Improving HIV Screening and Receipt of Results by Nurse-Initiated Streamlined Counseling and Rapid Testing

  • Henry D. Anaya
  • Tuyen Hoang
  • Joya F. Golden
  • Matthew Bidwell Goetz
  • Allen Gifford
  • Candice Bowman
  • Teresa Osborn
  • Douglas K. Owens
  • Gillian D. Sanders
  • Steven M. Asch
Original Article



HIV testing is cost-effective in unselected general medical populations, yet testing rates among those at risk remain low, even among those with regular primary care. HIV rapid testing is effective in many healthcare settings, but scant research has been done within primary care settings or within the US Department of Veteran’s Affairs Healthcare System.


We evaluated three methods proven effective in other diseases/settings: nurse standing orders for testing, streamlined counseling, and HIV rapid testing.


Randomized, controlled trial with three intervention models: model A (traditional counseling/testing); model B (nurse-initiated screening, traditional counseling/testing); model C (nurse-initiated screening, streamlined counseling/rapid testing).


Two hundred fifty-one patients with primary/urgent care appointments in two VA clinics in the same city (one large urban hospital, one freestanding outpatient clinic in a high HIV prevalence area).


Rates of HIV testing and receipt of results; sexual risk reduction; HIV knowledge improvement.


Testing rates were 40.2% (model A), 84.5% (model B), and 89.3% (model C; p = <.01). Test result receipt rates were 14.6% (model A), 31.0% (model B), 79.8% (model C; all p = <.01). Sexual risk reduction and knowledge improvement did not differ significantly between counseling methods.


Streamlined counseling with rapid testing significantly increased testing and receipt rates over current practice without changes in risk behavior or posttest knowledge. Increased testing and receipt of results could lead to earlier disease identification, increased treatment, and reduced morbidity/mortality. Policymakers should consider streamlined counseling/rapid testing when implementing routine HIV testing into primary/urgent care.


nurse-initiated HIV screening HIV rapid testing streamlined counseling 



The authors would like to thank Genia Williamson, Leslie Lange, Brenda Rue, Alicia Alcantara, Jamie Feld, Anne Taylor, and Jesse Dwyer for assistance in the development of this manuscript.

This research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, Project number IIR 04–023. Dr. Asch is the principal investigator at the VA Greater Los Angeles Healthcare System. The views expressed in this article are those of the author(s) and do not necessarily represent the views of the United States Department of Veterans Affairs. The Veterans Health Administration supported this study but had no input in the design or reporting or decision to submit this paper for publication. HIV rapid tests were donated by Orasure Technologies. The opinions expressed in this manuscript are solely the authors’ and do not necessarily reflect those of the US Department of Veterans Affairs. This study was reviewed and sanctioned by a US Department of Veterans Affairs Internal Review Board process.

Conflict of Interest Statement

The first author owns stock in a biotechnology company that develops biotechnological products, one of which is a rapid test for diagnosing the HIV virus. The first author also received an unrestricted grant to support dissemination of research results from two HIV rapid testing device manufacturers, and this grant supported author no. 8 as well. Author no. 4 has received both honoraria and grant support in the past 3 years.


