Missed Opportunities:

Improving Rates of HIV Screening and Linkage

among Primary Care Providers

Ann D. Bagchi, PhD, BSN, RN May 19, 2017

Missed Opportunities

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BACKGROUND

Missed Opportunities

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The Role of Primary Care

• Available tests are very accurate in detecting HIV

• Identifying those infected allows earlier initiation of antiretroviral therapy

• Testing is cost effective

• Risk-based screening is ineffective in identifying everyone

• Increasing routine screening can help to address HIV-related stigma

Rationale for routine screening (USPSTF)

Eradicating HIV requires participation of Primary Care Providers (PCPs)

• Since 2006, the Centers for Disease Control and Prevention (CDC) has recommended routine screening for everyone ages 13 to 64

• In 2013, the CDC recommendation was endorsed by the United States Preventive Services Task Force (USPSTF)

• Providers may not ask the right questions

• Patients do not think they are at risk

• Patients may not want to divulge risk behaviors to providers

Risk-based screening is ineffective

Missed Opportunities

PCPs are less likely to follow guidelines with a

public health benefit

168,000 people are living with HIV but

undiagnosed

4

Needs Assessment

Rates of routine testing are suboptimal

Evidence-based interventions are needed to overcome PCPs’

barriers to offering and implementing routine HIV testing

Approximately 6,800 may be undiagnosed

in New Jersey

PLHIV who are unaware of their

status are responsible for 30% of new transmissions

67% among HIV PCPs versus 38% among

non-HIV PCPs

HIV PCPs who are not credentialed as HIV

specialists have lower rates of routine HIV

testing than specialty providers

Focus on individual health concerns and

outcomes

Emphasize perceived individual risk factors

and behaviors for preventable conditions

Missed Opportunities

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DOCTOR OF NURSING PRACTICE PROJECT

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Objectives and Aims

• Identify PCPs’ barriers/facilitators to routine HIV testing

• Identify evidence-based approaches to improving guideline adherence

• Map testing barriers to evidence-based interventions

• Deliver interventions in a sample of PCPs

• Evaluate the effectiveness of interventions using a pre-/post-test design

Missed Opportunities

• PCPs (MDs / DOs / APNs / PAs)

• Provide health care services to consumers ages 13 to 64

• Family practice/Internal medicine/Pediatrics

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Participants / Setting

• Qualtrics on-line survey (baseline and follow-up)

Participant background / practice characteristics

Frequency of HIV screening

Barriers to routine screening

• Interventions

Evidence-based / practice-specific

Delivered via customized PowerPoint presentation

• Expected outcomes

Increased frequency of offering routine HIV screening

Increased screening by visit type/patient characteristics

Approach

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Intervention

• HIV prevalence/Care Continuum

• CDC/USPSTF recommendations

• Stigma/Ryan White

• Top 3 barriers identified from baseline survey

• Linked to TDF domains and evidence-based behavioral change techniques

• Copies of guidelines

• Referral sources/Ryan White providers

• Reporting forms/billing codes

• Patient/provider educational materials

• Interview: Dr. Yelena Karasina

Missed Opportunities

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Missed Opportunities

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Lack of Referral Sources

Primary care providers are increasingly providing care for people living with HIV in consultation with experts:

Contact Ryan White-funded sites for access to HIV specialists

(See Resources for list of sites in NJ)

For additional assistance identifying resources and referrals, contact:

848-932-4191 or

hivtraining@ejb.rutgers.edu 800-624-2377

Missed Opportunities

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

HIV SpecialistsWorking in Primary

Care Settings

Non-HIV SpecialistsWorking in HIVPrimary Care

Non-HIV SpecialistsWorking in Non-HIV

Primary CareSettings

Reported Estimatefor Your Practice

78%

57%

38%

5%

Rates of Routine HIV Screening

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FINDINGS

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Education on HIV in the Last 3 years

8%

15%

15%

23%

23%

23%

39%

39%

46%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

ONLINE WEBINAR

GRAND ROUNDS

JOURNAL ARTICLE

CONFERENCE PRESENTATION

TEXTBOOK

NONE

ACADEMIC COURSE

DISCUSSION WITH AN EXPERT/COLLEAGUE

CONTINUING EDUCATION COURSE

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Barriers Identified

Patients do not want to be tested for HIV.

Difficulty screening adolescents when accompanied by a parent/guardian.

Financial costs to patients if testing is not covered by insurance.

It should be the patient’s responsibility to request an HIV test.

Lack of access to point-of-care testing (i.e., a rapid test) for HIV.

Suggesting HIV testing might damage the patient-provider relationship.

It is not the responsibility of primary care providers to conduct HIV screening.

Discomfort discussing HIV risk behaviors with patients.

Discomfort discussing a positive test result with a patient.

Uncertainty about the legal obligations for reporting a positive test result.

HIV screening should be limited to those with risk factors for infection.

Lack of referral sources if a patient tested positive for HIV.

Pre-test counseling significantly lengthens the time required to screen for HIV.

Inadequate training in how to discuss HIV with patients.

HIV screening is not relevant to the reason for the patient visit.

Risk of breaking patient confidentiality when billing for HIV screening.

Lack of standardized practice protocol for HIV screening.

Lack of awareness of the CDC recommendation.

Lack of support for HIV screening among practice administration.

Forgetting to screen for HIV.

Missed Opportunities

15

25

20

80

90

5 5

20

35

4

10

1

20

50 50

20

80

70

10 10

25

75

10

25

0 0 0 0

10

20

30

40

50

60

70

80

90

100

PCP01 PCP03 PCP06 PCP08 PCP09 PCP10 PCP12 PCP13 PCP14 PCP16 PCP17 PCP07 PCP15

Rep

ort

ed

% o

f P

ati

en

ts S

cre

en

ed

Primary Care Providers (Coded)

Pre (Mean = 28.1%)

Post (Mean = 34.1%)

Pre vs Post: % of Patients Screened

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Pre vs Post: % of Patients Screened by Encounter

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Pre vs Post: % of Patients Screened by Age Groups

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Pre vs Post: % of Patients Screened by Patient Presentation

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Interview with Dr. Karasina

• Lack of awareness of HIV Testing Law

• Fear of damaging patient / provider relationship

• Perception regarding stigma among patients

• Incorporating HIV screening into the electronic medical record

• Identified 3 patients who were infected with HIV

Patients she would not have thought to screen

Would not have been identified otherwise

Patients referred to infectious disease specialist

Missed Opportunities

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IMPLICATIONS

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Opportunities

Ryan White-funded providers can help PCPs improve prevention and care

• Provide access to rapid testing

• Serves as referral sites when patients test positive

• Act as expert consultants for PCPs willing to provide care for PLHIV

• Offer education to enhance competencies of PCPs

Policy initiatives could enhance screening rates

Increasing routine screening in primary care can help identify PLHIV

• Require continuing education credits on HIV screening for PCPs

• Adopt an HIV Testing Law in New Jersey

• Implement interventions to address HIV-related stigma

Missed Opportunities

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Enhancing Linkages

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Q & A

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Ann D. Bagchi, PhD, DNP-F, RN Instructor, School of Nursing

Rutgers University – Newark

366 Ackerson Hall

180 University Avenue

Newark, NJ 07102

(973) 353-1042

ann.bagchi@rutgers.edu

Contact Information

Missed Opportunities

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Cane, J., O’Connor, D., & Michie, S. (2012). Validation of the theoretical domains framework for use in behavior change

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Frieden, T. R., Foti, K. E., & Mermin, J. (2015). Applying public health principles to the HIV epidemic – How are we

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References