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Acceptability and Feasibility of Rapid HIV Testing in an Adolescent Clinic Setting: Youth Testing Attitudes, Knowledge, and Behaviors
Journal of Adolescent Health 49 (2011) 609 – 614
www.jahonline.org Original article
Acceptability and Feasibility of Rapid HIV Testing in an Adolescent Clinic Setting: Youth Testing Attitudes, Knowledge, and Behaviors Selin Tuysuzoglu, M.D., M.P.H., Heather L. Corliss, M.P.H., Ph.D., Susan M. Fitzgerald, M.S.N., C.P.N.P., Brian R. Abascal, M.F.A.*, and Cathryn L. Samples, M.D., M.P.H. Division of Adolescent and Young Adult Medicine, Children’s Hospital Boston, Boston, Massachusetts
Article history: Received October 28, 2010; Accepted March 12, 2011 Keywords: Adolescent; HIV/AIDS; Rapid HIV testing
A B S T R A C T
Purpose: To assess youths’ attitudes, knowledge, and behaviors regarding rapid HIV testing (RHT) and measure acceptability and feasibility of RHT in an adolescent clinic setting. Methods: A 2007–2008 project introduced free RHT at an urban, hospital-based adolescent and young adult clinic in Boston, MA. Patients and HIV testing clients were offered either free nonrapid tests or fingerstick RHT. An anonymous questionnaire assessed youths’ testing attitudes, knowledge, and behaviors (N ⫽ 127). Ordinal logistic regression model was used to determine associations with youth demographic characteristics and testing experience. Results: Most participants valued rapid results. A minority desired confidentiality from parents and insurance providers. Older youth were more likely to know about testing methods (OR: 1.25; CI: 1.04 –1.51) and plan for follow-up (OR: 1.43; CI: 1.14 –1.81). Age, gender, and race were unrelated to testing facilitators such as rapidity, confidentiality, and cost, although younger clients were more likely to prefer noninvasive methods. Individuals with previous testing experience were more likely to say that they would contribute to expenses and value rapidity over cost. Conclusion: There was strong support for RHT among youth receiving HIV testing. Offering RHT to youth may facilitate routine testing. Future research should focus on increasing RHT access among diverse populations of youth. 䉷 2011 Society for Adolescent Health and Medicine. All rights reserved.
Despite public health efforts, adolescents remain at risk for sexually transmitted infections and may be underdiagnosed for HIV/AIDS [1]. In 2007, nearly one-third of new HIV infections in the United States occurred in persons aged ⬍29 years [2]. Because adolescents are at high risk for HIV, early testing and knowledge of status remain vital goals. In a nationally representative sample of 15–17-year-olds, only 27% had been tested for HIV and less than half knew where to obtain testing [3]. Although most adolescents want to discuss HIV/AIDS with physicians [4], one study found that HIV/STD counseling was offered at only 6% of adolescent ambulatory well visits and 14% of dedicated repro-
* Address correspondence to: Brian R. Abascal, M.F.A, Division of Adolescent and Young Adult Medicine, Children’s Hospital Boston, 300 Longwood Avenue, LO 306, Boston, MA 02115. E-mail address: [email protected] (B.R. Abascal).
ductive health visits [5]. These statistics suggest there are many missed opportunities for HIV prevention and screening because provider input motivates youth testing [4,6]. The CDC recommends routine opt-out screening for all persons of ages 13– 64 years and annual testing for high-risk individuals [7]. Adolescents face unique barriers to HIV testing, with high-risk youth testing less frequently than low-risk peers [8 –12]. Even with reliable access, testing method may significantly influence knowledge of status. A 1996 CDC report found that 40% of patients tested with the standard immunoassays (enzymelinked immunosorbent assay [ELISA]) with Western blot did not receive their results [13]. Even small decreases in turnaround time can improve receipt of results [14]. Increasing HIV testing among youth promises significant public health and clinical benefits [15]. Adolescents reduce risky behaviors after learning that they are HIV positive [1,16]. The
1054-139X/$ - see front matter 䉷 2011 Society for Adolescent Health and Medicine. All rights reserved. doi:10.1016/j.jadohealth.2011.03.007
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CDC estimates that sexually transmitted HIV could be reduced by 30% annually with earlier knowledge of status [1]. Early HIV diagnosis and initiation of highly active anti-retroviral therapy can slow disease progression, reduce viral load, and decrease mortality [17]. Lower viral loads may also reduce HIV transmission to sexual partners [18]. Understanding youth attitudes toward HIV testing methods can help guide clinical practices, improve outreach, inform social marketing, and increase knowledge of status. In a study of predominantly African American youth of ages 12–24 years, noninvasive oral mucosal rapid testing was the preferred method [19]. Even with knowledge of hypothetical turnaround times, a nonrapid oral method was favored over the rapid but more invasive fingerstick. These preferences were unrelated to gender, age, ethnic group, testing experience, or HIV risk behaviors. A related study of predominately minority youth of ages 12–24 years found that oral, rapid, free, and convenient testing were key facilitators [20]. These factors were more important for older youth, although other demographic characteristics were not examined. The Reaching for Excellence in Adolescent Care and Health (REACH) study suggested that young females are more likely than males to prefer confidential or anonymous testing [6]. The purpose of this study was to assess the acceptability and feasibility of RHT (rapid HIV testing) within an adolescent and young adult clinic serving a diverse urban population. We examined attitudes toward RHT and associations of demographic characteristics and previous testing experience with key barriers and facilitators such as confidentiality, cost, test method, and test-related anxiety. On the basis of existing data and experience, we hypothesized that youth would prefer a fingerstick rapid test to both an oral 2-week test and a traditional venous test requiring a return visit. We hypothesized that younger adolescents would have less knowledge of testing options and a stronger preference for key testing facilitators including noninvasiveness, rapidity, low cost, and confidentiality. We predicted that females would preferentially desire noninvasive methods, that privately insured clients may value confidentiality and be more willing to contribute to testing costs than uninsured or publicly insured peers, and that non-English speakers may have less awareness of testing options and preferentially value anonymity. We predicted that rapid testing would be a widely accepted and feasible testing method among surveyed adolescents, regardless of demographic profile or previous testing experience. This study builds on the existing literature by examining relationships among a broader range of adolescent demographic characteristics and testing preferences. Unlike many previous studies, it surveys adolescents during real-time testing experiences rather than using data from a hypothetical or staged testing scenario [19,20]. Finally, it is among the first studies to address youths’ willingness to pay for RHT. Methods Study setting, procedures, and participants Through affiliation with the Massachusetts Department of Public Health, the Adolescent and Young Adult clinic at CHB (Children’s Hospital Boston) houses an adolescent HIV program (Boston HIV Adolescent Provider & Peer Education Network for Services [HAPPENS]) that offers free HIV testing. Counseling and testing is performed by trained counselors, using either venous blood or an oral mucosal transudate specimen. Testing clients must
