Programming Connection

Targeted Testing Initiative 

Vancouver STOP Project
Vancouver, British Columbia
2013

How Does the Program Work?

The successful implementation and roll-out of the routine offer of HIV testing at sites where staff are  unaccustomed to offering HIV testing requires a number of resources and activities. These include: the development of a solid clinical and public health rationale for expanded HIV testing; the engagement and buy-in from leaders in the clinics and organizations implementing HIV testing; and extensive (and intensive) training and support for the staff at the various sites.

This initiative requires the leadership of a highly skilled team – the Targeted Testing Team – made up of nurse educators experienced in HIV testing, diagnosis, and linkage to care and a project manager skilled at developing a change management framework to guide the change in practice that the implementation of the routine offer of HIV testing requires. While the nurse educators train and support sites to integrate HIV testing into their services, the project manager guides implementation plans for each site.

Background: Policies and recommendations in place to facilitate implementation

Recommendation on testing frequency

Clinicians and service providers offering HIV testing are typically guided by recommendations and guidelines and Vancouver is no different. In British Columbia, HIV testing among high prevalence populations is guided by a provincial recommendation from the BC Centre for Disease Control (BCCDC) that stipulates that, depending on risk, in high prevalence populations, people should test at least once and up to four times annually. The complete recommendation can be found in the Program materials section of this case study.

This recommendation, which is followed by many Vancouver clinicians, is important to ensuring that clinicians support people at ongoing high risk for HIV infection to get tested often and be diagnosed as early as possible. Early detection and treatment are key to optimal health outcomes for people living with HIV.

Recommendations for pre-test counselling

Since September 2011, the BC Centre for Disease Control’s new HIV Test Pre and Post Test Guidelines do not require an in-depth pre-test counselling session prior to getting informed consent from a person and ordering an HIV test. Under the new guidelines, written information provided to clients is sufficient to receive verbal informed consent from people being offered and accepting an HIV test.

However, in settings now offering HIV testing routinely to people at high risk for HIV infection, clinicians are still encouraged to have an in-depth pre-test discussion with clients. That said, for people who test regularly—every three or six months—in-depth pre-test counselling may not be required. The new pre-test guidelines allow clinicians to streamline discussions with these clients.

Engaging, training, and supporting sites to routinely offer HIV testing

As of February 2013, staff at 88 sites have been trained to expand or introduce HIV testing services through this initiative. This was accomplished through engagement and training activities guided by the Targeted Testing Team. This team collaborates with a variety of programs that have competing clinical priorities along with their own strengths and challenges.  As a result, there has not been one standard process used to introduce the routine offer of HIV testing.

The goal of the project is to routinize the offer of HIV testing, and each site is free to determine how to do this with whatever tools and through whatever means are appropriate for their setting. Most settings implement the offer of a routine standard laboratory test, with results available in one or two weeks. Some offer a blended approach, with rapid testing offered to clients when it seems clinically appropriate (i.e. a client may have been exposed to HIV and is unlikely to return for a positive result).

The process described below is based on the process used to initiate the routine offer of HIV testing in primary healthcare centres. Where the process differs significantly for other settings that have integrated the routine offer of testing, mention is made of that. 

Identifying which services should implement the routine offer of HIV testing

The team uses a priority scale to identify services where it would be most appropriate to integrate the routine offer of an HIV test. The scale includes whether the service’s clients may be likely to be at high risk for HIV, based on the known risk factors of the population, the presence of supportive clinical and operational champions to promote testing, the potential reach of the service, and the presence of other competing clinical priorities. The priority scale is available in the Program Materials section of this case study.

Given these criteria, the team identified inner city primary healthcare centres, mental health and addictions services and youth clinics as primary settings in which HIV testing could be expanded. Expanded HIV testing has also been initiated in abortion clinics, supportive housing, First Nation communities within Vancouver Coastal Health (whose region extends up the B.C. Coast and includes 15 First Nation communities), and in the justice system.

Using a change management framework to guide change

The team uses a change management framework to guide each site to change their practice to incorporate or expand HIV testing. This process involves four phases:

  1. Initial engagement (why change?): In this phase, the medical health officer or a physician-leader and a nurse educator introduce the rationale for the routine offer of HIV testing and present the proposed change in practice to upper management at each site. Baseline testing numbers in their program area (if they are doing any testing) are shared. The goal of this phase is to get buy-in from leadership and identify site champions and a coordinator for implementation.
  2. Site preparation (how will we implement the change?): In this phase, the nurse educators and the project manager work directly with the frontline staff at a site to understand the unique nature of the site, existing work flows, and determine the best way to integrate change into existing practice. They also identify any challenges and support tools required.
  3. Go live (when do we start?): In this phase, nurse educators provide shoulder-to-shoulder support (where needed) on the date the team chooses to start the practice change.
  4. Site monitoring and check-in (how are we doing?): In this phase, nurse educators connect back with each team and provide a progress report showing the number of tests administered and number of positive diagnoses made as compared to baseline testing data (if any). The site check-ins are also used to identify and attempt to resolve any further barriers that prevent the integration of the routine offer of HIV testing. During check-in, the nurse educators also share best practices from other programs that have achieved implementation success.

