BACKGROUND AND OBJECTIVES:

Less than 50% of youth living with HIV know their status. The Centers for Disease Control and Prevention and the United States Preventive Services Task Force recommend universal HIV screening in adolescence. Pediatric primary care settings are still lacking in testing youth who are at risk for HIV. Our objective was to determine whether implementing rapid HIV screening improved HIV screening rates and result receipt in 13- to 25-year-old pediatric primary patients.

METHODS:

From March 2014 to June 2015, a 4-cycle plan-do-study-act quality improvement model was used. A total of 4433 patients aged 13 to 25 years were eligible for HIV screening on the basis of Centers for Disease Control and Prevention criteria. Logistic regression with random effects was used to estimate the odds of HIV screening and screening with a rapid test compared with each previous cycle. Statistical process control charts using standard interpretation rules assessed the effect of patients receiving rapid HIV screening.

RESULTS:

Baseline HIV screening rate was 29.6%; it increased to 82.7% in cycle 4. The odds of HIV screening increased 31% between cycle 1 and baseline (odds ratio 1.31 [95% confidence interval: 1.01–1.69]) to a 1272% increase between cycle 4 and baseline (odds ratio 12.72 [95% confidence interval: 10.45–15.48]), with most (90.4%) via rapid screening. Rapid screening yielded higher same-day result receipt . Five patients were identified with HIV and immediately linked to on-site care.

CONCLUSIONS:

Rapid HIV screening and system-level modifications significantly increased screening rates and result receipt, revealing this to be an effective method to deliver HIV services to youth.

An estimated 25% of all Americans and 41% to 50% of adolescents living with HIV do not know their HIV status.1 Earlier identification of individuals who are unaware of their HIV status can result in earlier antiretroviral initiation, decreased HIV transmission, and improved HIV outcomes.2 Universal HIV screening beginning in adolescence is recommended by the Centers for Disease Control and Prevention (CDC) and the United States Preventive Services Task Force.3,4 However, pediatric primary care settings have low rates of HIV screening because of poor awareness of guidelines, concerns over confidentiality, and screening barriers (eg, time constraints and a lack of training in providing results).5 

Primary care can play an important role in screening youth for HIV and linking them to care because this is the setting where most youth are served.6,8 One study revealed that only one-third of a nationally representative sample of young adults reported previous HIV screening, and the majority were screened in private physician offices, followed by public clinics.9 Youth prefer to be offered rather than request HIV screening and be tested in convenient settings (eg, primary care or school-based clinics).10,13 Barriers include stigma associated with screening, being uninsured, and poor access to age-appropriate services.14 Poor understanding of parental consent requirements also limit HIV screening in primary care.15,18 

Community-based and academic health settings that have incorporated HIV testing as standard care have transformed perceptions of HIV screening and capitalized on technologies to increase rates, with the use of rapid screening having the biggest effect.15,19,20 Youth find rapid screening approaches to be more acceptable than serology because of time efficiency (ie, only needing 1 visit and receiving results within 20 minutes) and not requiring a blood draw.21,23 The use of rapid screening may also increase adolescents’ perceived confidentiality because results are provided in person versus by phone or mail. However, most rapid HIV screening programs with pediatric populations have been evaluated in emergency departments or as targeted strategies.13,21 Little work has been focused on implementing and evaluating rapid screening in primary care and identifying and linking adolescents with HIV to care.21 

A systems-level approach in which providers use a continuous practice improvement model is 1 method that can be used to address screening barriers. A recent study revealed that the use of such an approach was associated with increased serologic HIV screening in adolescent primary care.24 The plan-do-study-act (PDSA) model is well established for implementing and assessing quality improvement through ongoing data to inform the implementation process.25,26 

To address the gaps in the literature, our goals were to determine the following: (1) whether implementing rapid HIV screening as standard practice improved screening rates and result receipt among patients aged 13 to 25 years in a pediatric primary care setting using a PDSA approach; (2) which PDSA cycle had the greatest impact on increasing HIV screening rates and the use of rapid versus serologic HIV tests; and (3) the number of new patients with HIV who are identified and linked to HIV care.

From March 2014 to June 2015, a systems-level continuous practice improvement approach designed to implement the CDC’s recommendations for HIV screening by using an opt-out approach in health care settings27 was conducted in an academic pediatric primary care practice that serves an urban city with a high HIV prevalence. The clinic provides primary care services to patients up to 25 years old. During the project period, the clinic served 6153 patients of all ages; 1891 were aged 13 to 25 years and HIV-seronegative and made a total of 7177 visits. Health care providers consisted of 12 general pediatricians, an average of 90 pediatric residents per year, 7 adolescent medicine providers, 3 adolescent medicine fellows, 6 HIV care providers, and 2 certified health educator (CHE) clinic staff who were trained and certified by the state to conduct rapid HIV screening.

Repeated PDSA cycles were used to determine the most effective way to increase HIV screening rates. A quality improvement team was assembled that consisted of medical directors, nurse managers, social workers, and CHEs from the primary care and HIV clinics who committed to meeting weekly to review progress. The use of CHEs has been shown to alleviate the time constraints that providers face when providing care by integrating testing into routine clinic flow and to be effective in individually tailoring counseling and providing rapid testing.22,28 

In each cycle, the team planned strategies to change practice that affects service quality (plan), identified strategies to be conducted (do), rapidly assessed the intervention and reflected on collected data at the end of each implementation phase (study), and reassessed progress toward rapid screening and successful strategies (act).26 Four iterative PDSA cycles were used to assess the uptake of rapid HIV screening. This quality improvement program was approved by the institutional review board as exempt.

