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Abstract
Objectives To explore staff attitudes towards and experiences of the implementation of routine HIV testing in four healthcare settings in areas of high diagnosed HIV prevalence.
Methods As part of the HINTS (HIV Testing in Non-traditional Settings) Study, routine offer of an HIV test to all 16–65-year-old patients was conducted for 3 months in an emergency department, an acute admissions unit, a dermatology outpatients department and a primary care practice. The authors conducted focus groups with staff at these sites before and after the implementation of testing. Transcriptions of focus groups were subject to thematic analysis.
Results Four major themes were identified: the stigma of HIV and exceptionalisation of HIV testing as a condition; the use of routine testing compared with a targeted strategy as a means of improving the acceptability of testing; the need for an additional skill set to conduct HIV testing; and the existence within these particular settings of operational barriers to the implementation of HIV testing. Specifically, the time taken to conduct testing and management of results were seen by staff as barriers. There was a clear change in staff perception before and after implementation of testing as staff became aware of the high level of patient acceptability.
Conclusions The routine offer of HIV testing in general medical services is feasible, but implementation requires training and support for staff, which may be best provided by the local sexual health service.
- HIV testing attitudes staff
- epidemiology (general)
- HIV
- sexual health
- heterosexuals
- sexuality
- risk factors
- sexual practices
- homosexual
- surveillance
- public health
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- HIV testing attitudes staff
- epidemiology (general)
- HIV
- sexual health
- heterosexuals
- sexuality
- risk factors
- sexual practices
- homosexual
- surveillance
- public health
Introduction
In the UK, over half of those newly diagnosed with HIV are at the stage at which treatment would be recommended (CD4 count <350 cells/mm3) and an estimated quarter of infected individuals are unaware of their infection.1 There is also evidence that undiagnosed HIV-positive individuals have attended healthcare facilities without having their HIV infection diagnosed.2 Most HIV testing currently occurs either in sexual health clinics or as part of antenatal care.3 National guidelines now recommend routinely offering HIV testing in general healthcare settings where the local diagnosed HIV prevalence exceeds two per thousand 15–59-year-olds.4–6
In antenatal and sexual health settings, implementation of a routine offer of an HIV test has been shown to be highly acceptable and has increased the uptake of testing among these patient groups.7 ,8 Nationally, uptake of testing is now over 90% in antenatal care and 78% in sexual health clinics.1
High levels of test uptake and acceptability have been seen in pilot projects when HIV testing is routinely offered in other non-specialist settings, such as emergency departments (EDs),9–11 inpatient wards,12 ,13 primary care14 and more specialist outpatient departments, such as termination of pregnancy services.15 However, to be successful, these strategies must be acceptable to the staff working within the department. Therefore, there is a need to understand staff attitudes towards routine HIV testing and how it can be implemented with minimal impact on the work of the department.
The HIV Testing in Non-traditional Settings (HINTS) Study was a multisite mixed-method study, which aimed to assess feasibility, acceptability and effectiveness of routinely offering HIV testing in four healthcare settings in London, UK: an ED, an acute admissions unit (AAU), a dermatology outpatients department (OPD) and a primary care facility (PC).
In this paper, we report findings from the qualitative component of the study. We describe staff attitudes to and experiences of the routine offer of an HIV test in their particular settings, in order to better understand how HIV testing can be integrated into routine practice.
Methods
Study overview
Study sites were located in areas of high diagnosed HIV prevalence (range, 8.15–13.28 per 1000 adults). The study consisted of three phases. During the pre-testing phase, focus groups were conducted with staff and a questionnaire administered to patients and staff (reported elsewhere).16 During the testing phase, all patients aged 16–65 years were routinely offered an HIV test. Additional staff, funded by the Department of Health, obtained consent for testing and collected the clinical sample where necessary. In PC, doctors conducted testing as part of their normal consultation and were paid for performing tests, in line with other screening tests conducted in primary care. Non-rapid tests were conducted on salivary samples for ED, OPD and PC patients and on serum samples for AAU patients. Further focus groups were conducted post-testing at each site.
The study received a favourable ethical opinion from the National Research Ethics Service (REC reference: 09/H0805/35).
Sampling
All staff working in the departments were invited to participate in focus groups, as were laboratory staff who processed the clinical specimens. Staff were provided with written and verbal information about the study and signed informed consent forms before participating.