return for a second visit after 2 weeks to receive results. Over a 4.5-month period, we conducted an anonymous cross-sectional survey of English- and Spanish-speaking youth receiving testing. Clients were offered the choice of oral testing using the OraSure HIV-1 Oral Specimen Collection Device (Orasure Technologies, Inc., Bethlehem, PA), serum testing using the standard immunoassays (ELISA) with reflex Western blot, or rapid fingerstick testing using the OraQuick ADVANCE Rapid HIV-1/2 Antibody Device (OraSure Technologies, Inc., Bethlehem, PA). After pretest counseling, clients consenting to a test who were able to read and write in English or Spanish were offered a 23-item self-administered questionnaire along with the study consent form and a visual depiction of test options. There were 164 testing clients during the study period, 150 of whom were offered a questionnaire. There were no other exclusion criteria for being offered a survey because all youth tested for HIV through HAPPENS’s counseling and testing services could participate in the study. Of those offered, 130 clients completed the questionnaire (86.7% response rate), but three age outliers (ⱖ30 years) were excluded from statistical analysis. Thus, the analytic sample size was 127. Test providers were asked to indicate the type of test performed for all clients, including those who refused the survey. Our testing site does not require parental consent for HIV testing at age ⱖ13. Given the highly sensitive nature of HIV testing and the minimal risk to subjects of completing the survey, parental consent was waived for minor participants. Anonymity was preserved with a checkbox for consent and by storing completed surveys in a locked box. The CHB Institutional Review Board (IRB) approved the study protocol as an anonymous survey with waiver of parental consent. To further protect that anonymity, our IRB also specifically excluded linkage of survey responses to risk behavior data, which was examined in a separate study reported elsewhere [21]. Study measures The questionnaire assessed client demographics as well as their previous experiences with, and attitudes toward, HIV testing. Demographic factors included race/ethnicity, age, gender, preferred language, and insurance status. The answers to two race/ethnicity questions: “Are you Latino/Hispanic?” and “Which race are you?” were combined into a single variable using the following categories: Hispanic/Latino and the non-Hispanic categories black, white, Asian/Pacific Islander, Native American, and “Multiracial” for youth who indicated more than one response. When the participants were questioned about their preferred language, those who marked “Multilingual” also marked “English”; therefore, we collapsed the variable into two categories: English (including multilingual) and other. The status of uninsured clients changed during the study period, with healthcare reform expanding health insurance availability to uninsured, low-income clients. To handle this historical change, we coded participants as having either private insurance or Medicaid, Medicare, Free Care (the uncompensated care pool), and no insurance grouped together. The questionnaire also inquired about previous HIV testing experience, receipt of latest test results, and reasons for visiting the clinic on test day. Willingness to pay for portions of testing costs ($0, $5 or less, $10, $15, or more than $20) was also queried. Ten questions, designed by researchers, measured youth knowledge and attitudes toward common testing barriers, facilitators, and concerns. Responses were coded with Likert scale style re-
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sponses as 1 ⫽ “strongly disagree,” 2 ⫽ “disagree,” 3 ⫽ “neutral,” 4 ⫽ “agree,” and 5 ⫽ “strongly agree.”
Table 2 Testing experience of survey participants receiving HIV testing at the CHB’s HAPPENS program (N ⫽ 127) N (%)
Statistical analysis We examined descriptive frequencies of respondents’ demographic characteristics, previous testing experiences, and responses to questions about HIV testing. Likert scale responses to testing attitudes were analyzed with univariate and multivariate ordinal logistic regression models. Given the discrete and ordinal nature of Likert scale dependent variables, ordinal regression was considered a technically superior analytic approach to linear regression, particularly given our a small sample size. Univariate ordinal logistic regression odds ratio (OR) and 95% confidence interval (CI) were calculated to examine the association between each testing attitude question and predictor variables, including age, adult legal status (18 years or older), race/ethnicity, gender, language preference, insurance status, previous testing experience, and testing choice. Multivariate ordinal logistic regression was then performed for each testing attitude outcome. Multivariate models included all predictor variables noted previously, except legal status because of colinearity with age. Finally, to examine financial feasibility, categories of willingness to pay were examined as a dichotomous variable to determine whether test clients would be willing to contribute at all to testing costs (yes vs. no) and assessed with binary logistic regression. All analyses were performed with SPSS 16.0 for Windows (SPSS Inc., Chicago, IL). Results Response frequencies
Previous testing Never tested Previously tested Previously tested at CHB Regular blood test Free blood test Free cheek swab Rapid test Previously tested elsewhere Rapid test Receipt of latest CHB results Never received Received 1–2 weeks later in person Received ⬎2 weeks later in person Received by phone or letter Rapid results on the same day Unsure Receipt of latest non-CHB results Never received Received 1–2 weeks later in person Received ⬎2 weeks later in person Received by phone or letter Rapid results on the same day Today’s test Boston HAPPENS CTSa Blood test Oral mucosal test Rapid test Reason for visit Appointment Appointment and HIV test Just HIV test a
Characteristics of survey respondents are presented in Table 1. The mean age of respondents was 19.7 years, with a majority (65.6%) female. Approximately one-third (32%) identified as nonHispanic white; 37.6% as non-Hispanic black; 17.6% as Hispanic/ Latino; and 12.8% were classified as Asian-Pacific Islander, Native American, Multiracial, or other. This racial/ethnic distribution is
Table 1 Demographic characteristics of survey participants receiving HIV testing at the CHB’s HAPPENS program (N ⫽ 127) Study clients (N ⫽ 127) % Mean age (range) Legal status Minor (⬍18 years) Adult Gender Male Female Race/ethnicity Non-Hispanic black Non-Hispanic white Hispanic/Latino API/NA/MR/Othera Preferred language English Other Insurance type Private None/public
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19.7 (14–29) 18.1 81.9 34.4 65.6
68 (53.3) 57 (44.8) 40 (32.0) 6 (15.0) 11 (27.5) 18 (45.0) 10 (25.0) 17 (13.6) 8 (20.0) N ⫽ 39 2 (5.1) 18 (46.2) 8 (20.5) 3 (7.7) 5 (12.8) 3 (7.7) N ⫽ 34 10 (29.4) 11 (32.5) 2 (5.9) 5 (14.7) 6 (17.7) N ⫽ 127 18 (14.4) 2 (1.6) 17 (13.6) 107 (85.6) 39 (31.2) 30 (24.0) 56 (44.8)
HAPPENS’s counseling and testing services.
