Journal of the Association of Nurses in AIDS Care
Volume 20, Issue 2 , Pages 87-88, March 2009

Nothing to Lose: A Harm Reduction Approach to Routine HIV Testing

Article Outline

 

We have too many high-sounding words, and too few actions that correspond with them.

—Abigail Adams, in a letter to John Adams, 1774

In September 2006, the Centers for Disease Control and Prevention (2006) published recommendations for universal voluntary routine HIV testing in the United States. The recommendations encouraged legal, institutional, and clinical practice changes to make HIV testing more convenient for both providers and patients, and many changes have been implemented (Bartlett et al., 2008). Despite these changes and the support of professional organizations (Association of Nurses in AIDS Care. (2008, August), Qaseem et al), however, a national conference on routine HIV testing in December 2008 reported little progress in implementation of the recommendations (Forum for Collaborative HIV Research, 2008).

Universal voluntary routine HIV testing is a win-win idea. Voluntary (or opt-out) testing preserves patient autonomy and transparency in personal health care. Universal and routine testing can find people with HIV infection earlier, which will decrease the number of late testers who present with advanced and difficult-to-treat disease. Universal testing can help guide HIV-infected people into care at an earlier point when they are better able—physically, mentally, and emotionally—to engage in care. Routine testing can increase prevention efforts by making HIV an issue for everyone and by helping HIV-infected people learn about transmission and protective measures for their sex and drug-using partners. There is even evidence that HIV testing for everyone older than 13 years, accompanied by immediate initiation of antiretroviral therapy, would save money and significantly decrease the burden of HIV infection by 2050 (Granich, Gliks, Dye, DeCock, & Williams, 2008).

Key points in support of behavior changes to increase HIV testing in clinical settings include the following: (a) universal routine voluntary HIV testing can decrease morbidity and mortality, (b) too many infected people are unaware of their HIV status, and (c) not enough HIV testing is being done. It seems like a no-brainer to make HIV testing as routine in primary care as cholesterol screening and as common in emergency medicine as the complete blood count. But it isn't happening. We don't need to go into detail on the many barriers to routine testing; these have been discussed and rehashed many times (Bartlett et al., 2008). What we need are tactics to change the behaviors of busy clinicians who are not inclined to add HIV testing to their hectic routines.

Whenever I think of behavior change, I think of harm reduction. Harm reduction includes a key premise that any positive behavior change—no matter how small—is a move in the right direction. So why not apply that principle to encourage clinicians to increase the number of HIV tests they order, as opposed to demanding that they test all 13- to 64-year-old patients who walk in the door? And rather than reverting to the old method of doing an HIV test only when there is suspicion of infection (which didn't work too well for finding cases early), how about focusing on doing more testing? This is a less onerous goal and one that can be reached by all providers; doing even one more test would, after all, be a success.

The question then is how to implement such a tactic. Harm reduction also acknowledges that one size does not fit all: some plans work for some people some of the time, but none work for all of the people all of the time. The trick is to have a lot of options to choose from and to tailor those options into a system that works for the individual in the context of her or his life (or clinical practice). In this case, picking the options and tailoring them will need to be done in a clinical care setting, often with the input and support of the entire staff. Here are some ideas:

•Pick one day a week (or month) and offer an HIV test to every clinic patient that day.

•Offer an HIV test to the first patient seen every day (or every shift).

•Have staff wear buttons that say, “Ask me about an HIV test,” and/or put the same message on posters in exam rooms.

•Develop a system in which rapid HIV tests can be completed while other clinical care occurs so that the results are known before the patient leaves.

•Set quotas: ask clinical staff to do at least one HIV test a day or 10 a month or some other goal.

•Ask clinical staff to come up with their own processes to increase testing. After implementation, ask them to share their methods and talk about the outcomes.

•Don't expect physicians to take on this burden without support; nurses and other clinic staff can volunteer to move the process along, and nurses should take a lead on this task—it is right up there on the list of innovative things that nurses can do to improve patient health and welfare.

•Provide training to all clinical staff to help them practice talking to patients about HIV testing.

This is just a start on a list of possible interventions. The bottom line is that we need to encourage more testing and, given the many barriers to implementation, it seems that a harm reduction approach is worth a shot. Remember, a common outcome of these kinds of tactics is that people gain confidence and decide to expand their efforts. But even if that doesn't happen, if every clinician tests just one more patient than he or she normally would, it would be a good thing.

Back to Article Outline

References 

  1. Association of Nurses in AIDS Care. (2008, August). Position statement: CDC revised recommendations for HIV testing of adults, adolescents and pregnant women in health-care settings. Retrieved December 29, 2008, from http://www.nursesinaidscare.org/files/public/PS_CDCRevisedGuidelines_Rev_8_2008.pdf
  2. Bartlett JG, Branson BM, Fenton K, Hauschild BC, Miller V, Mayer KH. Opt-out testing for human immunodeficiency virus in the United States: Progress and challenges. Journal of the American Medical Association. 2008;300:945–951
  3. Centers for Disease Control and Prevention. (2006, September). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Retrieved December 29, 2008, from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm
  4. Forum for Collaborative HIV Research. (2008, November 20). Despite national guidelines, private insurers, emergency rooms, federal and state agencies fail to routinely test for HIV: New data at national summit show that routine testing would lower record numbers of “late testers,” save lives and reduce transmission. Retrieved December 29, 2008, from http://www.eurekalert.org/HIV-Testing
  5. Granich, R.M., Gliks, G.F., Dye, C., DeCock, K.M., & Williams, B.G. (2008). Universal voluntary HIV testing with immediate antiretroviral therapy is a strategy for elimination of HIV transmission: A mathematical model. Retrieved December 29, 2008, from http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61697-9/abstract
  6. Qaseem, A., Snow, V., Shekelle, P., Hopkins, P., Jr., Owens, D., & the Clinical Efficacy Assessment Subcommittee of the American College of Physicians. (2009). Screening for HIV in health care settings: A guidance statement from the American College of Physicians and HIV Medicine Association. Retrieved December 29, 2008, from http://www.annals.org/cgi/reprint/0000605-200901200-00300v1.pdf

PII: S1055-3290(09)00002-8

doi:10.1016/j.jana.2009.01.001

Journal of the Association of Nurses in AIDS Care
Volume 20, Issue 2 , Pages 87-88, March 2009

Article Tools