The role of evidence and context for implementing a multimodal intervention to increase HIV testing

Abstract

BackgroundIncreasing the use of routine preventive care such as HIV testing is important, yet implementation of such evidence-based clinical care is complex. The Promoting Action on Research Implementation in Health Services (PARiHS) model for implementation posits that implementation will be most successful when the evidence, context, and facilitation strategies are strong for the clinical practice. We evaluated the relative importance of perceived evidence, context, and facilitation of HIV testing during the implementation of a multimodal intervention in US Department of Veterans Affairs primary care clinics.MethodsA multimodal intervention including clinical reminders (CRs), academic detailing—providing education sessions for providers—and social marketing to improve HIV testing was implemented in 15 VA primary care clinics in three regions. We conducted qualitative formative and process evaluations using semi-structured interviews with HIV lead clinicians, primary care lead clinicians, nurse managers, and social workers. Interviews were analyzed thematically to identify barriers and facilitators to implementation of HIV testing and how these were addressed by the intervention. Sites were then rated high, medium, or low on the dimensions of perceived evidence and the context for testing. We then assessed the relationship of these ratings to improvements in HIV testing rates found in earlier quantitative analyses.ResultsSites that showed greatest improvements in HIV testing rates also rated high on evidence and context. Conversely, sites that demonstrated the poorest improvements in testing rates rated low on both dimensions. Perceptions of evidence and several contextual aspects resulted in both barriers and facilitators to implementing testing. Evidence barriers included provider perceptions of evidence for routine testing as irrelevant to their population. Contextual barriers included clinical reminder overload, insufficient resources, onerous consent processes, stigma, provider discomfort, and concerns about linking individuals who test positive to HIV treatment. While most barriers were ameliorated by the intervention, HIV stigma in particular regions and concerns about linkage to care persisted.ConclusionsInterventions to implement evidence-based practices such as HIV testing can be successful when utilizing proven quality improvement techniques. However, it is critical to address providers’ perceptions of evidence and consider aspects of the local context in order to fully implement new routine clinical practices such as HIV testing.

Older African Americans and the HIV Care Continuum: A Systematic Review of the Literature, 2003–2018

“…For instance, promising educational models such as group education programs delivered by allied health professionals, peer education models, and directly delivered early intervention models (e.g., Senior HIV Intervention Project) could be culturally tailored for older African American PLWH to increase their testing rates and HIV risk awareness [55]. Provider-based interventions also have the potential to increase testing among older African Americans including those that educate providers about up-to-date clinical recommendations for HIV screening and testing, and promote sexual risk assessments, risk-reduction counseling, and HIV testing [56].…”

Indicators of self-reported human immunodeficiency virus risk and differences in willingness to get tested by age and ethnicity

“…[ 11 , 12 ] Although many older adults opt out of HIV testing, [ 4 , 13 ] providers often do not offer HIV tests to older adults [ 14 , 15 ] due to ageist assumptions about older adults’ sexual or drug use behaviors. [ 14 , 16 ] As a result, older adults infected with HIV are more likely than younger people to go undiagnosed or be diagnosed later in the disease course. [ 13 , 17 , 18 ]…”

A feasibility study for 3 strategies promoting HIV testing in primary health care in Madrid, Spain (ESTVIH project)

“…For example, in the UK, a meta‐analysis published in 2014 found that the pooled estimate of eligible people offered an HIV test was 9.3% (95%CI 1.2% to 17.3%) in patients diagnosed with an indicator disease, and in people attending screening settings was 29.5% (95%CI 23.6% to 35.4%); in the US in areas of ≥0.1% prevalence, only 25 health care settings (6.6%) reported screening all patients for HIV, whereas 131 (34.8%) reported screening only some patients . To assess barriers and facilitators is useful for understanding how different facilitation strategies may be effective in implementing disease screening and testing in primary care, and there are experiences that demonstrate that interventions to increase HIV testing can be successful when utilizing proven quality improvement techniques …”