representative of the community served by the HAPPENS program and of the primary care population of the Adolescent/ Young Adult clinic. Not surprisingly, testers were older than patients served by the primary care practice. Previous testing experiences are depicted in Table 2. More than half of the participants were first-time testers. The majority of previous testers confirmed receiving their most recent HIV test results, with greater follow-up reported among those last tested onsite (87% vs. 70%). Most (85.6%) youth received RHT at their visit, and nearly half presented to our program exclusively for HIV testing. Participants’ attitudes toward testing are presented in Table 3. Willingness to pay for RHT varied widely, with 31.1% of respondents unwilling to pay anything, 11.5% willing to contribute $5 or less, 14.8% willing to contribute $10, another 14.8% willing to contribute $15, and 27.9% willing to pay $20 or more. Ordinal and binary logistic regression
37.6 32.0 17.6 12.8 86.4 13.6 50.5 49.6
CHB ⫽ Children’s Hospital Boston; HAPPENS ⫽ Boston HIV Adolescent Provider & Peer Education Network for Services. a Asian-Pacific Islander/Native American/Multiracial/other.
Results of univariate and multivariate analyses are shown in Table 4. In univariate analysis, younger age was significantly associated with testing barriers, including fear of needles, lesser knowledge of different testing methods, and preference for free testing. Multivariate analysis suggested that preference for free testing was not related to age, but fear of needles (OR: .84; 95% CI: .71, 1.00) and lack of knowledge about testing methods (OR: .80; 95% CI: .66, .96) remained barriers for younger adolescents. Moreover, multivariate analysis suggested that older youth had significantly higher odds of planning to receive medical
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Table 3 HIV testing attitudes of survey participants receiving HIV testing at the CHB’s HAPPENS program (N ⫽ 127) HIV testing attitudes
Strongly disagree (%)
Disagree (%)
Neutral (%)
Agree (%)
Strongly agree (%)
“I want results as soon as possible” “I plan to discuss my results with my doctor or nurse” “I hate needles or having my blood drawn” “I do not want my parents to know I got tested today” “I will only get tested if it is free, even if it means waiting 2 weeks for results” “It is okay if my insurance is billed for this test” “I did not know there were different ways to get tested” “I am nervous waiting for my results” “I would rather come back for results than have to wait here longer today”
.0 2.5 14.2 20.0 22.0 35.1 30.4 9.7 55.3
.0 4.2 20.5 18.3 26.0 10.8 23.2 13.7 23.6
7.1 21.0 31.5 22.5 23.6 21.6 13.6 19.4 11.4
9.4 26.1 14.2 7.5 16.3 15.3 22.4 21.8 4.1
83.5 46.2 19.7 31.7 12.2 17.1 10.4 35.5 5.7
follow-up (OR: 1.43; CI: 1.14, 1.81), as did youth of “Other” ethnicity (OR: 13.94; CI: 1.55, 125.84). Our multivariate models revealed no other predictors of testing barriers or facilitator by race, ethnicity, gender, or language preference. In both univariate and multivariate models, private insurance predicted a desire for rapid results (OR: 11.31; CI: 2.06, 61.87). Although univariate analysis suggested that black and Latino youth were less likely to value rapidity than their white peers, these results were not significant in the multivariate model. In univariate analyses, females were more likely than males and Latinos were more likely than whites to say that they were okay with their insurance being billed for the test, whereas in the multivariate model, rapid testers had higher odds of agreement (OR: 3.62; CI: 1.04, 12.54). Having chosen RHT was the most frequent and strongest independent predictor of youth testing attitudes because rapid testers had significantly higher odds of valuing rapidity (OR: 5.0; CI: 1.24, 20.19), planning for medical follow-up (OR: 7.92; CI: 2.24, 28.05), and preferring to wait for results (OR: 16.6; CI: 4.54, 50.0). Age, gender, race/ethnicity, language preference, and insurance status were not associated with willingness to contribute to RHT costs. However, experienced testers (44.8%) were more
likely than first-time testers (53.3%) to value rapid results over free tests and to express willingness to contribute to testing costs (OR: 3.89; CI: 1.29 –11.72). Discussion Acceptability and feasibility This study revealed strong support for prompt results of HIV testing among youth at an urban adolescent/young adult clinic. Only one-third of participants were unaware of different testing methods, with younger adolescents significantly being less knowledgeable. These results mirror international findings that younger adolescents have lower rates of voluntary HIV testing [22]. Because younger teenagers may face greater structural, emotional, and psychological barriers to HIV testing, education and outreach are particularly important for this age group. Routine testing may help alleviate age discrepancies, but would cost more per testing result [23,24]. With routine testing, clinicians should heighten their awareness of vulnerable subgroups to ensure adequate follow-up because younger teenagers in our study were less inclined to discuss test results with medical providers.