CDC guidelines recommend HIV screening for all individuals aged 13 years or older at least once regardless of risk, and individuals who are at higher risk are to be screened at least annually with repeat screening on the basis of clinical judgment (higher risk is defined as being sexually active and living in a high-prevalence area for HIV [>0.1%], having sex without a condom, having multiple sexual partners, having transactional sex, having a history of injection drug use, or men who have sex with men).27 CHEs approached all eligible patients during clinic visits to obtain verbal consent for screening and to provide patients an opportunity to opt out of screening. CHEs explained the purpose of the test, screening recommendations, and how the test would be performed. Those who accepted screening were offered a third-generation oral rapid HIV test (OraQuick Advance; OraSure Technologies, Inc, Bethlehem, PA); patients reporting recent risk behaviors were screened via a serologic fourth-generation antigen and/or antibody test. A confirmatory fourth-generation test was completed for all patients with a preliminary positive rapid test result.

Patients were typically approached during wait times (eg, vital signs, waiting to be seen by a provider, etc) to minimize clinic workflow disruptions. CHEs spent ∼25 minutes with each patient. Although the CDC does not recommend pre-and posttest counseling, patients were offered optional pre- and posttest risk reduction counseling as an opportunity to provide education, increase HIV testing uptake, and address specific patient concerns regarding confidentiality, safe sex, and pregnancy prevention.29,30 

During the baseline period (September 1, 2013–February 28, 2014), clinic providers were given information on HIV screening guidelines and were responsible for identifying patients who were in need of screening. Rapid HIV tests were available at the providers’ request. Immediately before this baseline period, a quality improvement initiative had been used to provide information about the CDC’s guidance on HIV screening, and providers were open and willing to screen adolescents for HIV using a serology-based approach.24 

During cycle 1 (March 1, 2014–March 31, 2014), all clinical staff and providers were trained on HIV screening guidelines, the availability of rapid testing, and how to refer patients to CHEs using a paging system. Overall, providers were receptive to implementing rapid HIV testing but made few referrals.

During cycle 2 (April 1, 2014–September 30, 2014), in addition to the provider-based approach used in cycle 1, CHEs were colocated with providers in provider workrooms. Colocation allowed for greater involvement in patient care by CHEs and improved accessibility of rapid screening services, but there were still missed opportunities for testing.

During cycle 3 (October 1, 2014–December 31, 2014), CHEs continued to be colocated with providers as in cycle 2 but took more proactive roles in 2 ways:

  1. CHEs reviewed scheduled patients’ medical records each morning to identify individuals who were eligible for rapid screening using CDC guidelines and minimize missing patients in need of testing, and

  2. CHEs approached eligible patients at any opportunity during the clinical encounter without requiring provider referrals for screening to minimize patient wait time and maximize clinic workflow.

During cycle 4 (January 1, 2015–June 30, 2015), as in cycle 3, CHEs continued to be colocated with providers and in their proactive roles, and they also began to document reasons why rapid screening was not completed. Across cycles 1 through 3, 1 of the most significant challenges was understanding reasons for not screening. CHEs documented if a patient had been tested for HIV elsewhere during the past 365 days, was seen for an issue that took priority over screening (eg, sick visit, acute injury, or mental health issue), declined screening, or left before being seen by a CHE (a true “missed opportunity”). Patterns of missed opportunities were reviewed, and in-person feedback was shared with providers.

Outcome measures included the overall HIV screening rate, screening rate by test type, and result receipt by test type among patients aged 13 to 25 years. The overall HIV screening rate was calculated as the number of eligible patients who were screened per the number of eligible patients by cycle. A clinic administrative database was used to retrospectively determine a patient’s eligibility for screening at that day’s visit based on the most recent HIV test date. A patient was considered to be eligible for screening if he or she had no documentation of an HIV test ever, he or she was sexually active and had no test documented in the past 12 months, or there was documentation of recent risk behavior and no documentation of screening in the past 6 months. The HIV screening rate by test type rate was calculated as the number of patients who were screened with a rapid or serology test per the number of patients who were screened with total tests by cycle. Result receipt by test type was determined as follows: rapid test result receipt was calculated by the number of patients who received same-day test results per the number of patients who were tested (that accounts for patients who left without test result receipt); serology test result receipt was based on retrospective chart review and documentation of patient results receipt.

Three existing databases contributed to the merged administrative database based on patient medical record numbers and visit dates containing all clinic visits from September 2012 to June 2015. Data also included age (in years); race and/or ethnicity (non-Hispanic African American, non-Hispanic white, Hispanic, and other race and/or ethnicity [eg, Asian American and/or Pacific Islander and American Indian], refused, or unknown); sex (male or female); sexual activity (never or ever sexually active); rapid and serologic HIV test result (positive [serologic screen only], preliminary positive [rapid screen only], or negative); documentation of high-risk sexual behavior (per medical record); and, among newly diagnosed patients, documentation of linkage to and retention (2 or more visits within a 12-month period) in HIV care.31 During cycle 4, the reason why eligible patients were not screened was documented in the database.

