of innovative practice. Thus, elicitation research was undertaken with dental providers, students, and patients. This paper reports the results of qualitative interviews with 19 adults attending a university-based dental clinic in New York City. Overall, patients held very positive attitudes and beliefs toward HIV screening in dental sites and identified important factors that should be incorporated into the design of nurse-dentist collaborative HIV screening programs.

Intimate partner violence, mental health disorders, and sexually transmitted infections: important screening opportunities for pediatric healthcare providers

PURPOSE OF REVIEW

This article addresses three critical areas where pediatric healthcare providers must employ effective screening techniques to ensure the best care for patients: intimate partner violence (IPV), mental health issues, and sexually transmitted infections (STIs).

RECENT FINDINGS

IPV is now recognized as an important issue impacting the health of children. While long-term outcomes secondary to positive screening results are not known, routine, sensitive questioning can identify at-risk children and help connect families to resources in the community. Routine use of validated screening tools for mental health disorders (MHDs) in the office setting is now recommended. STIs disproportionately affect adolescents and young adults, yet timely diagnosis is often challenging because infections are frequently asymptomatic and adolescents may not be forthcoming about risk-taking behaviors. There is significant opportunity for pediatricians to improve screening rates of adolescents.

SUMMARY

Screening is an essential aspect of healthcare for pediatricians. An understanding of current screening recommendations for IPV, MHDs, and STIs will assist providers in earlier detection of medical problems in their patients and will likely improve patient outcomes.