Table 4 Results of univariate and multivariate logistic regression models examining associations among sociodemographic characteristics and testing attitudes of survey participants receiving HIV testing at the CHB’s HAPPENS program (N ⫽ 127)
1 2 3 4 5
“I want results as soon as possible”
“I plan to discuss my results with my doctor or nurse”
“I hate needles or having my blood drawn”
“I do not want my parents to know I got tested today”
OR (95% CI)
OR (95% CI)
OR (95% CI)
OR (95% CI)
AOR (95% CI)
AOR (95% CI) a
Older age 1.09 (.91, 1.30) .77 (.57, 1.04) 1.12 (.98, 1.27) 1.43 (1.14, 1.81) Young adult vs. minord 2.13 (.70, 6.52) — 1.96 (.81, 4.76) — a c c Rapid test vs. oral 5.12 (1.78, 14.78) 5.00 (1.24, 20.19) 3.04 (1.18, 7.83) 7.92b (2.24, 28.05) Female vs. male 2.08 (.81, 5.32) 3.71 (.95, 14.56) 1.32 (.65, 2.69) 1.22 (.47, 3.19) Preference for non-English .60 (.10, 3.45) .37 (.03, 5.45) .61 (.14, 2.69) .57 (.08, 4.01) language 6 Private vs. none/public 6.99a (1.86, 26.23) 11.30a (2.06, 61.87) .96 (.43, 2.11) .45 (.16, 1.25) insurance 7 Previous testing experience 1.17 (.46, 3.03) 1.51 (.41, 5.64) .89 (.45, 1.76) .51 (.20, 1.27) vs. never tested 8 Other vs. non-Hispanic .76 (.07, 8.82) .84 (.04, 20.49) 1.86 (.58, 6.01) 13.94c (1.55, 125.84) white .18 (.01, 2.48) .75 (.33, 1.69) 1.21 (.38, 3.86) 9 Non-Hispanic black vs. .15c (.03, .71) non-Hispanic white c .14 (.01, 2.01) .97 (.36, 2.64) 1.59 (.42, 6.03) 10 Latino/Hispanic vs. non.13 (.02, .72) Hispanic white
b
.82 (.73, .92) .44 (.19, 1.04) .68 (.28, 1.61) 1.46 (.75, 2.84) .51 (.13, 2.00)
AOR (95% CI)
AOR (95% CI)
.84 (.71, 1.00) .93 (.83, 1.04) .96 (.80, 1.14) — .45 (.18, 1.10) — .74 (.26, 2.10) 1.35 (.55, 3.31) .90 (.31, 2.66) 1.49 (.63, 3.50) .82 (.41, 1.62) 1.06 (.44, 2.58) .44 (.08, 2.46) 1.67 (.41, 6.71) 1.72 (.30, 9.83)
.61 (.29, 1.28)
.95 (.40, 2.29)
.97 (.45, 2.08) 1.04 (.42, 2.60)
1.08 (.57, 2.04)
.96 (.44, 2.12)
.77 (.40, 1.49)
1.90 (.67, 5.35)
2.33 (.54, 9.97) 1.72 (.59, 5.01) 2.71 (.55, 13.44)
2.54c (1.17, 5.52) 1.74 (.59, 5.12) 1.63 (.65, 4.31)
.80 (.35, 1.84)
.69 (.31, 1.51) .100 (.19, 1.89)
1.33 (.39, 4.54) 1.23 (.46, 3.26) .812 (.21, 3.61)
S. Tuysuzoglu et al. / Journal of Adolescent Health 49 (2011) 609 – 614
Despite the testing barriers associated with younger age, we found that age was not significantly associated with valuation of common facilitators like noninvasiveness, rapidity, confidentiality, or lower cost. These findings contrast previous research suggesting that noninvasive (oral) testing was preferred by older youth [20]. A sizeable minority (39%) of participants expressed confidentiality concerns, which may pose a larger barrier among younger populations. Using alternate Current Procedural Terminology (CPT) codes (the standardized codes used for billing patients or third-party insurers for medical procedures) may allow clinicians integrating routine testing to ensure patient confidentiality. Hospitals and clinics might explore confidential testing through funding mechanisms similar to family planning services. Moreover, minor consent laws can and should include HIV testing in the STD services package to which minors may consent without parental notification. Although these results suggest acceptability and feasibility of clinical RHT, implementing routine testing requires creative solutions to potential testing barriers, particularly for younger adolescents. The CDC’s routine screening recommendations have been met with widespread medical, public health, and political support, and endorsed by at least 35 national professional societies [25,26]. Routine testing may be difficult in pediatric and adolescent clinical settings because of parental presence and insurance requirements, but rapid testing may reduce testing barriers. Despite concerns over routine testing, sites implementing CDC recommendations have demonstrated significant testing rate improvements [26].
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reimbursement guidelines to support CDC recommendations [28]. California has modeled one potential solution by requiring insurers to cover HIV testing costs in healthcare settings [25]. Given some adolescents’ willingness to contribute to RHT costs, clinics might consider subsidizing youth testing. In our study, free testing was an important facilitator for first-time testers, whereas repeat testers were significantly more likely to be willing to contribute to RHT costs (and to value rapidity over cost). A graduated payment model may make RHT feasible for non-grant-funded settings. Our findings suggest that older individuals may not pay more for RHT, suggesting that age-based subsidization may not be an ideal model of cost sharing. For point-of-care testing, there exist manufacturer- and state-dependent mandated guidelines for how often staff must verify the accuracy of test results by running the RHT on purchased “control specimens,” whose results are known as positive or negative. Moreover, external proficiency testing is required, using a service that periodically sends blinded controls for staff interpretation. The product cost of RHT (approximately $27, including controls) is compounded by requisite staff time, staterequired consent and counseling, quality assurance, and documentation. Adolescent clinics may consider hiring ancillary staff, accepting co-location of staff from publicly funded sites, or crosstraining existing staff to provide RHT. Cost concerns are compounded by the diminishing federal HIV prevention budget [25]. Policy research, political support for HIV prevention, and strong school-based HIV education may help influence the reach of routine screening [29].