Data collection
Group discussions were best suited to the data we required as we sought to understand the range of attitudes and experiences of HIV testing and any operational and attitudinal barriers. Use of focus groups allowed differences and similarities in views to be explored both within and between the staff in the different medical settings.
A topic guide (online appendix 1) was developed by an independent qualitative researcher (GE) with input from the rest of the study group. Questions were organised within four subject areas: (1) knowledge and perceptions of current HIV testing practices, (2) staff perceptions of patient acceptability, (3) reactions to the proposed models of testing and results governance and (4) staff attitudes towards routine testing. Each subject area was explored consistently by the facilitator who followed the topic guide in all the groups. Questions were open-ended, framed to reflect the circumstances or experiences of participants. Further explanatory questions sought elaboration on points made, examples or reasons why an attitude was expressed. The discussions were recorded to produce anonymised verbatim transcripts.
Focus groups were facilitated by one of three trained facilitators (ACT, MR and GE), and each focus group lasted approximately 1 h. Group moderation techniques were used to encourage participants to compare views and experiences. During larger groups, more time was made available and checks carried out to ensure the full range of views present were expressed. Where possible, to allow maximum staff participation, focus groups took place on site and during regular staff meeting times. Most staff participated in both pre-testing and post-testing focus groups.
Data analysis
Open coding of transcripts was conducted using NVIVO software (QSR International Pty Ltd, V.9, 2010). Inductive thematic analysis was used to both describe the range of attitudes present and identify underlying issues that might explain their presence and impact on implementation of testing. Related codes were grouped into common issues raised by participants and these formed the basis of descriptive themes. These were reviewed, defined and named before being interrogated for explanatory themes that provided further insights into attitudes and experiences around HIV testing. Codes and themes were created jointly by MR and ACT and validated by presentation of the findings to the rest of the study group. Pre-testing and post-testing focus groups were analysed separately, but common themes were identified across both sets of data.
Results
Six focuses were conducted in the pre-testing phase and seven in the post-testing phase (table 1). In general, focus groups were divided by staff roles: nurses, administrative and laboratory staff attending the same focus groups and doctors attending separate focus groups.
Focus group participants
The stigma and exceptionalisation of HIV
Staff felt that HIV has been exceptionalised as a condition within the medical profession and in the broader public domain (see box 1). This exceptionalisation had been perpetuated by the confinement of HIV testing to specialist settings and was viewed as a barrier to the offer and acceptance of HIV testing outside sexual health clinics.
The stigma of HIV
Exceptionalisation of HIV
The whole idea that you can be treated and the rest of the healthcare individuals aren't part of that pathway. And the secrecy…people may be attending one hospital for one thing, at another hospital for…they're unaware. It's been really unhelpful to the medical profession…false identities, secret pathways (OPD doctor—pre-testing).
Normalisation through routine testing
If they're asking for an HIV test it's almost like a confession that they've done something naughty or whatever. Whereas I think that if it's offered to them as a routine thing there is a lot less stigma attached to it (AAU doctor—pre-testing).
I think…it's just a simple thing, by offering people a HIV test it may just change their attitudes. Probably in small population…but if it was carried out in other settings as well simultaneously, ultimately it will be the start of a change (ED doctor—pre-testing).
Changing staff perceptions
Can I just comment on one thing? We talk about misconceptions but the study has proved to me that the misconceptions were in our minds as clinicians—the patients are taking it onboard easily (ED doctor—post-testing).
They consented and I was shocked that people were willing (AAU nurse—post-testing).
But I'm surprised in general that they agreed and were happy to have the test (ED doctor—post-testing).
In pre-testing groups, staff expressed concerns that the stigma of HIV would manifest among their patients in the form of stereotyping17: patients may equate the offer of an HIV test with an inference about their behaviour. Staff were concerned that this stereotyping could lead to negative reactions from patients and refusal of a test. Staff believed that the stigma of HIV among patients was driven by misunderstandings of HIV risk factors, prognosis, treatment and how a HIV-positive result would affect them. There was clear evidence in the post-testing groups of changing opinions in this area. Across sites, staff were surprised that patients were happy to test and it was acknowledged that the stigma they had anticipated finding among patients was not realised.
