1 / 28

Laura M. Bogart, Ph.D. Associate Professor of Pediatrics Children’s Hospital Boston

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

beata
Download Presentation

Laura M. Bogart, Ph.D. Associate Professor of Pediatrics Children’s Hospital Boston

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. 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

  2. Presentation Overview • Barriers to HIV testing in communities • Policy barriers • Organizational/provider barriers • Rapid HIV testing study of organizational and provider barriers • Policy recommendations

  3. 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

  4. 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

  5. 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)

  6. 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

  7. 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)

  8. 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

  9. 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

  10. 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

  11. Method: Eligibility • Eligible if: • Non-profit • Direct provider of medical or social services • HIV test provider

  12. 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

  13. 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

  14. 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)

  15. Method: Regional and Community Characteristics Need for HIV testing: AIDS prevalence of PMSA Neighborhood proportion of African Americans and Latinos

  16. 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

  17. Cumulative Prevalence of U.S. Community Health Settings Offering Rapid HIV Tests from 2003-2006 (N = 373) Clinic Overall CBO

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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

  23. Association of Perceived Barriers to Rapid Test Use ** p < .01

  24. 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

  25. 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)

  26. 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

  27. 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)

  28. 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

More Related