Costs of rapid testing Study limitations and strengths Overall, although one-third of youth preferred completely free testing, most (57.8%) were willing to contribute at least $10 to RHT cost. Providers can now bill for RHT by adding a coding modifier to the standard HIV testing codes within the CPT system [27]. Although Medicaid covers RHT, most state guidelines do not address routine testing and few private insurers have updated their
Strengths of this study include its use of a diverse, urban, hospital-based adolescent clinic with a high survey response rate. Our study also focused on youth attitudes toward specific dimensions of RHT because this method’s popularity and utility are likely to expand HIV testing in both clinical and community-
Table 4 Continued “I will only get tested if it is free, even if it means waiting 2 weeks for results”
“It is okay if my insurance is billed for this test”
“I did not know there were different ways to get tested”
“I am nervous waiting for my results”
“I would rather come back for results than have to wait here longer today”
OR (95% CI)
OR (95% CI)
OR (95% CI)
OR (95% CI)
OR (95% CI)
AOR (95% CI)
AOR (95% CI)
b
AOR (95% CI)
AOR (95% CI)
c
1 .95 (.85, 1.06) .93 (.79, 1.10) .93 (.82, 1.05) .94 (.79, 1.13) .79 (.70, .90) .80 (.66, .96) .92 (.82, 1.03) .96 (.81, 1.14) 1.01 (.90, 1.14) 2 .42c (.17, .99) — 1.32 (.52, 3.40) — .28a (.12, .68) — .46 (.19, 3.78) — .97 (.39, 2.40) 3 .52 (.21, 1.29) .34 (.11, 1.04) 1.53 (.58, 4.03) 3.62c (1.04, 12.54) 1.46 (.59, 3.59) 1.49 (.50, 4.42) 2.02 (.84, 4.86) 2.05 (.71, 5.92) .09b (.03, .24) .77 (.39, 1.49) .90 (.38, 2.16) .92 (.46, 1.80) .76 (.31, 1.84) .94 (.45, 1.95) 4 1.31 (.67, 2.56) 1.38 (.57, 3.30) 2.39c (1.16, 4.95) 1.28 (.51, 3.24) 5 2.11 (.54, 8.22) 5.02 (.87, 29.14) 1.77 (.41, 7.69) 1.80 (.28, 11.73) .86 (.22, 3.36) .51 (.09, 2.97) 8.67c (1.04, 72.30) 5.34 (.51, 55.87) 2.77 (.70, 11.03) 6
.56 (.25, 1.26)
.59 (.22, 1.59)
1.06 (.54, 2.11)
1.26 (.52, 3.05)
8 2.71 (.35, 2.89) 1.60 (.35, 7.23)
1.86 (.36, 3.18)
.30 (.06, 1.58)
9 1.54 (.63, 2.96) 1.04 (.34, 3.19)
2.05 (.88, 4.74)
2.33 (.70, 7.77)
2.86c (1.05, 7.81)
1.67 (.44, 6.33)
7
.95 (.45, 2.01) 1.01 (.41, 2.53) c
.75 (.39, 1.43) .40 (.17, .92)
10 2.30 (.43, 2.83)
.75 (.21, 2.67)
.40c (.19, .86)
AOR (95% CI) 1.40 (.74, 1.10) — .06b (.02, .22) .75 (.28, 1.98) 2.52 (.42, 15.04)
.55 (.22, 1.35)
.71 (.33, 1.51)
.83 (.33, 2.06)
.97 (.43, 2.18)
1.42 (.51, 3.95)
.83 (.37, 1.88)
.66 (.35, 1.28)
.66 (.29, 1.50)
.77 (.38, 1.56)
.93 (.37, 2.32)
.84 (.29, 2.42) 1.21 (.26, 5.51)
.95 (.34, 2.70)
1.66 (.38, 7.22)
1.37 (.44, 4.23)
.49 (.07, 3.26)
.97 (.45, 2.10)
.72 (.33, 1.56)
1.20 (.40, 3.58)
1.35 (.58, 3.11)
1.10 (.33, 3.70)
2.09 (.57, 7.65)
.88 (.40, 2.51)
.91 (.23, 3.64)
.86 (.45, 1.64)
.96 (.32, 2.90)
1.78 (.69, 4.57) 1.19 (.34, 4.13) 2.90c (1.02, 8.23)
OR ⫽ odds ratio; AOR ⫽ adjusted odds ratio; CI ⫽ 95% confidence interval. a p ⱕ .01. b p ⱕ .001. c p ⱕ .05. d Multivariate models excluded because of colinearity with age.
