Determine Optimal Test Types

 

Consider Clinic Settings and Patient Needs

Deciding on which HIV test to utilize can be difficult. Each type of test may fit differently into clinic workflow. Different patient populations may react differently to the various options for test sampling. And billing considerations may come into play that will influence your choice of testing methods. In the end, different clinic sites may require the use of different tests and procedures.

We approached these decisions on a site by site basis, gathering data from clinic staff on:

• Current workflows and how each testing option would impact it. This included whether the lab location was on-site or down the street.
• The patient population and how staff felt they would react to different sampling methods. This too was impacted by the location of the lab and how convenient it would be for patients to use, how quickly results would be available and how likely patients were to follow-up on potential positives after their visit.
• Billing options that would work with the types of visits being conducted.

See additional information in the Strategize about Billing and Adjust Workflows sections.

 

Review Test Sampling Options

Note: Testing methodology is always changing and the information included in this toolkit may not be up-to-date with the latest recommendations.

Overall, it’s important to balance the desire to use the most sensitive and specific test possible with its potential screening uptake, the likelihood that the patient will agree to be tested and go to the lab to provide a sample for testing. Screening uptake varies by patient population as well as by the testing logistics at each individual site.

We considered the pros and cons of all three types of sampling methods, as well as where and when to insert the test into workflow. We often chose to make more than one method available at a given site:

	Traditional Blood Draw	In-House Rapid
		Finger Stick	Oral
Pro	Recommended by the CDC, this is considered the most sensitive test With confirmatory positive result, higher linkage to care rates. If patient is already having a blood draw, it’s easy to add in an HIV test	Single visit on-site results means more convenience for patients and higher likelihood of completion Patients can receive results almost immediately Many staff members loved learning and employing a new skill, especially where patient population had higher risk factors
		Patients afraid of blood draws are more likely to opt for testing if finger stick is an option	Patients afraid of blood draws may find this method less invasive
Cons	Some patients are afraid of the procedure or have a history of difficult blood draws If only lab during that visit, patients are less likely to complete the test; they’ll accept the order but not go to the lab to give the sample	Test not considered a final result More time-consuming for staff so more effort may be needed to achieve & maintain staff buy-in Potential reticence of staff to offer due to potential “false positive” preliminary reactive result
		Less sensitive than blood draws. False positives can be very upsetting for patients	Less sensitive than blood draws. False positives can be very upsetting for patients
Where Used	Because it’s the most sensitive, we tried to use it wherever possible	Implemented where labs were not on site and with teen, transient, and mental health populations	Some patients, particularly teens and those who have had trauma, prefer this method Offered in mobile clinic van and at special testing promotions

We always opted for traditional blood draw wherever we could, since this method is the most accurate, and allows for higher linkage to care rates. However, at our community college and high school clinics, we found patients would take the lab order but not fulfill. This was also true for our clinic that serves a mostly transient, homeless, and mentally unstable population. In all of these instances, we decided that rapid, in-house finger stick was our best option. However, even though our pediatric clinic did not have a lab on site, their leadership and staff determined that training Medical Assistants in phlebotomy would be a win for both patients and staff. The bottom line is we worked within the optimal workflows and with the culture of clinical staff, leadership and patients to determine the best fit.

 

Systematize with Policy Updates and EHR Modifications

Once you have a plan for testing, update your organization’s written protocols and policies to include it, making site-level modifications if needed. Be sure the EHR is also updated to handle any new test types. These structural changes will help to integrate testing into your overall systems, contributing to sustainability.

You’ll also need to train staff on the tests that will be offered, how they should collect/prepare the samples, how they should enter testing and billing data into the EHR, and how to talk to patients about their options. See the Culture & Knowledge > Understand HIV Tests & Results section for more on staff training.

 

Resources:

• Presentation including information on HIV antigens and antibodies, test product information and clinical data, testing procedures, external controls, and a quiz (.pdf)
• Explanation of antigens and antibodies and how they are produced, along with a description of how different HIV tests detect them (.pdf)
• Explanation of sample collection using fingerstick method (.pdf)
• Explanation how to read results for Ag/Ab Combo test (.pdf)