Initial engagement

It was crucial to secure senior medical and operational leadership to support change in each program, before engaging each site in the implementation of the routine offer of HIV testing. The clinical practice leader and medical health officer request to present the STOP Project’s goals and objectives, outline the rationale for the routine offer of HIV testing, review the testing initiative and timelines, and secure the support for the initiative of the clinical and operational leadership.

Communicating this support from site leaders to site staff is key to integrating the routine offer of HIV testing in certain settings. For example, after encountering some resistance at the site level in primary care in Vancouver Coastal Health sites, it was determined that a high-level policy directive was needed to reach all clinicians, some of whom were resistant to the change.  The Vancouver Coastal Health primary care operational and medical directors then sent a supportive memo to all clinicians, briefly outlining the rationale for the routine offer of testing and indicating their endorsement of the initiative. This reduced resistance.

Site preparation

When the leadership is engaged and the Targeted Testing Team has addressed any concerns, the team will deliver a minimum of one educational workshop to the whole staff. During this presentation, the medical health officer and nurse educator provide an update on improvements in HIV testing, treatment, prognosis and community supports for people living with HIV. The medical health officer then presents the rationale for the routine offer of HIV testing and how routine testing has been implemented in some areas of the United States and in the United Kingdom. Using local data, the nurse educator demonstrates how some diagnoses are being missed in Vancouver. During this meeting, the nurse educator also provides a trends analysis of the site’s testing data between 2009 and the time of the initial meeting (if any testing has been done).

Finally, the nurse educator presents the sample tools and supports available to help sites implement a routine offer of HIV testing. Please see the Program materials section for more information about these tools. During the meeting, staff are encouraged to identify a reminder system that would work best for the site. Frequently selected tools that are used as reminders include a green sticker or a stamp on lab requisitions, two sets of lab requisitions, both pre-ticked and blank, changes to electronic medical records systems to include blood orders for HIV tests, and a change to existing intake packages or standing orders.

The nurse educator always follows up with the clinical leadership and reviews the decisions made during the staff meeting. This includes the types of resources needed from the Targeted Testing Team such as posters or patient information pamphlets and the implementation date the site has chosen. This reminds the clinical leaders that the nurse educator is available for any added support. The nurse educator follows up again during the first week of implementation and offers any additional support.

Site monitoring and check in

Three months after the roll-out of HIV testing (discussed below), the nurse educator returns to the site and reviews how testing trends have changed. They also encourage discussion of the barriers that remain to integrating a routine offer of HIV testing at the site and what facilitators have made integration easier.

Best practices from other sites are also shared at these meetings. These have included clerical staff handing out the patient FAQ on HIV testing to all patients seeking care, and brightly coloured reminders on charts that ask “Have you offered your client an HIV test today?” Admissions forms at one addictions clinic include a question about a patient’s last HIV test. Clinics with labs onsite involve laboratory technicians and licensed practical nurses as a secondary safety net. These professionals check lab requisitions to make sure an HIV test has been offered and if one has been offered, make sure that the client does not have any additional questions.

Using resources to facilitate implementation

The Targeted Testing Team developed new resources and adapted others for clinicians to facilitate the routine offer of an HIV test. This includes a matrix that covers the recommended frequency of HIV testing in high prevalence populations, examples of laboratory requisition form reminders, a FAQ for primary care providers on routine HIV testing and a patient FAQ on HIV and HIV testing. These, and other materials, can be found in the Program Materials section of the case study. Clinicians were also offered materials from the It’s Different Now campaign. For more information on the It’s Different Now campaign, please see the It’s Different Now case study.

HIV testing workshops and training

The Targeted Testing Team hosts regular workshops on HIV testing for all clinicians working in the Vancouver Coastal Health region to increase their capacity to offer HIV testing. During these workshops, they go over HIV basics, the rationale for the routine offer of HIV testing, and provide training on how to use the point-of-care HIV test. They also review pre- and post-test counselling guidelines and provide information on how to link newly diagnosed people to care and support.  Workshops from one hour to two days in length are given depending on clinicians’ previous experience and learning goals.

Onsite rollout of HIV testing (go live)

Offering an HIV test

The offer of an HIV test is made routinely during provider-patient interactions, at any time during the appointment when the provider feels the offer is appropriate. A nurse, nurse practitioner or physician makes the offer. However, this does not preclude the ongoing importance of patient-initiated HIV testing or risk-based HIV testing, which continues to be a part of healthcare in Vancouver.

Clinicians at many sites also have the option to provide point-of-care testing when it is clinically appropriate.

Sites where the offer of an HIV test differed from the typical procedure

Abortion Clinics

In abortion clinics, the counsellor rather than a nurse or a physician offers the HIV test. This decision was made because women typically do not meet with their providers before the procedure. The offer of an HIV test during the pre-procedure counselling was deemed the best fit in this setting.