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based settings. Our analysis adjusted for numerous potential covariates in the relationship among youth characteristics, testing barriers, and facilitators. Several limitations are important to consider. First, small sample size limits statistical power of our findings. Answers to these questions may suffer from recall and social desirability bias, although this was mitigated by querying most recent experiences and by ensuring anonymity. Because this survey was conducted anonymously, we could not gather demographic data on nonrespondents; thus, the role of self-selection bias remains unknown. Finally, generalizability of these findings may be limited because participants were sampled from a clinic setting rather than the general population. Although we believe that the conclusions from this study are applicable to most clinical settings, our sample might be biased toward youth who are more comfortable testing through a dedicated, confidential, and free HIV program with trained counselors rather than a routine medical setting. Conclusion Our study revealed strong support for RHT among adolescents, with a minority desiring confidentiality from parents and insurance providers. Younger adolescents were significantly less knowledgeable about testing options and less likely to follow-up with healthcare professionals after testing— both significant barriers to knowledge of status. Younger adolescents were also more likely to prefer noninvasive methods, although this association was marginally significant in multivariate analysis. Overall, the value of key testing facilitators such as rapidity, noninvasiveness, confidentiality, and lower cost did not vary significantly by age, gender, or race. These findings suggest that RHT is an acceptable and feasible option for a diverse range of adolescents and young adults. Routine testing is most likely to be acceptable among youth if it is free or of low cost, and designed to respect confidentiality, privacy, and rapidity. The cost of RHT remains problematic, and partial support of testing costs may be a feasible funding strategy. Future research should address potential barriers, such as price and confidentiality, among diverse youth samples while exploring funding possibilities. Acknowledgments This research and rapid testing pilot program was supported by the Aerosmith Endowment Fund at CHB and by the Massachusetts Department of Public Health. The funding sources provided financial support for the costs of rapid testing and had no role in the study design; the collection, analysis, or interpretation of data; the writing of this manuscript; or the decision to submit for publication. Selin Tuysuzoglu, M.D., M.P.H., developed and designed the data analysis plan, analyzed and interpreted the data, and drafted and coordinated subsequent revisions of the manuscript; Heather Corliss, M.P.H., Ph.D., analyzed and interpreted the data and assisted with critical revisions of the manuscript; Susan Fitzgerald, M.S.N., C.P.N.P., assisted in the study design, survey design, and administration of the study; Brian Abascal, M.F.A., supervised the collection and entry of study data, designed data collection tools, and assisted with critical revisions of the manuscript; Cathryn Samples, M.D., M.P.H., served as the study PI, secured the funding, designed the study, acquired IRB approval, interpreted the data, and assisted with critical revisions of the manuscript. All authors read and approved the final manuscript.
References [1] Rotheram-Borus MJ, Futterman D. Promoting early detection of human immunodeficiency virus infection among adolescents. Arch Pediatr Adolesc Med 2000;154:435–9. [2] Centers for Disease Control and Prevention. HIV/AIDS surveillance report. Atlanta, GA: Centers for Disease Control and Prevention, 2009. [3] Kaiser Family Foundation. National survey of teens on HIV/AIDS. Park, CA: Kaiser Family Foundation, 2000. [4] Rawitscher LA, Saitz R, Friedman LS. Adolescents’ preferences regarding human immunodeficiency virus (HIV)-related physician counseling and HIV testing. Pediatrics 1995;96(1 Pt 1):52– 8. [5] Rand CM, Auinger P, Klein JD, Weitzman M. Preventive counseling at adolescent ambulatory visits. J Adolesc Health 2005;37:87–93. [6] Murphy DA, Mitchell R, Vermund SH, et al. Factors associated with HIV testing among HIV-positive and HIV-negative high-risk adolescents: The REACH Study. Reaching for Excellence in Adolescent Care and Health. Pediatrics 2002;110:e36. [7] Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents and pregnant women in health-care settings. Atlanta, GA: Centers for Disease Control and Prevention, 2006. [8] Campsmith ML, Goldbaum GM, Brackbill RM, et al. HIV testing among men who have sex with men: Results of a telephone survey. Prev Med 1997;26: 839 – 44. [9] Cargill VA, Stone VE. HIV/AIDS: A minority health issue. Med Clin North Am 2005;89:895–912. [10] Centers for Disease Control and Prevention. A heightened national response to the HIV/AIDS crisis among African American. Atlanta, GA: Centers for Disease Control and Prevention, 2007. [11] Goodman E, Berecochea JE. Predictors of HIV testing among runaway and homeless adolescents. J Adolesc Health 1994;15:566 –72. [12] Metro TeenAIDS. Surveying HIV, risk factors among young people. Washington, DC: Metro TeenAIDS, 2007. [13] Centers for Disease Control and Prevention. HIV counselling and testing in publicly funded sites: 1996 annual report. Atlanta, GA: Centers for Disease Control and Prevention, 1998. [14] Branson BM. Point-of-care rapid tests for HIV antibodies. J Lab Med 2003; 27:288 –95. [15] Gostin LO. HIV screening in health care settings: Public health and civil liberties in conflict? JAMA 2006;296:2023–5. [16] Weinhardt LS, Carey MP, Johnson BT, et al. Effects of HIV counseling and testing on sexual risk behavior: A meta-analytic review of published research, 1985–1997. Am J Public Health 1999;89:1397– 405. [17] U.S. Preventive Services Task Force. Screening for HIV: Recommendation statement. Ann Intern Med 2005;143:32–7. [18] Chou R, Huffman LH, Fu R, et al. Screening for HIV: A review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2005;143:55–73. [19] Peralta L, Constantine N, Griffin-Deeds B, et al. Evaluation of youth preferences for rapid and innovative human immunodeficiency virus antibody tests. Arch Pediatr Adolesc Med 2001;155:838 – 43. [20] Peralta L, Deeds BG, Hipszer S, Ghalib K. Barriers and facilitators to adolescent HIV testing. AIDS Patient Care STDs 2007;21:400 – 8. [21] Samples CS, Tuysuzoglu S, Abascal BR, et al. Impact of rapid HIV testing roll-out in an adolescent clinic. J Adolesc Health 2009;44:S5– 6. [22] Renzi C, Zantedeschi E, Signorelli C, Osborn JF. Factors associated with HIV testing: Results from an Italian general population survey. Prev Med 2001; 32:40 – 8. [23] Farnham PG, Hutchinson AB, Sansom SL, Branson BM. Comparing the costs of HIV screening strategies and technologies in health-care settings. Public Health Rep 2008;123(Suppl 3):51– 62. [24] Shrestha RK, Sansom SL, Richardson-Moore A, et al. Costs of voluntary rapid HIV testing and counseling in jails in 4 states: Advancing HIV Prevention Demonstration Project, 2003–2006. Sex Transm Dis 2009;36(Suppl 2): S5– 8. [25] Bartlett JG, Branson BM, Fenton K, et al. Opt-out testing for human immunodeficiency virus in the United States: Progress and challenges. JAMA 2008;300:945–51. [26] Qaseem A, Snow V, Shekelle P, et al. Screening for HIV in health care settings: A guidance statement from the American College of Physicians and HIV Medicine Association. Ann Intern Med 2009;150:125–31. [27] American Medical Association, American Academy of HIV Medicine. Coding guidelines for routine HIV testing in health care settings; 2008 [Online]. Available at: http://www.stdhivtraining.org/x/ama_coding_guidelines_ for_hiv_testing.pdf. [28] Boonstra HD. Making HIV test “routine”: concerns and implications. Guttmacher Policy Rev 2008;11:13–18. [29] Blake SM, Ledsky RA, Sawyer RJ, et al. Local school district adoption of state-recommended policies on HIV prevention education. Prev Med 2005; 40:239 – 48.