Frequencies were first generated to describe patient characteristics. Separate crosstabs were then performed to summarize HIV screening eligibility by patient characteristic and stratified by patient sex. Next, data from each cycle were used to generate the overall HIV screening rate and screening rate by test type by cycle to make comparisons between cycles and against the baseline period.

The change in the HIV screening rate by cycle was examined by using a random intercept logistic regression model accounting for 2 levels (repeated measures and individuals) and estimating the odds of a patient being screened for HIV from each follow-up cycle compared with baseline and each subsequent cycle compared with the previous cycle.32 Then, the change in the HIV test type used by cycle was examined by using a random intercept logistic regression model accounting for 2 levels (repeated measures and individuals) and estimating the odds of a patient being screened for HIV by test type from each follow-up cycle compared with baseline and each subsequent cycle compared with the previous cycle.32 These analyses were conducted by using Stata 9 (Stata Corp, College Station, TX).

Statistical process control (SPC) charts with weekly time intervals were constructed to assess the effect of the intervention on the proportion of patients receiving rapid HIV screening. Control limits were set at 3 SDs from the mean to identify special causes by using standard criteria.33 SPC charts were constructed by using QI Macros 2017 for Excel (KnowWare International, Inc, Denver, CO).

A total of 4433 visits occurred during the study period in which patients were eligible for HIV screening (of 7177 total visits). The majority of these visits were made by non-Hispanic African American (94.1%) and female (65.8%) patients, comprising a nearly equal age distribution of patients aged 13 to 14 years (21.4%), 15 to 17 years (35.3%), 18 to 19 years (21.8%), and 20 to 25 years (21.6%; Table 1). Patient demographics for eligible visits are consistent with the general clinic population, in which 95.8% of patients were non-Hispanic African American and 56.0% were female.

TABLE 1

Background Characteristics of Patients Who Were Eligible for HIV Screening From September 2013 to June 2015

Patient CharacteristicsPatients Who Were Eligible for HIV TestingPatient Sexa
MaleFemale
N (%)N (%)N (%)
Total 4433 (100.0) 1789 (40.4) 2644 (59.6) 
Age, y    
 13–14 1262 (28.5) 583 (46.2) 679 (53.8) 
 15–17 1621 (36.6) 696 (49.9) 925 (57.1) 
 18–19 792 (17.9) 281 (35.5) 511 (64.5) 
 20–25 758 (17.1) 229 (30.2) 529 (69.8) 
Race and/or ethnicity    
 Non-Hispanic African American 4189 (94.5) 1673 (39.9) 2516 (60.1) 
 Non-Hispanic white 109 (2.5) 49 (45.0) 60 (55.0) 
 Hispanic 36 (0.8) 10 (27.8) 26 (72.2) 
 Other 77 (1.7) 39 (50.7) 38 (49.3) 
 Refused 5 (0.1) 4 (80.0) 1 (20.0) 
 Unknown 17 (0.4) 14 (82.4) 3 (17.6) 
Patient CharacteristicsPatients Who Were Eligible for HIV TestingPatient Sexa
MaleFemale
N (%)N (%)N (%)
Total 4433 (100.0) 1789 (40.4) 2644 (59.6) 
Age, y    
 13–14 1262 (28.5) 583 (46.2) 679 (53.8) 
 15–17 1621 (36.6) 696 (49.9) 925 (57.1) 
 18–19 792 (17.9) 281 (35.5) 511 (64.5) 
 20–25 758 (17.1) 229 (30.2) 529 (69.8) 
Race and/or ethnicity    
 Non-Hispanic African American 4189 (94.5) 1673 (39.9) 2516 (60.1) 
 Non-Hispanic white 109 (2.5) 49 (45.0) 60 (55.0) 
 Hispanic 36 (0.8) 10 (27.8) 26 (72.2) 
 Other 77 (1.7) 39 (50.7) 38 (49.3) 
 Refused 5 (0.1) 4 (80.0) 1 (20.0) 
 Unknown 17 (0.4) 14 (82.4) 3 (17.6) 
a

Gender identity was not included because it was systematically collected only for patients who received a rapid HIV test during cycles 1–4.

The HIV screening rate at baseline was 29.6% and was 28.8% during cycle 1, 37.9% during cycle 2, 61.2% during cycle 3, and 82.7% during cycle 4 (Table 2). During cycle 4, 109 (12.9%) eligible patients were determined to be missed screening opportunities at that visit, 19 (2.2%) had issues that took priority over screening at that visit, 10 (1.2%) received serologic screening because of reporting recent risk behaviors, and 8 (1.0%) declined screening.