Addictions services

Some addictions teams opted to have the HIV test offered at intake as the client is filling out other assessment materials. This allows the intake worker to provide an in-depth pre-test discussion, using the patient FAQ on HIV testing as a guide.

In all cases when a test is positive, a registered nurse, nurse practitioner or physician provides post-test counselling.

Diagnosis and linkage to care

The sites that have introduced the routine offer of HIV testing do not all have the same experience offering post-test counselling and public health follow-up, or the same knowledge about existing HIV services in Vancouver. This limits the capacity of some service providers to offer comprehensive diagnosis, follow-up and linkage to care services.

The STOP Outreach Team and the Vancouver Coastal Health Communicable Disease Control team are two available resources whose staff have the appropriate skills to support and facilitate diagnosis and linkage to care for clinicians and patients.

Primary care, onsite clinics in housing projects and youth clinics

Clinicians working in primary healthcare centres often have significant experience diagnosing HIV and linking patients to care. Many primary care clinics also have physicians on staff who have experience caring for people living with HIV. For patients diagnosed in these settings, this means that a seamless transition to HIV care can be accomplished, with their testing, diagnosis and treatment all handled in the same space. Clinicians who need coaching or in-person support can access that through the STOP Outreach Team, whose nurses offer advice over the phone and are available to come to the clinic and help with diagnosis.

Mental health and addictions services

In mental health and addictions services where clinicians may have limited experience with HIV diagnosis or care, follow-up services can be delegated to the STOP Outreach Team. A nurse from the team will meet with the clinician when a test is positive, discuss the client and their needs and determine a referral site for primary care.

Typically, the testing clinician and the nurse offer the diagnosis. After the diagnosis, however, the STOP Outreach Team takes on the responsibility for public health follow-up, contact tracing, and primary care until a strong linkage to an HIV primary care provider is developed. Once a plan for the client’s healthcare is determined, the testing clinician is informed, with the consent of the client, of the plan.

Abortion Clinics

In abortion clinics, diagnosis and follow-up support are offered through the BC Centre for Disease Control (BCCDC). Patients do not tend to have an ongoing relationship with their abortion providers, so the BCCDC, which has a pre-existing relationship with abortion clinics in Vancouver for chlamydia and gonorrhea follow-up, offers public health follow-up and contact tracing as well as linkage-to-care services.

Testing events in First Nation communities

As part of the targeted testing initiative, the team has engaged with several First Nations communities within the Vancouver Coastal Health region to build the capacity of nurses to offer point-of-care testing and standard laboratory testing.  They have also worked with urban Aboriginal organizations such as the Vancouver Native Health Society and the Aboriginal Wellness Program to expand access to testing for off-reserve Aboriginal clients.

Engagement

Typically, members of the Targeted Testing Team facilitate the introduction of HIV testing in First Nation communities by participating in wellness days or health fairs. These usually serve as kick-off events to the introduction of the routine offer of HIV testing in a pre-existing youth clinic or health centre. Embedding HIV testing in a wellness model can increase confidentiality and decrease stigma for community members by normalizing testing as an important part of healthcare. 

Rather than nurse educators from the Targeted Testing Team leading the initiative and engaging First Nation leadership and healthcare professionals, nurses from the First Nations and Inuit Health  Branch (FNIH) (now the First Nations Health Authority) and the Aboriginal Engagement Office at Vancouver Coastal Health often lead discussions about introducing expanded testing opportunities. The team never travels to reserves without an invitation and without consulting First Nation leadership in the community.

Before the team travels to these communities, it consults with the Chee Mamuk Aboriginal Program, a program of the BCCDC, for their guidance and leadership around community readiness.  Where possible, the team collaborates on the implementation of HIV testing in First Nation communities with Chee Mamuk, BCCDC and FNIH. Before implementing HIV testing, the team ensures some preliminary education and stigma reduction are done. 

Once the groundwork is laid, the clinical leader, a nurse educator, nurses from FNIH and often from Chee Mamuk travel to the community. Prior to the event, the team is present to provide mentorship to the on-reserve nurses on how to offer HIV testing and how to perform a point-of-care and a traditional blood test.  During health fairs, either standard laboratory testing or point-of-care testing is offered to community members, depending on which seems most appropriate based on community input.

Expanding HIV testing at other sites

In addition to implementing HIV testing in health and social service settings, the Targeted Testing Team has implemented testing in other venues. Bathhouses and outdoor sex venues were selected to help expand testing options for gay men and other men who have sex with men. Specific events to help connect with university students and the healthcare providers who serve them have also been held.

For more information on these initiatives, please see the Mobile and bathhouse testing project program element.

Next Steps

The routine offer of HIV testing in these and other settings is now standard practice in Vancouver. The Targeted Testing Team is working closely with services and clinics that have implemented testing to embed testing more fully in their regular services and to integrate testing at new sites.