www.jahonline.org Original article
Acceptability and Feasibility of Rapid HIV Testing in an Adolescent Clinic Setting: Youth Testing Attitudes, Knowledge, and Behaviors Selin Tuysuzoglu, M.D., M.P.H., Heather L. Corliss, M.P.H., Ph.D., Susan M. Fitzgerald, M.S.N., C.P.N.P., Brian R. Abascal, M.F.A.*, and Cathryn L. Samples, M.D., M.P.H. Division of Adolescent and Young Adult Medicine, Children’s Hospital Boston, Boston, Massachusetts
Article history: Received October 28, 2010; Accepted March 12, 2011 Keywords: Adolescent; HIV/AIDS; Rapid HIV testing
A B S T R A C T
Purpose: To assess youths’ attitudes, knowledge, and behaviors regarding rapid HIV testing (RHT) and measure acceptability and feasibility of RHT in an adolescent clinic setting. Methods: A 2007–2008 project introduced free RHT at an urban, hospital-based adolescent and young adult clinic in Boston, MA. Patients and HIV testing clients were offered either free nonrapid tests or fingerstick RHT. An anonymous questionnaire assessed youths’ testing attitudes, knowledge, and behaviors (N ⫽ 127). Ordinal logistic regression model was used to determine associations with youth demographic characteristics and testing experience. Results: Most participants valued rapid results. A minority desired confidentiality from parents and insurance providers. Older youth were more likely to know about testing methods (OR: 1.25; CI: 1.04 –1.51) and plan for follow-up (OR: 1.43; CI: 1.14 –1.81). Age, gender, and race were unrelated to testing facilitators such as rapidity, confidentiality, and cost, although younger clients were more likely to prefer noninvasive methods. Individuals with previous testing experience were more likely to say that they would contribute to expenses and value rapidity over cost. Conclusion: There was strong support for RHT among youth receiving HIV testing. Offering RHT to youth may facilitate routine testing. Future research should focus on increasing RHT access among diverse populations of youth. 䉷 2011 Society for Adolescent Health and Medicine. All rights reserved.
Despite public health efforts, adolescents remain at risk for sexually transmitted infections and may be underdiagnosed for HIV/AIDS [1]. In 2007, nearly one-third of new HIV infections in the United States occurred in persons aged ⬍29 years [2]. Because adolescents are at high risk for HIV, early testing and knowledge of status remain vital goals. In a nationally representative sample of 15–17-year-olds, only 27% had been tested for HIV and less than half knew where to obtain testing [3]. Although most adolescents want to discuss HIV/AIDS with physicians [4], one study found that HIV/STD counseling was offered at only 6% of adolescent ambulatory well visits and 14% of dedicated repro-
* Address correspondence to: Brian R. Abascal, M.F.A, Division of Adolescent and Young Adult Medicine, Children’s Hospital Boston, 300 Longwood Avenue, LO 306, Boston, MA 02115. E-mail address: [email protected] (B.R. Abascal).
ductive health visits [5]. These statistics suggest there are many missed opportunities for HIV prevention and screening because provider input motivates youth testing [4,6]. The CDC recommends routine opt-out screening for all persons of ages 13– 64 years and annual testing for high-risk individuals [7]. Adolescents face unique barriers to HIV testing, with high-risk youth testing less frequently than low-risk peers [8 –12]. Even with reliable access, testing method may significantly influence knowledge of status. A 1996 CDC report found that 40% of patients tested with the standard immunoassays (enzymelinked immunosorbent assay [ELISA]) with Western blot did not receive their results [13]. Even small decreases in turnaround time can improve receipt of results [14]. Increasing HIV testing among youth promises significant public health and clinical benefits [15]. Adolescents reduce risky behaviors after learning that they are HIV positive [1,16]. The
1054-139X/$ - see front matter 䉷 2011 Society for Adolescent Health and Medicine. All rights reserved. doi:10.1016/j.jadohealth.2011.03.007
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CDC estimates that sexually transmitted HIV could be reduced by 30% annually with earlier knowledge of status [1]. Early HIV diagnosis and initiation of highly active anti-retroviral therapy can slow disease progression, reduce viral load, and decrease mortality [17]. Lower viral loads may also reduce HIV transmission to sexual partners [18]. Understanding youth attitudes toward HIV testing methods can help guide clinical practices, improve outreach, inform social marketing, and increase knowledge of status. In a study of predominantly African American youth of ages 12–24 years, noninvasive oral mucosal rapid testing was the preferred method [19]. Even with knowledge of hypothetical turnaround times, a nonrapid oral method was favored over the rapid but more invasive fingerstick. These preferences were unrelated to gender, age, ethnic group, testing experience, or HIV risk behaviors. A related study of predominately minority youth of ages 12–24 years found that oral, rapid, free, and convenient testing were key facilitators [20]. These factors were more important for older youth, although other demographic characteristics were not examined. The Reaching for Excellence in Adolescent Care and Health (REACH) study suggested that young females are more likely than males to prefer confidential or anonymous testing [6]. The purpose of this study was to assess the acceptability and feasibility of RHT (rapid HIV testing) within an adolescent and young adult clinic serving a diverse urban population. We examined attitudes toward RHT and associations of demographic characteristics and previous testing experience with key barriers and facilitators such as confidentiality, cost, test method, and test-related anxiety. On the basis of existing data and experience, we hypothesized that youth would prefer a fingerstick rapid test to both an oral 2-week test and a traditional venous test requiring a return visit. We hypothesized that younger adolescents would have less knowledge of testing options and a stronger preference for key testing facilitators including noninvasiveness, rapidity, low cost, and confidentiality. We predicted that females would preferentially desire noninvasive methods, that privately insured clients may value confidentiality and be more willing to contribute to testing costs than uninsured or publicly insured peers, and that