TABLE 2

Rate and Odds of HIV Screening by PDSA Cycle

BaselineaCycle 1bCycle 2cCycle 3dCycle 4e
Cycle length, mo 
Eligible for HIV screen by test status,fN (%)      
 Not tested 914 (70.4) 151 (71.2) 878 (62.1) 257 (38.8) 146 (17.3) 
 Tested 385 (29.6) 61 (28.8) 535 (37.9) 406 (61.2) 700 (82.7) 
Change in HIV screening, OR (95% CI)g      
 Compared with baseline Reference 1.31 (1.01–1.69)* 1.65 (1.44–1.89)*** 4.67 (3.91–5.57)*** 12.72 (10.45–15.48)*** 
 Compared with cycle 1 — Reference 1.26 (0.98–1.64) 3.58 (2.70–4.74)*** 9.75 (7.27–13.08)*** 
 Compared with cycle 2 — — Reference 2.83 (2.39–3.36)*** 7.71 (6.37–9.34)*** 
 Compared with cycle 3 — — — Reference 2.73 (2.18–3.41)*** 
HIV-positive outcomes, N (%)      
 Positive HIV test results 2 (0.4) 1 (0.3) 2 (0.3) 
 Same-d link to care n/a n/a 2 (100.0) 1 (100.0) 2 (100.0) 
 Retained in care n/a n/a 1 (50.0) 1 (100.0) 1 (50.0) 
BaselineaCycle 1bCycle 2cCycle 3dCycle 4e
Cycle length, mo 
Eligible for HIV screen by test status,fN (%)      
 Not tested 914 (70.4) 151 (71.2) 878 (62.1) 257 (38.8) 146 (17.3) 
 Tested 385 (29.6) 61 (28.8) 535 (37.9) 406 (61.2) 700 (82.7) 
Change in HIV screening, OR (95% CI)g      
 Compared with baseline Reference 1.31 (1.01–1.69)* 1.65 (1.44–1.89)*** 4.67 (3.91–5.57)*** 12.72 (10.45–15.48)*** 
 Compared with cycle 1 — Reference 1.26 (0.98–1.64) 3.58 (2.70–4.74)*** 9.75 (7.27–13.08)*** 
 Compared with cycle 2 — — Reference 2.83 (2.39–3.36)*** 7.71 (6.37–9.34)*** 
 Compared with cycle 3 — — — Reference 2.73 (2.18–3.41)*** 
HIV-positive outcomes, N (%)      
 Positive HIV test results 2 (0.4) 1 (0.3) 2 (0.3) 
 Same-d link to care n/a n/a 2 (100.0) 1 (100.0) 2 (100.0) 
 Retained in care n/a n/a 1 (50.0) 1 (100.0) 1 (50.0) 

CI, confidence interval; n/a, not available; OR, odds ratio; —, not applicable.

a

Baseline was September 2013 to February 2014 with serology screening as standard practice.

b

Cycle 1 was March 2014 and included the implementation of rapid HIV screening in the clinic with screening dependent on referral by provider.

c

Cycle 2 was April 2014 to September 2014. CHEs were colocated with providers.

d

Cycle 3 was October 2014 to December 2014. CHEs proactively approached patients for screening.

e

Cycle 4 was January 2015 to June 2015. CHEs proactively approached patients for screening and tracked actual missed opportunities for screening.

f

Eligible patients were considered to be missed opportunities for screening if the patients left before the CHEs could approach them. Patients who were seen for an issue taking priority over screening or who declined screening were not considered to be missed opportunities.

g

Logistic regression with random effects was used to estimate the odds of being tested for HIV.

*

P < .05;

***

P < .001.

Compared with at baseline, a patient was more likely to be screened for HIV in cycle 1 (odds ratio [OR] 1.31 [95% confidence interval (CI): 1.01–1.69]); this increased to 65% increased odds in cycle 2 (OR 1.65 [95% CI: 1.44–1.89]); >4 times increased odds in cycle 3 (OR 4.67 [95% CI: 3.91–5.57]), and ∼13 times increased odds in cycle 4 (OR 12.72 [95% CI: 10.45–15.48]; Table 2). Analyses revealed that for each cycle, the odds of being screened for HIV significantly increased compared with the previous cycle except when cycle 2 was compared with cycle 1 (Table 2). As such, the total number of eligible patients decreased each cycle as patients were tested (Table 2).

Overall, 5 patients were identified as HIV-positive during the program (Table 2), and all those patients were linked on the same day to on-site HIV care. At the program’s end, 3 of the 5 patients were retained in care.

At baseline, 2.9% of the HIV screening tests conducted were rapid and 97.1% were serology (Table 3). In cycle 1, 42.6% of tests were rapid and 57.4% were serology; in cycle 2, 63.2% were rapid and 36.8% were serology; in cycle 3, 87.9% were rapid and 12.1% were serology; and in cycle 4, 90.4% were rapid and 9.6% were serology.

