1. community health centers
Routine HIV testing in
community health centers
Karen Barton, MD, Akron Community Health Resources
Kris Drummond, DDS, Akron Community Health Resources
National Association of Community Health Centers, Inc.

2. Brief Description of HIV Testing Initiative
Objective:
To develop a model for the integration of HIV testing into routine primary care at Non-Ryan White funded health centers along with a model for post test counseling and referral to specialty care
Target States:
Mississippi (3 health centers; 9 clinical sites)
North Carolina (2 health centers; 7 clinical sites)
South Carolina (1 health center; 3 clinical sites)
Ohio (4 health centers; 6 clinical sites)

3. National Association of Community Health Centers (NACHC)
Who We Are NACHC is a non-profit organization that represents the interests of America’s community health centers
Our Mission To promote the provision of high quality, comprehensive health care that is accessible, coordinated, culturally and linguistically competent, and community directed for all underserved populations. 3

4. In 2007, 1076 grantees served over 18 million pts in nearly 63 million visits

5. Health Centers Nationally Patient Profile
1 in 4 minorities below poverty
1 in 7 rural Americans
1 in 8 Medicaid beneficiaries
1 in 7 uninsured persons, including
1 in 5 low income uninsured
1 in 3 people in poverty
936,000 Farmworkers, 1,044,000 Homeless Persons
Line four about the uninsured…?

6. Akron Community Health Resources
Location
Akron, Ohio
Size
3 Sites
2 Medical Sites (11 providers)
1 Dental (1 Dentist)
Demographics
In 2008, 75% of patients (5,770) were years of age

7. Patient Care Model with Integrated Rapid HIV Testing
Front Desk
Check-in
ROUTINE SCREENING FLOW SHEET attached to encounter form
Waiting Room
During intake process (which may occur in a “vitals area” in some centers), dental team offers RAPID HIV SCREENING
Negative results given by any team member
Reactive results given by provider
Exam Room
(or dental operatory)
Laboratory
Blood draw, if needed
Check Out
Check out

8. Routine HIV Screening Algorithm
Rapid HIV Test
Negative
Reactive
Inform patient
Give “Negative” handout, if desired
Review risks, if appropriate
Discuss “window period”
No further testing
Inform pt preliminary results are reactive
Give “Reactive” results handout
Draw confirmatory Western Blot
Schedule follow-up appt in 5 days
Advance call to DIS with f/u appt date & time
Patient likely negative
unless recent risk
Review risks & prevention
Schedule 3 mo repeat
Western Blot
?change colors
Western Blot
Negative
Positive
Indeterminate
Counsel patient
Notify DIS
Ensure referral to HIV care
Complete “Reactive Tracking Sheet”
Repeat Western Blot
at 5 day follow-up visit

9. Post Test Counseling & Referral
Rapid HIV Test
Reactive
CHC informs pt preliminary results reactive
CHC provides written “Reactive” results handout
CHC draws confirmatory Western Blot
CHC schedules follow-up appt in 5 days
CHC* Notifies DIS of Reactive result
DIS may come to CHC to counsel pt regarding results, window period, risk reduction; if not CHC does counseling
Western Blot
Negative
Positive
Indeterminate
DIS performs post-test counseling
DIS completes CDC data form
DIS refers to HIV specialty care and case management
DIS addresses partner notification
DIS comes to CHC to counsel
pt and Western Blot redrawn
*CHC=Community Health Center

10. HIV Testing Experiences
Southeast
Jan/Feb 07-March 08
Ohio
Sept 08 – July 09
Offered HIV testing
(% of total patients)
17,237
3,733
Received HIV testing
(% of those offered)
11,255 (66%)
1,908 (51%)
Reactive Rapid Test
(% of tests performed)
42 (0.37%)
5 (0.26%)
Confirmed as newly HIV-infected
17 (0.15%)
Linked to care
(% of newly confirmed HIV-infected linked to care)
161 (94%)
5 (100%)
1One patient moved out of state but was believed to be in care.

11. Akron HIV Testing Medical Dental 1630 520 698 (43%) 376 (72%) 1 n/a
Offered HIV testing
(% of total patients)
1630
520
Received HIV testing
(% of those offered)
698 (43%)
376 (72%)
Reactive Rapid Test
(% of tests performed) 1
Confirmed as newly HIV-infected
n/a
Linked to care
(% of newly confirmed HIV-infected linked to care)

12. OraSure Technologies, INC
Step 1 – Collect sample.
Swab between the teeth and upper and lower gum once.
Step 2 –
Insert the device into the buffer.
Step 3 - Read between 20 and 40 minutes.
Preliminary Positive
Line in the C and T Zones
Non-Reactive
Line in the C zone

13. Patients Tested1
African Americans and Latinos were significantly more likely to test than were Whites.
Women were more likely to test than were men in the southeast; women and men were equally likely to accept testing in Ohio.
Uninsured patients were more likely to test than those with any kind of insurance.
Patients insured under Medicare or Medicaid were less likely to test in the southeast; this difference was not noted in Ohio.
Patient age was not associated with testing in the southeast. In Ohio, older patients were slightly less likely to accept testing than younger patients.
1Findings are across the southeast and Ohio unless otherwise noted.

14. New Access1 This project provided new access to HIV screening.
For 56% of patients, this was their first HIV test.
Patients who had not been tested before were significantly more likely to accept testing (p=.009).
Of those testing before in the southeast, only 19% had been tested 3 or more times; the majority were not repeat testers.
1Findings are across the southeast and Ohio unless otherwise noted.

15. A Conundrum?
“I am surprised by the data. I thought we would have more confirmed cases. I am surprised based on some judgments I made but now I wonder if we need to make more effort to reach those who are really positive. We know it is there.” – Medical Director
“We have found low prevalence and have had false positives. We need to prove why it’s worth it.”

16. What Worked Well? Development of a model for routine screening
Design of a uniform data collection tool for routine HIV screening in primary care.
Having patient level data
Engagement of leadership and staff…understanding “why”
Training and preparation of staff…understanding “what”
External coaching and support - NACHC
Testing well received by patients
Easy test with immediate results
Partnerships established for follow-up HIV counseling/care
Involving state and national partners
Tests FREE to health centers…FREE to patients

17. What Did Not Work?
Difficulty of building in another task for staff to do in an already busy day – buy in.
Competing priorities for entities engaged in HIV screening: health departments, AIDS Education and Training Centers (AETC).
Lack of state health department support and understanding for the initiative
Lack of a uniform data collection process at the onset of the project – e.g., there was no data collection tool applicable to routine HIV screening in a primary care setting
Lack of a clear plan at the onset for handling reactives and addressing false positives
Lack of funding for, or access to, tests on an ongoing basis after the pilot effort!

18. Creation of a new paradigm!
From Our Perspective, the Opportunity for HIV Testing in Primary Care is…….
Creation of a new paradigm!
If routine HIV screening in primary care is the goal, then primary care providers need to be part of the programmatic model and test distribution process

19. For More Information NACHC ( www.NACHC.com)
Kathy McNamara
Cheryl Modica 19

20. For More Information Kris Drummond, DDS, MPH, CPH 330/785-2044 20

21. Support:
This project was made possible through funding from the Centers for Disease Control and Prevention (CDC) and Gilead. Rapid HIV Tests for the southeast project were donated by Health Providers Direct. 21