A system-wide intervention to improve HIV testing in the Veterans Health Administration

Abstract

Background: Although the benefits of identifying and treating asymptomatic HIV-infected individuals are firmly established, health care providers often miss opportunities to offer HIV-testing.

Objective: To evaluate whether a multi-component intervention increases the rate of HIV diagnostic testing.

Design: Pre- to post-quasi-experiment in 5 Veterans Health Administration facilities. Two facilities received the intervention; the other three facilities were controls. The intervention included a real-time electronic clinical reminder that encourages HIV testing, and feedback reports and a provider activation program.

Patients: Persons receiving health care between August 2004 and September 2006 who were at risk but had not been previously tested for HIV infection.

Measurements: Pre- to post-changes in the rates of HIV testing at the intervention and control facilities

Results: At the two intervention sites, the adjusted rate of testing increased from 4.8% to 10.8% and from 5.5% to 12.8% (both comparisons, p < .001). In addition, there were 15 new diagnoses of HIV in the pre-intervention year (0.46% of all tests) versus 30 new diagnoses in the post-intervention year (0.45% of all tests). No changes were observed at the control facilities.

Conclusions: Use of clinical reminders and provider feedback, activation, and social marketing increased the frequency of HIV testing and the number of new HIV diagnoses. These findings support a multimodal approach toward achieving the Centers for Disease Control and Prevention's goal of having every American know their HIV status as a matter of routine clinical practice.

Figure 1

Opening screen of HIV testing clinical reminder. The HIV testing clinical reminder appears for all persons with identified HIV risk factors who have not been previously tested for HIV, who have not been otherwise identified as being HIV-infected or for whom there has been no previous indication of HIV testing outside of the VA, refusal of HIV testing, or inability to provide informed consent.

Figure 2

Longitudinal incident and cumulative HIV testing rates at intervention vs control sites. “−1” refers to results in the quarter (90 days) prior to implementation of the intervention, whereas 1–4 refers to results in the 4 subsequent 90-day periods. The quarterly testing rate (striped bars) refers to the proportion of at risk, previously untested patients who received care and were tested for HIV infection during each quarter. The cumulative proportion ever tested (solid bars) is the proportion of at risk patients who received care and who had a previous HIV test. The cumulative rate is sum of the incident and previous testing rates.