TABLE 3

Rate and Odds of Test Type Use by PDSA Cycle

BaselineaCycle 1bCycle 2cCycle 3dCycle 4e
Cycle length, mo 
HIV test type, N (%)      
 Rapid test 11 (2.9) 26 (42.6) 338 (63.2) 357 (87.9) 633 (90.4) 
 Serology test 374 (97.1) 35 (57.4) 197 (36.8) 49 (12.1) 67 (9.6) 
Rapid versus serology, OR (95% CI)f      
 Compared with baseline Reference 26.24 (11.92–57.79)*** 61.37 (32.65–115.34)*** 256.99 (130.75–505.12)*** 332.36 (172.64–639.84)*** 
 Compared with cycle 1 — Reference 2.34 (1.37–3.99)** 9.79 (5.44–17.62)*** 12.67 (7.20–22.27)*** 
 Compared with cycle 2 — — Reference 4.19 (2.96–5.92)*** 5.42 (3.99–7.36)*** 
 Compared with cycle 3 — — — Reference 1.29 (0.88–1.91) 
Result receipt by test type, N (%)      
 Rapid test 11 (100.0) 26 (100.0) 337 (99.7) 356 (99.7) 621 (98.1) 
 Serology test 68 (18.2) 10 (28.6) 30 (15.2) 4 (8.2) 13 (19.4) 
Of patients receiving serology test result, d to return to get result, mean (SD) 64.2 (128.6) 18.4 (27.9) 81.3 (145.3) 71.3 (114.8) 23.4 (46.4) 
BaselineaCycle 1bCycle 2cCycle 3dCycle 4e
Cycle length, mo 
HIV test type, N (%)      
 Rapid test 11 (2.9) 26 (42.6) 338 (63.2) 357 (87.9) 633 (90.4) 
 Serology test 374 (97.1) 35 (57.4) 197 (36.8) 49 (12.1) 67 (9.6) 
Rapid versus serology, OR (95% CI)f      
 Compared with baseline Reference 26.24 (11.92–57.79)*** 61.37 (32.65–115.34)*** 256.99 (130.75–505.12)*** 332.36 (172.64–639.84)*** 
 Compared with cycle 1 — Reference 2.34 (1.37–3.99)** 9.79 (5.44–17.62)*** 12.67 (7.20–22.27)*** 
 Compared with cycle 2 — — Reference 4.19 (2.96–5.92)*** 5.42 (3.99–7.36)*** 
 Compared with cycle 3 — — — Reference 1.29 (0.88–1.91) 
Result receipt by test type, N (%)      
 Rapid test 11 (100.0) 26 (100.0) 337 (99.7) 356 (99.7) 621 (98.1) 
 Serology test 68 (18.2) 10 (28.6) 30 (15.2) 4 (8.2) 13 (19.4) 
Of patients receiving serology test result, d to return to get result, mean (SD) 64.2 (128.6) 18.4 (27.9) 81.3 (145.3) 71.3 (114.8) 23.4 (46.4) 

CI, confidence interval; OR, odds ratio; —, not applicable.

a

Baseline was September 2013 to February 2014 with serology screening as standard practice.

b

Cycle 1 was March 2014 and included the implementation of rapid HIV screening in the clinic with screening dependent on referral by provider.

c

Cycle 2 was April 2014 to September 2014. CHEs were colocated with providers.

d

Cycle 3 was October 2014 to December 2014. CHEs proactively approached patients for screening.

e

Cycle 4 was January 2015 to June 2015. CHEs proactively approached patients for screening and tracked actual missed opportunities for screening.

f

Logistic regression with random effects was used to estimate the odds of being tested via a rapid versus serology HIV test.

**

P < .01;

***

P < .001.

In cycle 1 compared with at baseline, a patient had 26 times increased odds of being tested via rapid HIV screening test (OR 26.24 [95% CI: 11.92–57.79]); this increased to 61 times increased odds in cycle 2 (OR 61.37 [95% CI: 32.65–115.34]), ∼257 times increased odds in cycle 3 (OR 256.99 [95% CI: 130.75–505.12]), and 332 times increased odds in cycle 4 (OR 332.36 [95% CI: 172.64–639.84]; Table 3). Analyses revealed that in each cycle, the odds of being tested via rapid HIV screening test significantly increased compared with the previous cycle except between cycles 4 and 3.

Almost all patients (range: 98.1%–100%) who received a rapid screening test received same-day results (Table 3). Among the patients who were screened via serology, a minority had medical record documentation that they received their serology test results (range: 8.2%–28.6%), and the mean days to receiving them ranged from 18.4 (SD 27.9) to 81.3 (SD 145.3).

During the project period, an average of 45.4 (SD 16.1) patients were eligible per week, ranging from 6 to 76. The proportion of eligible patients who were screened by using rapid HIV tests increased from 0% at baseline to 22%, 56%, and 74% in each of the following cycles, respectively (Fig 1). SPC screening was used to identify multiple shifts in the data with subsequent stages of the program, revealing special cause variation. The observed drop between cycles 3 and 4 is due to fewer patients being seen during the holiday period.

FIGURE 1

SPC chart of the proportion of eligible patients who received rapid HIV screening tests each week from September 2013 to June 2015.

FIGURE 1

SPC chart of the proportion of eligible patients who received rapid HIV screening tests each week from September 2013 to June 2015.

Close modal

We found that introducing CHE-driven routine opt-out rapid HIV screening and system-level modifications significantly increased HIV screening rates, rapid tests, and result receipt among youth seen in pediatric primary care. These findings can be used to support other research that has revealed increases in HIV screening rates when screening is included as part of standard care for youth.10,19 

Having CHEs colocated in the provider workrooms and proactively approach patients was the most effective strategy for improving HIV screening rates and the use of rapid HIV tests. CHE review of patient charts in advance of the visit allowed for improved identification of eligible patients and screening rates. Study findings can be used to extend other work, which reveals that adolescent-specific system-level approaches to incorporating rapid HIV screening into family planning settings result in high rates of screening and result receipt.10 Integrating rapid HIV screening into primary care has the potential to promote earlier diagnosis and linkage to care and has important implications for improving health outcomes of youth with HIV.34,35 The ability to provide immediate test results and link individuals with positive results to care was a unique feature to the current study given the clinic’s colocation with an HIV clinic. Future researchers will need to investigate how pediatric primary care clinics that do not have colocated HIV clinics can ensure timely linkage to care.

