A System-wide Intervention to Improve HIV Testing in the Veterans Health Administration



Although the benefits of identifying and treating asymptomatic HIV-infected individuals are firmly established, health care providers often miss opportunities to offer HIV-testing.


To evaluate whether a multi-component intervention increases the rate of HIV diagnostic testing.


Pre- to post-quasi-experiment in 5 Veterans Health Administration facilities. Two facilities received the intervention; the other three facilities were controls. The intervention included a real-time electronic clinical reminder that encourages HIV testing, and feedback reports and a provider activation program.


Persons receiving health care between August 2004 and September 2006 who were at risk but had not been previously tested for HIV infection


Pre- to post-changes in the rates of HIV testing at the intervention and control facilities


At the two intervention sites, the adjusted rate of testing increased from 4.8% to 10.8% and from 5.5% to 12.8% (both comparisons, p < .001). In addition, there were 15 new diagnoses of HIV in the pre-intervention year (0.46% of all tests) versus 30 new diagnoses in the post-intervention year (0.45% of all tests). No changes were observed at the control facilities.


Use of clinical reminders and provider feedback, activation, and social marketing increased the frequency of HIV testing and the number of new HIV diagnoses. These findings support a multimodal approach toward achieving the Centers for Disease Control and Prevention’s goal of having every American know their HIV status as a matter of routine clinical practice.

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This project was supported by a research grant to Drs. Goetz and Asch by the Veterans Health Administration Health Services Research & Development Service (SDP 06–001).

Conflicts of Interest

Matthew Bidwell Goetz: consultancy with Monogram Biosciences, grant support from Gilead Pharmaceuticals, GlaxoSmithKline; Henry D. Anaya: stock ownership in Trinity Biotechnology, which develops biomarker devices, one of which is a test for the HIV virus, and educational support in the form of unrestricted grants from both Trinity Biotechnology and OraSure Technologies; Allen Gifford: royalties for authorship of Living Well With HIV And AIDS, Ball Publishing Company; Steven Asch: unrestricted travel grant from Trinity Pharmaceuticals. The other authors have no conflicts of interest.

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Correspondence to Matthew Bidwell Goetz MD.



Triggers for the HIV testing Clinical Reminder

Hepatitis C Infection:

ICD-9 codes

070.41, 070.44, 070.51, 070.54, 070.6, 070.70, 070.71, 070.9, 571.40, 571.41, 571.49, 571.5, 571.8, 571.9, 573.3, 573.8, V02.62

Laboratory tests

Positive HCV antibody test or HCV viral load test

VHA-defined Hepatitis C Risk Factors:

Excessive alcohol use, injection drug use, lack of housing, multiple sexual partners, tattoos, body piercing, receipt of blood/blood products before 1992, unequivocal blood exposure (e.g., in combat), hemodialysis, or unexplained liver disease (including abnormal serum alanine aminotransferase levels). These data are collected through the VHA hepatitis C risk factors dataset.

Hepatitis B Infection:

ICD-9 codes

070.20, 070.21, 070.22, 070.23, 070.3, 070.30, 070.31, 070.32, 070.33, 070.52

Laboratory tests

Positive HBV core antibody test or positive surface antigen

Sexually-transmitted Disease: Includes Gonorrhea, Chlamydia, Syphilis, Herpes

ICD-9 codes

054.10, 054.11, 054.12, 054.13, 054.19, 098.xx, 099.40, 099.41, 099.50, 099.51, 099.52, 099.53, 099.54, 099.55, 099.56, 099.59, 099.8, 099.9, 090.0, 090.1, 090.2, 090.3, 090.40, 090.41, 090.42, 090.49, 099.56, 090.5, 090.6, 090.7, 090.9, 091.0, 091.1, 091.2, 091.3, 091.4, 091.50, 091.51, 091.52, 091.61, 091.61, 091.69, 091.7, 091.81, 091.82, 091.84, 091.89, 091.9, 092.0, 092.9, 093.0, 093.1, 093.20, 093.21, 093.22, 093.23, 093.24, 093.81, 093.82, 093.89, 093.9, 094.0, 094.1, 094.2, 094.3, 094.51, 094.52, 094.7, 094.81, 094.82, 094.83, 094.84, 094.85, 094.86, 094.87, 094.89, 094.9, 095.0, 095.1, 095.2, 095.3, 095.4, 095.5, 095.6, 095.7, 095.8, 095.9, 096.0, 097.0, 097.1, 097.9

Laboratory tests


Drug Abuse:

ICD-9 codes

304.00, 304.01, 304.02, 304.03, 304.20, 304.21, 304.22, 304.23, 304.40, 304.41, 304.42, 304.43, 304.60, 304.61, 304.62, 304.63, 304.70, 304.71, 304.72, 304.73, 304.90, 304.91, 304.92, 304.93, 305.50, 305.51, 305.52, 305.53, 305.60, 305.61, 305.62, 305.63, 305.70, 305.71, 305.72, 305.73, 305.90, 305.91, 305.92, 305.93

Laboratory tests


HIV Infection

ICD-9 codes

042., 042.1, 042.2, 042.9, 043.0, 043.1, 043.2, 043.3, 043.9, 044.9, 079.53, V08

Laboratory tests

Positive HIV antibody test or viral load


ICD-9 codes


Laboratory tests


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Goetz, M.B., Hoang, T., Bowman, C. et al. A System-wide Intervention to Improve HIV Testing in the Veterans Health Administration. J GEN INTERN MED 23, 1200 (2008). https://doi.org/10.1007/s11606-008-0637-6

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  • diagnosis
  • HIV testing
  • quality improvement