In pre-testing focus groups, the provision of routine HIV testing in non-specialist settings was viewed as being a potentially useful tool in the reduction of HIV-related stigma among patients and in normalisation of the condition among healthcare professionals. This view was shared by staff who had reservations and those who were more confident about the testing. It was substantiated in the post-testing phase, where staff reported that “the more it [HIV testing] is done, the more acceptable [it becomes].”
Targeted versus routine testing
Current practice in all departments was based on diagnostic and risk-based testing, where knowledge of HIV status was likely to have an impact on immediate clinical management. Pre-testing, opinions varied regarding the value of routine testing. Some placed emphasis on the importance of risk assessment of individuals and on the value of targeting testing towards high-risk individuals. Others saw the value of routine testing as a means of diagnosing individuals who may not otherwise present to specialist services. Concerns about a targeted approach were underpinned by concerns that it perpetuated stigma. Post-testing, it was reported that the lack of targeting was helpful in maximising the acceptability of the intervention to patients (see box 2).
Targeted versus routine testing
Targeted testing
If you've got a certain amount of limited resources; you want to target high risk groups. There's no point in targeting everyone (ED doctor—pre-testing).
I think if it's going to affect the management of a condition that they've come in with, then I think it's as important as any other test (ED doctor—pre-testing).
Routine testing
I think we need to consider everyone really. I think you can't just say one group in particular because, erm, you know, then you are going to miss some. You can't really guess it, you just have to test everyone (AAU doctor—pre-testing).
People didn't feel as if they were being homed in on and that ‘there must be a reason why it's just me?’, it was offered to everybody (AAU nurse—post-testing).
Post-testing, there was evidence of a shift from perceiving HIV testing as a diagnostic tool, only to be conducted when clinically indicated, to viewing it as a useful public health intervention. As such, staff felt that routine testing could fall within their health promotion remit. Overall prevalence among those tested in the study was 0.2% (8/4105).16 Post-testing staff were encouraged that new diagnoses had been made as a result of the study and that these individuals had been successfully transferred into HIV care.
Special skills
The historical exceptionalisation18 of HIV testing and care was manifest in the widely held belief that the provision of HIV testing required a specialist skills set (see box 3). While some took a pragmatic approach and understood that the pretest discussion could be brief and focused, as recommended by international and UK health organisations,4 ,19 ,20 others believed that this was a complex process. Staff were concerned about their ability to answer patients' questions in a satisfactory manner. Staff identified particular training needs around HIV epidemiology, and HIV management immediately after diagnosis. Post-testing, staff from all sites and professions acknowledged that many of these anxieties were unfounded: they were rarely asked questions by patients and felt able to competently address questions that did arise. Staff felt that a principal barrier to offering testing was operational—in terms of having sufficient time to do so.
Special skills
Specialist knowledge
I haven't got the right knowledge to be able to say to someone, “I need to do an HIV test on you”. I don’t know enough about HIV—it’s not my speciality (ED doctor—pre-testing).
I think people who are counselling need to have certain knowledge of the condition and its treatment (AAU doctor—pre-testing).
It's just having that knowledge isn't it? It's like everything—once you have the knowledge, you're fine. So maybe …maybe I need to recognise that I need to swot up on it a bit more (ED nurse—post-testing).
Pragmatic pretest discussion
It's just a normal consent really, but with additional sensitivity I think (AAU doctor—pre-testing).
Answering patient questions
We came round a couple of times [to testing team] saying “No-one's asking us loads of questions” you know…we were so surprised. It was nice. And patients who did mention it thought it was a really good idea (ED nurse—post-testing).
Operational considerations
Concerns about the practical aspects of delivering HIV testing emerged as the dominant theme (see box 4). These concerns led staff to question the appropriateness of their setting as a venue for routine HIV testing. Medical, nursing and administrative staff in hospital settings suggested that the most appropriate environment for routine HIV testing was primary care, where health promotion and prevention is already ingrained in practice.
Operational considerations
Time
I think one of the barriers from the clinicians point of view is that if you are responsible and want to consent appropriately, it's quite difficult to do that in the time frame (AAU doctor—pre-testing).
If we were to do it here, we'd definitely need more staff (OPD nurse—post-testing).
I also expected my time consumption, the time consumption to be a lot more than 2 to 3 minutes. I was actually quite surprised. I expected my consultation times to double (GP—post-testing).
Type of test
They were delighted there were no needles—that was a factor for some people (OPD doctor—post-testing).
