Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) are significant contributors to death and illness in the United States. People who have HIV but don’t know it are less likely to get the treatment and support services they need, and they are more likely to transmit the disease to others.
To increase knowledge of HIV disease, the Centers for Disease Control and Prevention (CDC) recommends routine, opt-out HIV testing in health care settings for everyone between ages 13 and 64.1
Making HIV Testing a Standard of Practice
The HIV-STD Program of the TB-HIV-STD Section of the Texas Department of State Health Services (DSHS) is a comprehensive, integrated program that guides HIV and STD prevention and infection tracking. They also provide education and guidance to programs that plan for, oversee, and administer related care services across the state. Jenny McFarlane, their HIV Prevention Manager, says the program takes an evidence-based, continuum of care approach to increasing people’s knowledge of their HIV status.
Key to this effort is making HIV testing the standard of care for everyone, not just for people at higher risk. Because the program had already integrated HIV, STD, and syphilis testing in local health departments, McFarlane and her team were on board immediately when CDC first released its guidelines in 2006.
Texas is a huge state with 254 counties, so making sure everyone gets the services and care they need is a huge undertaking. McFarlane’s team started by using surveillance data to identify the areas with the highest HIV prevalence and the greatest need for services. They also reviewed existing screening programs within medical services supported by the state health department and worked to bring testing to departments that didn’t yet have it.
Next, they began connecting medical institutions—including hospital systems, emergency centers, community health centers, and jails—with resources to implement routine HIV testing with lab-based tests. In addition to working with large institutions, the program provided—and continues to provide—public health detailing, training, and support to medical societies and community programs. The goal is to help them implement policy and practice change to conduct routine HIV screening as a standard of care. They also provide funding for HIV testing when there’s not a payer already in place.
Just Another Vital Sign
Across the board, the goal is to make HIV testing routine. As McFarlane and her team have heard from other champions in the field, HIV status is “just another vital sign.”
One important aspect of the program, she explains, is that staff members will visit health care facilities to talk about the impact of undiagnosed infections and to provide training and technical assistance for implementing routine HIV testing. This helps to address the mentality of “That’s not my patients,” which they sometimes encounter in health care providers.
Clinics that have adopted the screening guidelines have seen some of their existing patients finally getting diagnosed, even after visiting the clinic multiple times already. This can happen for any number of reasons, McFarlane says. Some people may have simply never been tested, while others may know their status but don’t share the information unless their clinician asks about it.
Taking a Multi-pronged Approach
The HIV/STD Program supports the following strategies to promote HIV testing at multiple levels:
- Screening administered by STD programs, including screening of people connected to someone with a positive diagnosis as part of public health follow-up efforts
- Focused testing, which makes onsite testing easily available in the communities most vulnerable to acquiring HIV
- Routine testing in medical settings, which accounts for about 200,000 tests per year
McFarlane estimates that focused testing leads to about 50,000 tests per year in Texas. To support routine testing, the program holds trainings, convenes coalitions of stakeholders, and identifies ambassadors within facilities who can act as “champions” for the cause.
The program’s evaluation team validates patient status by matching testing data to surveillance data. This gives them more accurate prevalence estimates, and it’s also a way to know at the time of the test whether or not someone was previously diagnosed. Additionally, they’re able to assess whether or not people have access to care at time of diagnosis and to track the care they get moving forward.
Success by the Numbers
Currently, the program has 3 years’ worth of validated data to show the impact of their testing efforts, and the results are impressive. CDC recommendations suggest that HIV screening is cost effective with a positivity rate of .1 percent or above (meaning that at least 1 in 1,000 people screened test positive for HIV).2
Thanks to the screening program, in 2017:3
- The true new diagnosis rate for routine testing was .17%
- The overall positivity rate was .61%
- The percent of people with new diagnoses linked to care within 90 days was 73.3%
- The number of new diagnoses was 337
The true new diagnosis rate is the percent of people with confirmed new diagnoses of HIV (without a previous diagnosis) compared to the total number of people who were tested.
The overall positivity rate represents how many people tested positive for HIV (both previous and new diagnoses) compared to the total number people who were tested.
Advancing Health Equity Through Education and Advocacy
Trying to change clinical practice in large, complex medical systems has its share of challenges. Since Texas doesn’t have the authority to require mandatory routine HIV testing as a standard of care, there aren’t many external incentives for health care providers to do it. McFarlane and her team rely on education and outreach to advocate for change. They have placed ads in medical journals and presented at conferences, and they continue to educate providers and community members about the CDC recommendations.
McFarlane’s been in the field a long time, and she says they’ve come a long way—both technologically and culturally. As more institutions implement routine HIV testing, more people are being diagnosed. This means longer life expectancies, lower transmission rates, and more people getting connected to health care. And patients who test negative but are at risk get connected with preventive services and treatments, like pre-exposure prophylaxis (PrEP).
McFarlane says that routine HIV testing advances health equity for people with HIV because it lowers barriers to care and counteracts stigma. Justin Irving, the program’s evaluator, notes that it’s a way to reach those in the state that experience the greatest health disparities.
In the future, the program will continue to support routine HIV testing and linkage to care. A key piece of this will be to make routine testing truly “opt out” in electronic medical records, says McFarlane.
Irving adds that there’s plenty of work to do in evaluation, especially around translating the data into direct activities in the field, bringing best practices into the community, and teaching communities how to conduct their own evaluation. One piece of this will be evaluating the impact of PrEP at the population level. The program also plans to create a university learning collaborative to advance HIV prevention efforts and increase knowledge of HIV status.
McFarlane and her colleagues are confident that these efforts will help bring Texas closer to fully implementing routine HIV testing as a standard of care and increasing the number of Texans who know their HIV status.
3 Data provided by Sarah Norkin, MPH, Texas Department of State Health Services.