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HIV testing increases 15-fold among teens after improvement initiative
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NEW ORLEANS — A center with typically low HIV testing rates achieved a 15-fold increase in the number of adolescents screened for infection at well visits and a fourfold increase in screening at visits for both preventive and illness concerns.
The research, presented at the AAP National Conference & Exhibition, highlights the improvements that can be made with access to point-of-care screening, by educating providers on guideline recommendations and families on reducing stigma associated with HIV.
According to the CDC, nearly 21% of all new HIV diagnoses in 2017 were made among youth aged 13 to 24 years. The agency recommends that all adolescents be screened for HIV routinely, beginning at age 13 years.
The U.S. Preventive Services Task Force (USPSTF) also recommends routine screening for adolescents aged 15 years and older, as well as younger adolescents who are at increased risk for infection. Additionally, the AAP recommends screening between ages 15 and 18 years and backs the USPSTF recommendations.
Jaron Smith, MD, from the Maricopa Medical Center and Phoenix Children’s Hospital, told Infectious Diseases in Children that the study began when a group of residents and attending physicians identified a need to implement clinical practices that were in line with these national guidelines. Additionally, they noted a need for point-of-care testing.
“Apart from high-risk patients — those who engage in risky sexual behaviors, IV drug use or had suspected exposure — we had no clear decision point regarding who to test before implementing this intervention,” Smith said. “It was entirely up to the provider to order a test and up to the patient to get the test at a lab as we didn’t have the point-of-care test.”
According to the researchers, before the study, only 3% of patients presenting to their general pediatrics and adolescent clinic were screened for HIV between 2015 and 2016. Smith and colleagues aimed to increase screening rates at all visits to 50%.
To accomplish this goal, they implemented an educational intervention for their multidisciplinary clinic team, created a standardized workflow for screening, began using rapid point-of-care HIV tests, developed educational materials for families and improved awareness of HIV in their community.
HIV testing was also added to the list of intake information for patients aged 15 years and older presenting for a well visit.
Between November 2015 and April 2016, 3.2% of teens presenting for well visits and 3.8% of teens presenting for both preventive and illness issues (combined visits) were screened for HIV. From May to December 2016, this percentage increased to 10.6% of teens presenting for a well visit, 7.1% for a sick visit and 7.9% for combined visits.
Between January and August 2017, the rate of testing increased further among teens presenting for well visits (21.9%) and combined visits (10.8%). However, the rate of testing decreased to 4.5% among teens presenting for a sick visit.
At the end of 2018, additional increases were observed among well visits (35.9%), sick visits (5.9%) and combined visits (16.7%). As of March 2019, 46.8% of teenagers presenting for well visits, 6% of teens presenting for sick visits and 18.8% of those presenting for combined visits were screened for HIV.
“Implementing the point-of-care test in other practices is something we’ve considered doing via outreach and training,” Smith said. “The test takes about 15 minutes to result, is relatively inexpensive, requires minimal training to perform and serves as an excellent screening test thanks to its high sensitivity.”
However, Smith also noted that barriers to its routine use exist, including the need for a confirmatory test. This requires additional lab draws rather than a point-of-care test. Smith also cited that the number of patients who need to be tested to identify a patient who has HIV remains unknown. He said that the researchers have not identified this number because his institution has not yet diagnosed a patient with HIV with routine screening.
Furthermore, Smith also noted that a lack of accessible follow-up care could create issues in the future.
“We're privileged at our tertiary care center to have a multidisciplinary team dedicated to HIV care in pediatric patients, but we know that we're the exception rather than the rule in the United States. — even in Arizona,” he said.
Reference:
Smith J, et al. HIV screening in an urban adolescent population. Presented at: AAP National Conference & Exhibition; Oct. 25-29, 2019; New Orleans.
Disclosure: Smith reports no relevant financial disclosures.
Perspective
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Michelle Collins Ogle, MD, FAAP, AAHIVS
There are many missed opportunities for adolescents to be tested for HIV and other STIs because clinicians often underestimate or do not thoroughly discuss sexual activity with their patients. I appreciate the effort from this urban general pediatric and adolescent practice to assess missed opportunities to educate and test their patients for HIV, which helps reduce the stigma and shame associated with being tested.
I also think it is a very good plan to have nurse-driven testing because it is less intimidating, and patients generally have a very close relationship with the clinic nurse.
It would be nice to know the demographics of the patients, whether parents and/or patients refused testing and why.
The handouts are also really informative and in language that young people can understand, that does not appear "scary" and stresses that providers care about them and want to keep them safe.
This is really a great model for other practices to use in suburban, rural and urban clinics. Often, suburban and rural practices tend to approach HIV as a problem among "urban youth," or in other words, youth of color. This is very stigmatizing and inaccurate.
Kudos to this pediatric and adolescent practice to look at what they could do instead of expecting the kids to come in and ask for an HIV test!
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