High screening rates in the current study may be a result of removing the stigma associated with requesting an HIV test by offering routine opt-out rapid tests. Data reveal that youth prefer to be offered screening for HIV rather than asking for it.14,36 Not requiring explicit parental consent for HIV screening may also have promoted screening among younger patients; previous work reveals that minors perceive the requirement of parental consent to be a barrier to accessing HIV screening.37,38 Higher screening rates may also be due to this program’s use of noninvasive oral rapid tests. Because newer diagnostic screening algorithms recommend using fourth-generation immunoassay tests,39 future researchers will need to evaluate whether using this test type will result in similarly high screening rates. By pairing HIV screening with health education, youth can simultaneously be provided with access to information about minors’ consent for screening, protecting themselves from sexually transmitted infection and/or HIV, and earlier linkage to HIV care.

In this current study, we extend findings from a previous study that revealed that adhering to CDC guidance resulted in an increase of overall testing and rapid testing.19 However, unlike us in the current study, researchers in this previous study focused solely on testing sexually experienced adolescents and did not present results receipt or the identification of positive results. By following the most recent opt-out CDC guidance among all adolescents at least once and annually thereafter on the basis of clinical judgement or risk, we identified 5 patients with HIV who were immediately linked to on-site care. Approaches such as those described in this study reveal the importance of providing this age group with HIV screening regardless of sex or gender.40,41 There is a call to expand HIV screening among youth who are most at risk for HIV, especially in settings where youth are more likely to be unaware of their HIV status.42 Universal opt-out screening of youth living in high-prevalence areas is 1 possible solution to further improving the HIV cascade in this population. Given that most youth report a recent visit with their primary care providers, primary care settings are key locations that may benefit from increasing screening through the use of system-level strategies to identify youth with HIV.

This study has several limitations. Although systematic approaches were used to review the medical records of all patients seen and to identify those meeting the criteria for screening, some eligible patients may have been missed, and some ineligible patients may have been tested. The documentation of sexual activity or sexual risk in the medical record may not have accurately reflected patient behavior, which may have led to over- or underscreening. For example, some patients who were tested may have not been eligible (eg, they were tested previously and had never been sexually active), resulting in overscreening, whereas some may have initiated sexual activity but lacked documentation in their medical record and were not referred for screening by their providers, leading to underscreening. Serology test result receipt may not have been adequately documented in the medical record; a lack of this documentation does not necessarily mean that patients did not receive their test results. CHEs were used in this study to coordinate and provide testing. Other settings may find the training of existing staff, such as medical or nursing assistants, to be easier to implement and sustain over time. Data were collected in 1 urban pediatric primary care setting, potentially limiting the generalizability of this work to other settings. Despite these limitations, the findings of this quality improvement study have important implications for improving HIV screening and the receipt of results in primary care.

This study reveals that a system-level strategy in which established clinical structures are leveraged can improve the use of routine opt-out rapid HIV screening, receipt of results, identification of individuals who were unaware of their HIV status, and linkage to care. Expanding routine opt-out HIV screening in primary care is needed to address the HIV epidemic in youth. Such programs can be easily integrated and may be effective in reaching those who might not otherwise seek testing or be screened for HIV.

     
  • CDC

    Centers for Disease Control and Prevention

  •  
  • CHE

    certified health educator

  •  
  • PDSA

    plan-do-study-act

  •  
  • SPC

    statistical process control

Dr Arrington-Sanders conceptualized and designed the study, drafted the initial manuscript, assisted with data analysis, and reviewed and revised the manuscript; Mr Wheeler conceptualized and designed the study, designed the data collection instruments, collected data, conducted the initial analyses, drafted the initial manuscript, and reviewed and revised the manuscript; Drs Kim and Matson contributed to the analysis and interpretation of data and critically reviewed the manuscript for important intellectual content; Ms Tawe conceptualized and designed the study, collected data, and reviewed and revised the manuscript; Dr Upadhya, Ms Tomaszewski, Ms Campbell, and Mr Rogers conceptualized and designed the study and reviewed and revised the manuscript; Dr Marcell conceptualized and designed the study, conducted the initial analyses, drafted the initial manuscript, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Supported by a contract (principal investigator: Dr Marcell) through the Maryland Department of Health and Mental Hygiene Office of Family Planning and Reproductive Health and by the Department of Health and Human Services Office of Population Affairs.