It [saliva] was a good option because lots of people if you'd offered them a blood test wouldn't necessarily have taken it up (OPD nurse—post-testing).
Confidentiality
It's really complicated, because often they're with a family member as well and that makes it doubly complicated. You can't ask it in front of their parents, their long term partner (ED doctor—pre-testing).
I think A&E generally is not very confidential because of the curtains. Things you hear…I don't think hearing ‘Do you mind having an HIV test?’ is any worse than ‘I’m just going to stick my finger up your bottom' (ED doctor—post-testing).
Results
If it's negative I can go in and say “It's negative”, if it's positive someone must be prepared to speak to him (ED doctor—post-testing).
How do you get in contact with somebody about their result and what's the follow-up and who does that patient then link in with (AAU doctor—post-testing)?
Primary care setting is best
General practice is absolutely the key, it's an environment where they have a strong rapport with the clinician built up over a long time and where health screening is routine. So you go…you're having your smear, you're having your blood pressure, you're having your asthma check or your diabetes check. It is a screening environment. It's about health prevention (OPD doctor—pre-testing).
Time
Lack of time was cited in all departments as an operational barrier to conducting HIV testing. This was of particular concern in the ED. There was concern that offering an HIV test during a consultation for an apparently unrelated medical complaint may serve as a distraction or was trying ‘to do too much in one go’. In the post-study focus groups, staff reported that due to the use of additional study staff to conduct testing, there had been very little impact on the department, but that if testing were to be conducted by themselves, then there would be infrastructural and resource implications. In the PC setting, GPs reported that testing did add time to their consultations, but that this was substantially less than they had expected.
Type of test
The use of non-invasive oral fluid sampling in the ED, OPD and PC settings was received favourably as it was quick and highly acceptable to patients. Many believed that other sampling techniques, such as venepuncture, may act as a disincentive to test. Testing in AAU was performed on serum samples, and no staff voiced objections to this method.
Confidentiality
Maintaining confidentiality was a concern in the acute settings, where consultations may take place in open areas, and where patients are frequently accompanied by friends and family.
Managing results
Results management was a principal concern in all settings. Staff, who felt that they would be comfortable delivering a negative result to a patient, expressed concerns about delivering a reactive result. It was suggested that the latter required specialist staff, such as sexual health advisors. In light of these concerns, it was felt that while testing would be feasible, the delivery of results was best conducted outside the setting, with specialist help. A further concern was the safe governance and follow-up of results; informed by perceived ambiguity regarding where and with whom ultimate responsibility for checking and delivering results lay.
Cost
An emergent theme in the post-testing phase was cost-effectiveness. Staff requested evidence to substantiate claims that routine testing in high prevalence areas was likely to be a cost-effective intervention. They did not appear doubtful, just eager for the evidence. In the PC facility only, payment to clinicians for conducting testing emerged as an incentive for testing.
Discussion
The results of our study show that there is support from staff for routinely offering HIV testing in healthcare settings beyond sexual health and antenatal clinics. Staff viewed this as having the potential to normalise testing in healthcare settings and destigmatise HIV among patients. The routine nature of the test offer was perceived as useful for offering HIV testing in a non-judgemental manner.
Our study has some limitations. It is possible that only those staff who had particularly strong feelings about the study chose to attend focus groups. However, given that staff from a range of different roles did participate (table 1) and there was a balance between support for HIV testing and reservations about its implementation, we do not believe that there was a strong influence of participation bias on our findings. Focus groups were conducted by members of the study team who both developed the study protocol and two of whom were responsible for the roll out of testing (ACT and MR). Therefore, the researchers themselves may have had preconceived ideas, which guided the direction of discussion. The impact of this was minimised by use of the focus group topic guide. While further discussion topics were identified during the study as part of a reflective process, these new topics were additional and did not replace those discussed with earlier groups.
As with all qualitative research using focus groups, there is the possibility that participants express attitudes and ideas during the focus groups, which differ from the way that they behave in practice. The extent to which this affects the results is difficult to assess. However, we hope that by conducting the focus groups in a familiar environment and organising groups to include participants who work together, the views expressed during the focus groups closely reflect the actions of the staff during their work. In addition, staff provided examples from their practice and experiences were compared before and after the roll-out of the testing. Therefore, the emphasis was on experiential attitudes to testing. Many of the staff attitudes related to how they expected patients to respond to the offer of a test. It is not possible from these data to assess the actual patient experience. Finally, this study took place in areas of high HIV prevalence. Results may not be generalisable to locations where HIV is encountered rarely and staff attitudes in other settings may be affected by the number of new diagnoses that would result from routine testing.
