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Barriers to HIV Testing in Community Settings in the United States: Current Issues and Recommendations. Laura M. Bogart, Ph.D. Associate Professor of Pediatrics Children’s Hospital Boston Harvard Medical School. Presentation Overview. Barriers to HIV testing in communities Policy barriers
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Barriers to HIV Testing in Community Settings in the United States: Current Issues and Recommendations Laura M. Bogart, Ph.D. Associate Professor of Pediatrics Children’s Hospital Boston Harvard 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 Community-Based Testing • CDC’s 2006 recommendations to increase routine HIV testing in health care settings • No longer require: • Pretest counseling • HIV-specific written informed consent (vs. general medical) • Recommend rapid HIV testing • Do not apply to non-medical settings
Policy Barriers to Community-Based Testing 3 states require pretest counseling MI, PA, WI Required in 20 other states under certain conditions (e.g., non-physician testing) 6 states require HIV-specific written informed consent MA, MI, NE, NY, PA, WI Required in 18 other states under certain conditions e.g., for community testing in CO, MD
Policy Barriers to Community-Based Testing • Laws in 48 states/DC allow modified testing scenarios • No pretest counseling (n=48) • 13 require pretest explanation/information • Modified consent process (n=44) • General medical consent for HIV testing (n=22) • HIV-specific written or oral informed consent (n=11) • No specific provisions found regarding consent (n=7) or informed consent (n=4)
Organizational/Provider Barriers to Community-Based Testing • Lack of provider training • On conducting tests • On integrating testing • Insufficient time • Perceived low patient risk Burke et al., 2007
Organizational/Provider Barriers to Community-Based Testing • Cost • Routine and rapid testing expensive in short-term • If good linkage to treatment and prevalence >0.1%, then cost of routine testing outweighed by increased serostatus awareness (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 recommendations Bogart et al., 2008a, 2008b
Method: Multistage Sampling • 12 Primary Metropolitan Statistical Areas (PMSAs) randomly selected • 3 per U.S. region • Sampling probabilities proportional to AIDS prevalence in each PMSA • West: Los Angeles-Long Beach, Oakland, Riverside-San Bernardino • Northeast: New York, Boston, Newark • South: Miami, Atlanta, Washington, DC • Midwest: Chicago, Indianapolis, St. Louis
Method: Multistage Sampling • 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: Eligibility • Eligible if: • Non-profit • Direct provider of medical or social services • HIV test provider
Method: Final Sample • 575 (77%) of 746 sites contacted • 375 eligible and interviewed (56% community clinics, 44% CBOs) • Of those, 111 randomly selected and surveyed on provider barriers
Method: Survey • Respondents asked: • If and when rapid testing implemented • Perceived barriers scale • 19 translational barriers: difficulty translating policy into practice (e.g., quality assurance concerns) • 12 staffing barriers: difficulty meeting staffing requirements, training concerns
Method: Survey • Organizational size and resources • Number of unique clients served • Onsite laboratory • Mobile testing sites • Other branches, locations, offices • Other diagnostic tests provided (in addition to HIV)
Method: Regional and Community Characteristics Need for HIV testing: AIDS prevalence of PMSA Neighborhood proportion of African Americans and Latinos
Results: Rapid Test Use • 17% (22% CHCs, 10% CBOs) were using rapid HIV tests • Of those not using rapid tests: • 14% (20% CHCs, 8% CBOs) had plans to start • 53% (26% CHCs, 82% CBOs) provided referrals • To health department (51%), clinic (31%), CBO (31%), hospital (29%) • 39% had formal agreements with other organizations
Cumulative Prevalence of U.S. Community Health Settings Offering Rapid HIV Tests from 2003-2006 (N = 373) Clinic Overall CBO
Results: Predictors of Rapid Testing • In multivariate model, rapid testing more likely: • In areas of greater need • PMSAs with higher AIDS prevalence, OR=1.7, CI=1.2-2.3, p<.01 • In larger sites with more resources: • On-site laboratory, OR=3.1,CI=1.8-5.4, p<.001 • Multiple locations, OR=1.9, CI=1.1-3.5, p<.05 • Other diagnostic tests offered, OR=13.4, CI=1.8-101.0 p<.05 • Mobile units, OR=1.60, CI=0.9-2.8, p<.10 • In South vs. West, OR=2.9, CI=1.2-6.8, p<.05 OR = odds ratio; 95% CI = confidence interval
Results: Predictors of Testing Referral In multivariate model, referral more likely in sites with: With no on-site laboratory, OR=0.3,CI=0.1-0.9, p<.05 That did not provide other diagnostic tests, OR=0.4, CI=0.1-0.9 p<.05 In CBOs vs. CHCs, OR=3.9, CI=1.6-9.5 p<.01 OR = odds ratio; 95% CI = confidence interval
Results: Translational Barriers • Greater agreement among non-users vs. users: • Rapid tests are difficult to integrate into my organization (14.9% vs. 0%**) • My organization does not have enough space to confidentially conduct rapid tests (34.3% vs. 10.5%*) • Regulations for rapid testing are difficult to understand (27.7% vs. 7.7%+) **p<.001; *p<.05; +p<.10
Results: Translational Barriers • Greater agreement among non-users vs. users: • Rapid testing does not allow more people to know their HIV status (3.1% vs. 0%**) • The procedures for running rapid tests are difficult to learn (0.5% vs. 0%**) **p<.001; *p<.05; +p<.10
Results: Staffing Barriers • Greater agreement among non-users vs. users: • My organization is unable to employ dedicated staff members to perform rapid testing (32.1% vs. 5.2%*) • My organization does not have a sufficient number of staff to provide rapid tests (34.2% vs. 15.7%+) *p<.05; +p<.10
Association of Perceived Barriers to Rapid Test Use ** p < .01
Summary • Prior to 2006 CDC recommendations and policy changes, rapid tests used infrequently in community settings • Many CBOs refer out for HIV testing, possibly due to capacity barriers • Updated survey needed
Recommendations • Identify barriers to policy change in remaining states, especially for community settings • Natural experiments show increased testing with revised counseling/consent procedures (Weis et al 2009, Wing 2009, Zetola et al 2008) • However, effect of reduced or no counseling on risk behavior unknown (Holtgrave & McGuire 2007)
Recommendations • Build community capacity • Provide education, training, ongoing technical assistance tailored to each setting • If funding available, invest in infrastructure (e.g., mobile units) and rapid test kits
Recommendations • Increase community awareness and support • Partner with communities to identify feasible testing venues and key social marketing messages • Prior community-based participatory research suggests promising interventions for high risk groups (Bucher et al 2007; Erausquin et al 2009; Galvan et al 2006; Olshefsky et al 2008; Rhodes et al 2009)
Acknowledgements • Funded by Grant #U65/CCU924523-01 from the Centers for Disease Control and Prevention (CDC) • Contributors • CDC: Devery Howerton, James Lange • RAND: Steven Asch, Kirsten Becker, Claude Messan Setodji, David Klein • Center for AIDS Intervention Research/Medical College of Wisconsin: Steven Pinkerton