1
Centers for Disease Control and Prevention
. HIV among youth. 2015. Available at: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2015-vol-27.pdf. Accessed May 8, 2017
2
Zanoni
BC
,
Mayer
KH
.
The adolescent and young adult HIV cascade of care in the United States: exaggerated health disparities.
AIDS Patient Care STDS
.
2014
;
28
(
3
):
128
135
[PubMed]
3
Branson
BM
,
Handsfield
HH
,
Lampe
MA
, et al;
Centers for Disease Control and Prevention (CDC)
.
Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.
MMWR Recomm Rep
.
2006
;
55
(
RR–14
):
1
17; quiz CE1–CE4
[PubMed]
4
Moyer
VA
;
US Preventive Services Task Force
.
Screening for HIV: U.S. Preventive Services Task Force recommendation statement.
Ann Intern Med
.
2013
;
159
(
1
):
51
60
[PubMed]
5
Goyal
MK
,
Dowshen
N
,
Mehta
A
,
Hayes
K
,
Lee
S
,
Mistry
RD
.
Pediatric primary care provider practices, knowledge, and attitudes of human immunodeficiency virus screening among adolescents.
J Pediatr
.
2013
;
163
(
6
):
1711
1715.e6
6
Freed
GL
,
Nahra
TA
,
Wheeler
JR
.
Which physicians are providing health care to America’s children? Trends and changes during the past 20 years.
Arch Pediatr Adolesc Med
.
2004
;
158
(
1
):
22
26
[PubMed]
7
Rand
CM
,
Shone
LP
,
Albertin
C
,
Auinger
P
,
Klein
JD
,
Szilagyi
PG
.
National health care visit patterns of adolescents: implications for delivery of new adolescent vaccines.
Arch Pediatr Adolesc Med
.
2007
;
161
(
3
):
252
259
[PubMed]
8
Marcell
AV
,
Klein
JD
,
Fischer
I
,
Allan
MJ
,
Kokotailo
PK
.
Male adolescent use of health care services: where are the boys?
J Adolesc Health
.
2002
;
30
(
1
):
35
43
[PubMed]
9
Inungu
J
,
Lewis
A
,
Mustafa
Y
,
Wood
J
,
O’Brien
S
,
Verdun
D
.
HIV testing among adolescents and youth in the United States: update from the 2009 behavioral risk factor surveillance system.
Open AIDS J
.
2011
;
5
:
80
85
[PubMed]
10
Buzi
RS
,
Madanay
FL
,
Smith
PB
.
Integrating routine HIV testing into family planning clinics that treat adolescents and young adults.
Public Health Rep
.
2016
;
131
(
suppl 1
):
130
138
[PubMed]
11
Coates
TJ
,
Kulich
M
,
Celentano
DD
, et al;
NIMH Project Accept (HPTN 043) Study Team
.
Effect of community-based voluntary counselling and testing on HIV incidence and social and behavioural outcomes (NIMH project accept; HPTN 043): a cluster-randomised trial.
Lancet Glob Health
.
2014
;
2
(
5
):
e267
e277
[PubMed]
12
Schechter-Perkins
EM
,
Koppelman
E
,
Mitchell
PM
,
Morgan
JR
,
Kutzen
R
,
Drainoni
ML
.
Characteristics of patients who accept and decline ED rapid HIV testing.
Am J Emerg Med
.
2014
;
32
(
9
):
1109
1112
[PubMed]
13
Haines
CJ
,
Uwazuoke
K
,
Zussman
B
,
Parrino
T
,
Laguerre
R
,
Foster
J
.
Pediatric emergency department-based rapid HIV testing: adolescent attitudes and preferences.
Pediatr Emerg Care
.
2011
;
27
(
1
):
13
16
[PubMed]
14
Peralta
L
,
Deeds
BG
,
Hipszer
S
,
Ghalib
K
.
Barriers and facilitators to adolescent HIV testing.
AIDS Patient Care STDS
.
2007
;
21
(
6
):
400
408
[PubMed]
15
Futterman
D
,
Stafford
S
,
Meissner
P
, et al
.
Ten sites, 10 years, 10 lessons: scale-up of routine HIV testing at community health centers in the Bronx, New York.
Public Health Rep
.
2016
;
131
(
suppl 1
):
53
62
[PubMed]
16
Hyden
C
,
Allegrante
JP
,
Cohall
AT
.
HIV testing sites’ communication about adolescent confidentiality: potential barriers and facilitators to testing.
Health Promot Pract
.
2014
;
15
(
2
):
173
180
[PubMed]
17
Strauss
M
,
Rhodes
B
,
George
G
.
A qualitative analysis of the barriers and facilitators of HIV counselling and testing perceived by adolescents in South Africa.
BMC Health Serv Res
.
2015
;
15
:
250
[PubMed]
18
Kurth
AE
,
Lally
MA
,
Choko
AT
,
Inwani
IW
,
Fortenberry
JD
.
HIV testing and linkage to services for youth.
J Int AIDS Soc
.
2015
;
18
(
2
,
suppl 1
):
19433
[PubMed]
19
Mullins
TL
,
Kollar
LM
,
Lehmann
C
,
Kahn
JA
.
Changes in human immunodeficiency virus testing rates among urban adolescents after introduction of routine and rapid testing.
Arch Pediatr Adolesc Med
.
2010
;
164
(
9
):
870
874
[PubMed]
20
Sanchez
TH
,
Sullivan
PS
,
Rothman
RE
, et al
.
A novel approach to realizing routine HIV screening and enhancing linkage to care in the United States: protocol of the FOCUS program and early results.
JMIR Res Protoc
.
2014
;
3
(
3
):
e39
[PubMed]
21
Turner
SD
,
Anderson
K
,
Slater
M
,
Quigley
L
,
Dyck
M
,
Guiang
CB
.
Rapid point-of-care HIV testing in youth: a systematic review.
J Adolesc Health
.
2013
;
53
(
6
):
683
691
[PubMed]
22
Kendrick
SR
,
Kroc
KA
,
Withum
D
,
Rydman
RJ
,
Branson
BM
,
Weinstein