  1. 1.
    Palella FJ Jr, Deloria-Knoll M, Chmiel JS, et al. Survival benefit of initiating antiretroviral therapy in HIV-infected persons in different CD4+ cell strata. Ann Intern Med. 2003;138(8):680–681.Google Scholar
  2. 2.
    Anastos K, et al. Women’s interagency HIV study collaborative study group: risk of progression to AIDS and death in women infected with HIV-1 initiating highly active antiretroviral treatment at different stages of disease. Arch Intern Med. 2002;162(17):1973–1980.PubMedCrossRefGoogle Scholar
  3. 3.
    Centers for Disease Control (US). HIV and AIDS—United States, 1981–2001. MMWR. 2001;50:430–434.Google Scholar
  4. 4.
    Gandhi NR, et al. Delayed presentation for HIV care among veterans: an opportunity for intervention. (Annual meeting, 13th Conference on Retrovirus and Opportunistic Infections, Denver, 2006).Google Scholar
  5. 5.
    Sanders GD, Bayoumi AM, Sundaram V, et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med. 2005;352:570–85.PubMedCrossRefGoogle Scholar
  6. 6.
    Centers for Disease Control (US). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMRW. 2006;55(14):1–17.Google Scholar
  7. 7.
    Simmons E, Roberts M, Ma M, et al. Routine testing for HIV in the United States: the intersection between recommendations and practices. AIDS Patient Care STDS. 2006;20(2):79–83.PubMedCrossRefGoogle Scholar
  8. 8.
    Wenrich MD, Carline JD, Curtis JR, et al. Patient report of HIV risk screening by primary care physicians. Am J Prev Med. 1996;12(2):116–122.PubMedGoogle Scholar
  9. 9.
    Spielberg F, Branson BM, Goldbaum GM, et al. Overcoming barriers to HIV testing: preferences for new strategies among clients of a needle exchange, a sexually transmitted disease clinic, and sex venues for men who have sex with men. JAIDS. 2003;32(3):318–327.PubMedGoogle Scholar
  10. 10.
    Melnyk KAM. Barriers: a critical review of recent literature. Nurs Res. 1998;37:196–201.Google Scholar
  11. 11.
    Centers for Disease Control (US). Revised guidelines for HIV counseling, testing, and referral. MMWR. 2001;50(19):1–57.Google Scholar
  12. 12.
    Rothman RE, Lyons MS, Haukoos JS. Preventive care in the emergency department: should emergency departments conduct routine HIV screening? A systematic review. Acad Emerg Med. 2003;10(3):278–285.PubMedGoogle Scholar
  13. 13.
    Kelen GD, Shahan JB, Quinn TC. Emergency department-based HIV screening and counseling: experience with rapid and standard serologic testing. Ann Intern Med. 1999;33:147–55.Google Scholar
  14. 14.
    Centers for Disease Control (US). Technical guidance on HIV counseling. MMWR. 1993;42(2):5–9.Google Scholar
  15. 15.
    Centers for Disease Control (US). HIV counseling, testing and referral standards and Guidelines. Atlanta, GA: US Department of Health and Human Services, Public Health Service.Google Scholar
  16. 16.
    Rhew DC, Goetz MB, Shekelle PG. Evaluating quality indicators for patients with community-acquired pneumonia. Jt Comm J Qual Improv. 2001;27(11):575–590.PubMedGoogle Scholar
  17. 17.
    Phillips BR, LI Backus, JP Halloran, et al. Caring for veterans with HIV disease. Fiscal Year 2002 Report, Center for Quality Management in Public Health, Public Health Strategic Health Care Group, Department of Veterans Affairs, March, 2003.Google Scholar
  18. 18.
    US Department of Veterans Affairs, Public Law 100–322, Section 124: Testing for HIV (Human Immunodeficiency Virus) and Informed Consent. 1988.Google Scholar
  19. 19.
    Robson J, Boomla K, Fitzpatrick S, et al. Using nurses for preventive activities with computer assisted follow-up: a randomized controlled trial. BMJ. 1989;298:433–436.PubMedGoogle Scholar
  20. 20.
    Centers for Disease Control (US). Notice to readers: approval of a new rapid test for HIV antibody. MMWR. 2002;51(46):1051–1052.Google Scholar
  21. 21.
    Gerbert B, Bronstone A, McPhee S, et al. Development and testing of an HIV-risk screening instrument for use in health care settings. Am J Prev Med. 1998;15:103–113.PubMedCrossRefGoogle Scholar
  22. 22.
    Mirand AL, Beehler GP, Kuo CL, et al. Explaining the de-prioritization of primary prevention: physicians’ perceptions of their role in the delivery of primary care. BMC Public Health. 2003;3:15.PubMedCrossRefGoogle Scholar
  23. 23.
    Tudor-Hart J. Practice nurses: an underused resource. BMJ. 1985;290:1162–1163.CrossRefGoogle Scholar
  24. 24.
    Spitzer WO, Sackett DL, Sibley JC, et al. The Burlington randomized trial of the nurse practitioner. N Engl J Med. 1974;290:251–256.PubMedGoogle Scholar
  25. 25.
