Earlier this month, the Office of the Inspector General at the U.S. Department of Health and Human Services released a report on a study about HIV testing practices at HRSA-funded health centers. These health centers are important partners in our coordinated efforts to achieve the goals of the National HIV/AIDS Strategy (NHAS): reducing new HIV infections, increasing access to HIV care and improve health outcomes for people living with HIV, and reducing HIV-related health disparities.

Why OIG Did This Study

Health center sites funded by HRSA provide primary health care to millions of patients each year and are critical to efforts to test patients for HIV and reduce its spread. CDC estimates that one in five people in the United States who are living with HIV do not know their status and, therefore, are more likely to transmit the disease to others. Given the additional investments in health center funding by both The American Recovery and Reinvestment Act of 2009 and the Patient Protection and Affordable Care Act of 2010, health centers will be able to greatly increase the number of patients served, thus providing increased opportunities for identifying undiagnosed HIV infections.

Since 2006, the Centers for Disease Control and Prevention (CDC) has recommended routine HIV testing—i.e., that patients be tested as a routine part of care and be told they will be tested unless they decline. This approach aims to expand HIV testing to a wider patient population, reduce the stigma that surrounds testing, and increase the number of people who know their status. OIG undertook this study to determine the extent to which HRSA-funded sites adopted four practices that CDC recommended: (1) routine HIV testing of all patients 13-64 years of age; (2) not requiring prevention counseling for all patients; (3) gaining patient consent for the HIV test in the same way as for other screening and diagnostic tests; and (4) providing HIV tests as standard, opt-out tests.

How OIG Did This Study

The report is based on a 2011 survey of a random sample of health centers and analysis of the 324 responses. The results are projectable to the estimated population of 5,275 sites that provide primary care. We determined the extent to which sites adopted the four CDC-recommended HIV testing practices and how Federal recommendations influenced their written HIV testing policies. We also asked sites to describe factors that affected their adoption of these practices and their provision of HIV testing.

What OIG Found

Though 90 percent of HRSA-funded health center sites offered onsite HIV testing and rates of HIV testing reported by health center sites have increased in recent years, health center sites have not fully adopted all four practices recommended by CDC for routine HIV testing. Regarding whom to test, 20 percent of sites reported testing all patients 13-64 years of age; 1 percent tested all adults, but not teens; and 55 percent targeted testing to high-risk patients.

Regarding the other three practices,

• 29 percent adopted the practice regarding prevention counseling;
• 27 percent adopted the practice regarding gaining patient consent for the HIV test; and
• 15 percent adopted the practice regarding providing HIV tests as standard, opt-out tests.

The OIG study found that most HRSA-funded health center sites had written HIV testing policies that were influenced by the CDC recommendation. Various factors affected the adoption of the practices at health centers.

What OIG Recommends

In light of the study findings, OIG recommends that HRSA require grantees to establish and report to HRSA two HIV testing metrics: prevalence and positivity, as follows:

1. grantees should establish and report the prevalence of undiagnosed HIV among their patient populations, and
2. grantees should report HIV positivity (the proportion of patients who test positive among all those tested). Required reporting of HIV positivity would align data collection by HRSA health center grantees with that of other HHS-funded HIV programs and services consistent with the recently released seven core indicators for monitoring HHS-funded HIV prevention, treatment, and care.

Finally, we also recommend that HRSA continue to provide guidance and education to grantees and sites regarding the CDC-recommended practices and HIV testing.

HRSA’s Response

HRSA has concurred with our recommendations and shared details of past and current activities to improve HIV testing in health centers. Regarding the first recommendation to establish and report metrics for HIV testing, HRSA stated that it will begin collecting HIV positivity rates as part of health centers’ annual Uniform Data System (UDS) reports. HRSA also stated that it will work with CDC to assess HIV prevalence rates in health center service areas. Regarding the second recommendation to provide additional guidance and education, HRSA stated that it will continue to support health centers by developing new resources and enhancing existing resources.

For more information about this study, read the full report (PDF 1.3MB).