RA
.
Outcomes of offering rapid point-of-care HIV testing in a sexually transmitted disease clinic.
J Acquir Immune Defic Syndr
.
2005
;
38
(
2
):
142
146
[PubMed]
23
San Antonio-Gaddy
M
,
Richardson-Moore
A
,
Burstein
GR
,
Newman
DR
,
Branson
BM
,
Birkhead
GS
.
Rapid HIV antibody testing in the New York state anonymous HIV counseling and testing program: experience from the field.
J Acquir Immune Defic Syndr
.
2006
;
43
(
4
):
446
450
[PubMed]
24
Arrington-Sanders
R
,
Ellen
J
.
A systems approach to improve human immunodeficiency virus screening in sexually active youth in urban academic ambulatory settings.
Sex Transm Dis
.
2011
;
38
(
8
):
777
779
[PubMed]
25
Varkey
P
,
Reller
MK
,
Resar
RK
.
Basics of quality improvement in health care.
Mayo Clin Proc
.
2007
;
82
(
6
):
735
739
[PubMed]
26
Langley
G
,
Nolan
K
,
Nolan
T
, et al
.
The Improvement Guide: A Practical Approach to Enhancing Organizational Performance
, 1st ed.
San Francisco, CA
:
Josey-Bass
;
1996
27
Centers for Disease Control and Prevention
;
Health Resources and Services Administration
. Recommendations for HIV prevention with adults and adolescents with HIV in the United States, 2014. Available at: https://stacks.cdc.gov/view/cdc/44064. Accessed August 6, 2018
28
Yarnall
KS
,
Pollak
KI
,
Østbye
T
,
Krause
KM
,
Michener
JL
.
Primary care: is there enough time for prevention?
Am J Public Health
.
2003
;
93
(
4
):
635
641
[PubMed]
29
Wheeler
NJ
,
Upadhya
KK
,
Tawe
MS
,
Tomaszewski
K
,
Arrington-Sanders
R
,
Marcell
AV
.
Integrating pregnancy prevention into an HIV counseling and testing program in pediatric primary care.
J Adolesc Health
.
2018
;
63
(
1
):
50
56
[PubMed]
30
HIV and Adolescents
.
Guidance for HIV Testing and Counselling and Care for Adolescents Living With HIV: Recommendations for a Public Health Approach and Considerations for Policy-Makers and Managers
.
ANNEX 12, Adolescent HIV testing and counselling: a review of the literature.
Geneva, Switzerland
:
World Health Organization
;
2013
. Available at: https://www.ncbi.nlm.nih.gov/books/NBK217943/. Accessed August 8, 2018
31
Kay
ES
,
Batey
DS
,
Mugavero
MJ
.
The HIV treatment cascade and care continuum: updates, goals, and recommendations for the future.
AIDS Res Ther
.
2016
;
13
:
35
[PubMed]
32
Singer
JD
,
Willett
JB
.
Applied Longitudinal Data Analysis: Modeling Change and Event Occurrence
, 1st ed.
New York, NY
:
Oxford Press
;
2003
33
Provost
L
,
Murray
S
.
The Health Care Data Guide: Learning From Data for Improvement
, 1st ed.
San Francisco, CA
:
Jossey-Bass
;
2011
34
Lundgren
JD
,
Babiker
AG
,
Gordin
F
, et al;
INSIGHT START Study Group
.
Initiation of antiretroviral therapy in early asymptomatic HIV infection.
N Engl J Med
.
2015
;
373
(
9
):
795
807
[PubMed]
35
Danel
C
,
Moh
R
,
Gabillard
D
, et al;
TEMPRANO ANRS 12136 Study Group
.
A trial of early antiretrovirals and isoniazid preventive therapy in Africa.
N Engl J Med
.
2015
;
373
(
9
):
808
822
[PubMed]
36
Arrington-Sanders
R
,
Ellen
J
,
Thorpe
RJ
,
Leonard
L
.
What makes a teen get tested? A case of urban based sample of adolescents.
J AIDS Clin Res
.
2014
;
5
:
336
37
Fowler
CI
,
Gable
J
,
Wang
J
,
McClure
E
.
Family Planning Annual Report: 2012 National Summary
.
Research Triangle Park, NC
:
RTI International
;
2013
. Available at: www.hhs.gov/opa/pdfs/fpar-national-summary-2012.pdf. Accessed August 8, 2018
38
Jackson
S
,
Hafemeister
TL
.
Impact of parental consent and notification policies on the decisions of adolescents to be tested for HIV.
J Adolesc Health
.
2001
;
29
(
2
):
81
93
[PubMed]
39
Centers for Disease Control and Prevention
;
Association of Public Health Laboratories
. Laboratory testing for the diagnosis of HIV infection: updated recommendations. Available at: http://stacks.cdc.gov/view/cdc/23447. Accessed May 2, 2018
40
Marcell
AV
,
Bell
DL
,
Lindberg
LD
,
Takruri
A
.
Prevalence of sexually transmitted infection/human immunodeficiency virus counseling services received by teen males, 1995-2002.
J Adolesc Health
.
2010
;
46
(
6
):
553
559
[PubMed]
41
Thomas
M
,
Haas
TS
,
Doerer
JJ
, et al
.
Epidemiology of sudden death in young, competitive athletes due to blunt trauma.
Pediatrics
.
2011
;
128
(
1
). Available at: www.pediatrics.org/cgi/content/full/128/1/e1
[PubMed]
42
Lindong
I
,
Edwards
L
,
Dennis
S
,
Fajobi
O
.
Similarities and differences matter: considering the influence of gender on HIV prevention programs for young adults in an urban HBCU.
Int J Environ Res Public Health
.
2017
;
14
(
2
):
E133
[PubMed]

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.