Developments in HIV treatment and the good prognosis for those diagnosed promptly have changed the way in which HIV is approached and it can now be considered a manageable condition.21 However, the exceptionalisation of HIV, at a policy level, has persisted. A European review found that 14/24 countries had high levels of exceptionalisation, and only three had high levels of normalisation.22 Increasing the range of services in which an HIV test is routinely offered may go some way to removing the exceptionalisation of HIV as a condition.18 ,23 This was acknowledged by participants within our study.
Despite the supportive stance of most staff towards routine HIV testing, there were a number of operational barriers to testing which formed a key theme of the results. In particular, time taken for HIV testing, maintaining confidentiality and dealing with results were areas that staff repeatedly cited as barriers. These findings are in line with other studies24–27 and may be viewed as a manifestation of the exceptionalisation of HIV as a condition. A financial incentive for conducting testing was paid to clinicians in the primary care facility in line with other tests carried out in these facilities. Without this incentive, which has clear cost implications, routine offer of a test may have been less acceptable to staff in this setting.
We believe that co-operation with and support from the local sexual health service is key to overcoming these barriers and ensuring that testing in these settings is sustainable. Although it should be within the competency of any healthcare professional to conduct an HIV test,4 the local sexual health service can provide support by ensuring that results are managed appropriately, there is a simple referral process for individuals with reactive test results, providing training in areas where staff feel they are not adequately knowledgeable and by providing specialist knowledge if patients have particularly complex questions. The routine nature of the test offer meant that only a limited amount of time was required for obtaining patient consent and collecting the clinical sample (approximately 2 min). Since rapid tests were not used and results were managed by the local sexual health service, there was no additional time added to patient consultations for discussing results. As HIV testing becomes more normalised in non-specialist settings, the additional time taken to conduct testing and confidentiality arrangements should be limited to those extended to consenting a patient for any other procedure. One study in the USA has previously shown that where HIV testing is offered by dedicated staff within an ED, no additional time is added to the patient's stay in the department.28
To our knowledge, this is the first study in a developed country assessing attitudes to routine HIV testing in non-specialist settings both before and after the implementation of the testing. The exact model of routine HIV testing, which is successful will be different in each setting and in certain circumstances (eg, in EDs), may require a small increase in staff numbers. However, we believe that our findings, in combination with results showing patient acceptability of HIV testing,9–14 ,29 and evidence of successful implementation of routine HIV testing in healthcare settings in developing countries,30 indicate that HIV testing can and should be implemented in a range of healthcare settings.
Key messages
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A qualitative study of attitudes of staff towards the introduction of HIV testing in non-specialist settings before and after the implementation of testing.
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There is support for normalisation of HIV testing, and testing in non-specialist settings is feasible.
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The main barriers to HIV testing are operational, in particular, the time needed to conduct testing and management of results.
Acknowledgments
The authors report that these finding on behalf of the HINTS Study group, which comprised all the named authors in addition to Rebecca Cridford, Eric Doku, Robert Ghosh, Shweta Gidwani, Rachel Morris-Jones, Sifiso Mguni, Danna Millett, David Mummery, Matthew Pearn, Karen Phekoo, Caroline Rae, Malur Sudhanva and Tanya Welz. Patient and public engagement: Gus Cairns and John Holland. The study group were involved in the day-to-day conduct of the study: provision of HIV testing, distribution of patient and staff literature and questionnaires or laboratory procedures. Gus Cairns and John Holland reviewed the protocol and all study literature from a patient perspective. We acknowledge all staff who participated in the focus groups and all patients who attended the departments during the study and who were offered an HIV test by one of the study team.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online Appendix 1
Footnotes
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Funding The qualitative arm of the HINTS Study was funded by the Department of Health. The funders of the study, and its sponsor (Chelsea and Westminster NHS Foundation Trust), had no role in the study design, data collection, data analysis, data interpretation or writing up of the report.
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Competing interests None.
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Ethics approval Ethics approval was provided by the National Research Ethics Service.
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Provenance and peer review Not commissioned; externally peer reviewed.