    Gonzalez JJ, Ranney J, West J. Nurse-initiated health promotion prompting system in an internal medicine residents’ clinic. South Med J. 1989;82:3.Google Scholar
  26. 26.
    Stone EG, Morton SC, Hulscher ME, et al.. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med. 2002;136:641–651.PubMedGoogle Scholar
  27. 27.
    Centers for Disease Control (US). HIV counseling, testing and referral standards and guidelines. Atlanta, GA: US Department of Health and Human Services, Public Health Service, 1994;1–15.Google Scholar
  28. 28.
    Centers for Disease Control (US). Advancing HIV prevention. Interim Technical Guidance for Selected Interventions. Atlanta, GA: US Department of Health and Human Services, Public Health Service. 2003.Google Scholar
  29. 29.
    Spielberg F, Kurth A, Gorbach PM, et al. Moving from apprehension to action: HIV counseling and testing preferences in three at-risk populations. AIDS Educ Prev. 2001;13(6):524–540.PubMedCrossRefGoogle Scholar
  30. 30.
    Center for Disease Control (US). Current trends: additional recommendations to reduce sexual and drug abuse-related transmission of human T-lymphotropic virus type III/lymphandenopathy-associated virus. MMWR. 1986;3:152–155.Google Scholar
  31. 31.
    Centers for Disease Control (US). Perspectives in disease prevention and health promotion: public health service guidelines for counseling and antibody testing to prevent HIV infection and AIDS. MMWR. 1987;36:509–515.Google Scholar
  32. 32.
    Centers for Disease Control (US). Guidelines for national human immunodeficiency virus case surveillance, including monitoring for human immunodeficiency virus infection and acquired immunodeficiency syndrome. MMWR. 1999;48131–28.Google Scholar
  33. 33.
    Molitor F, Bell RA, Truax SR. Predictors of failure to return for HIV test result and counseling by test site type. AIDS Educ Prev. 1999;11(1):1–13.PubMedGoogle Scholar
  34. 34.
    Josefson D. Rapid HIV testing urged in the United States. BMJ. 1998;316:1037.PubMedGoogle Scholar
  35. 35.
    Kassler WJ, Dillon BA, Haley C, et al. On-site, rapid HIV testing with same-day results and counseling. AIDS. 1997;8:1045–1051.CrossRefGoogle Scholar
  36. 36.
    Kroc K, Kendrick S, Withum D, et al. Rapid HIV testing in an emergency department. Available at: Accessed September 12, 2006.
  37. 37.
    Farmham PG, Gorsky RD, Holtgrave DR, et al. Counseling and testing for HIV prevention: costs, effects, and cost-effectiveness of more rapid screening tests. Public Health Rep. 1996;111:44–53.Google Scholar
  38. 38.
    Metcalf CA, Douglas JM, Malotte CK, Cross H, Dillon BA, Paul SM, et al. Relative efficacy of prevention counseling with rapid and standard HIV testing: a randomized controlled trial (RESPECT-2). STDS. 2005;32:130–138.Google Scholar
  39. 39.
    Kamb ML, Fishbein M, Douglas JM, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. JAMA. 1998;280:1161–1167.PubMedCrossRefGoogle Scholar
  40. 40.
    Sanders GD, Anaya H, Asch S, et al. Cost effectiveness of rapid HIV testing with streamlined counseling [abstract]. Proceedings of the 4th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, Sydney, Australia; July 22–25, 2008.Google Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Henry D. Anaya
    • 1
  • Tuyen Hoang
    • 1
  • Joya F. Golden
    • 1
  • Matthew Bidwell Goetz
    • 1
    • 10
  • Allen Gifford
    • 1
    • 5
  • Candice Bowman
    • 1
    • 2
  • Teresa Osborn
    • 6
  • Douglas K. Owens
    • 7
    • 8
  • Gillian D. Sanders
    • 9
  • Steven M. Asch
    • 1
    • 3
    • 4
  1. 1.Veterans Affairs (VA) Quality Enhancement Research Initiative for HIV and Hepatitis (QUERI-HIV/HEP) and Center for the Study of Healthcare Provider Behavior, VA Greater Los Angeles Health Services Research and Development (HSRD) Center of ExcellenceVA Greater Los Angeles Healthcare SystemLos AngelesUSA
  2. 2.The Center for Research in Patient Oriented CareVA San Diego Healthcare SystemLa JollaUSA
  3. 3.Division of General Internal Medicine and Health, Services Research (GIM and HSR)UCLA School of MedicineLos AngelesUSA
  4. 4.RAND HealthSanta MonicaUSA
  5. 5.VA New England Healthcare SystemBedfordUSA
  6. 6.VA VISN22Long BeachUSA
  7. 7.VA Palo Alto Healthcare SystemPalo AltoUSA
  8. 8.Stanford University School of MedicineStanfordUSA
  9. 9.Duke University School of MedicineDurhamUSA
  10. 10.Infectious Diseases Section, Department of MedicineVA Greater Los Angeles Healthcare System and the David Geffen School of Medicine at UCLALos AngelesUSA

Personalised recommendations