non-English speakers may have less awareness of testing options and preferentially value anonymity. We predicted that rapid testing would be a widely accepted and feasible testing method among surveyed adolescents, regardless of demographic profile or previous testing experience. This study builds on the existing literature by examining relationships among a broader range of adolescent demographic characteristics and testing preferences. Unlike many previous studies, it surveys adolescents during real-time testing experiences rather than using data from a hypothetical or staged testing scenario [19,20]. Finally, it is among the first studies to address youths’ willingness to pay for RHT. Methods Study setting, procedures, and participants Through affiliation with the Massachusetts Department of Public Health, the Adolescent and Young Adult clinic at CHB (Children’s Hospital Boston) houses an adolescent HIV program (Boston HIV Adolescent Provider & Peer Education Network for Services [HAPPENS]) that offers free HIV testing. Counseling and testing is performed by trained counselors, using either venous blood or an oral mucosal transudate specimen. Testing clients must
return for a second visit after 2 weeks to receive results. Over a 4.5-month period, we conducted an anonymous cross-sectional survey of English- and Spanish-speaking youth receiving testing. Clients were offered the choice of oral testing using the OraSure HIV-1 Oral Specimen Collection Device (Orasure Technologies, Inc., Bethlehem, PA), serum testing using the standard immunoassays (ELISA) with reflex Western blot, or rapid fingerstick testing using the OraQuick ADVANCE Rapid HIV-1/2 Antibody Device (OraSure Technologies, Inc., Bethlehem, PA). After pretest counseling, clients consenting to a test who were able to read and write in English or Spanish were offered a 23-item self-administered questionnaire along with the study consent form and a visual depiction of test options. There were 164 testing clients during the study period, 150 of whom were offered a questionnaire. There were no other exclusion criteria for being offered a survey because all youth tested for HIV through HAPPENS’s counseling and testing services could participate in the study. Of those offered, 130 clients completed the questionnaire (86.7% response rate), but three age outliers (ⱖ30 years) were excluded from statistical analysis. Thus, the analytic sample size was 127. Test providers were asked to indicate the type of test performed for all clients, including those who refused the survey. Our testing site does not require parental consent for HIV testing at age ⱖ13. Given the highly sensitive nature of HIV testing and the minimal risk to subjects of completing the survey, parental consent was waived for minor participants. Anonymity was preserved with a checkbox for consent and by storing completed surveys in a locked box. The CHB Institutional Review Board (IRB) approved the study protocol as an anonymous survey with waiver of parental consent. To further protect that anonymity, our IRB also specifically excluded linkage of survey responses to risk behavior data, which was examined in a separate study reported elsewhere [21]. Study measures The questionnaire assessed client demographics as well as their previous experiences with, and attitudes toward, HIV testing. Demographic factors included race/ethnicity, age, gender, preferred language, and insurance status. The answers to two race/ethnicity questions: “Are you Latino/Hispanic?” and “Which race are you?” were combined into a single variable using the following categories: Hispanic/Latino and the non-Hispanic categories black, white, Asian/Pacific Islander, Native American, and “Multiracial” for youth who indicated more than one response. When the participants were questioned about their preferred language, those who marked “Multilingual” also marked “English”; therefore, we collapsed the variable into two categories: English (including multilingual) and other. The status of uninsured clients changed during the study period, with healthcare reform expanding health insurance availability to uninsured, low-income clients. To handle this historical change, we coded participants as having either private insurance or Medicaid, Medicare, Free Care (the uncompensated care pool), and no insurance grouped together. The questionnaire also inquired about previous HIV testing experience, receipt of latest test results, and reasons for visiting the clinic on test day. Willingness to pay for portions of testing costs ($0, $5 or less, $10, $15, or more than $20) was also queried. Ten questions, designed by researchers, measured youth knowledge and attitudes toward common testing barriers, facilitators, and concerns. Responses were coded with Likert scale style re-
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sponses as 1 ⫽ “strongly disagree,” 2 ⫽ “disagree,” 3 ⫽ “neutral,” 4 ⫽ “agree,” and 5 ⫽ “strongly agree.”
Table 2 Testing experience of survey participants receiving HIV testing at the CHB’s HAPPENS program (N ⫽ 127) N (%)
Statistical analysis We examined descriptive frequencies of respondents’ demographic characteristics, previous testing experiences, and responses to questions about HIV testing. Likert scale responses to testing attitudes were analyzed with univariate and multivariate ordinal logistic regression models. Given the discrete and ordinal nature of Likert scale dependent variables, ordinal regression was considered a technically superior analytic approach to linear regression, particularly given our a small sample size. Univariate ordinal logistic regression odds ratio (OR) and 95% confidence interval (CI) were calculated to examine the association between each testing attitude question and predictor variables, including age, adult legal status (18 years or older), race/ethnicity, gender, language preference, insurance status, previous testing experience, and testing choice. Multivariate ordinal logistic regression was then performed for each testing attitude outcome. Multivariate models included all predictor variables noted previously, except legal status because of colinearity with age. Finally, to examine financial feasibility, categories of willingness to pay were examined as a dichotomous variable to determine whether test clients would be willing to contribute at all to testing costs (yes vs. no) and assessed with binary logistic regression. All analyses were performed with SPSS 16.0 for Windows (SPSS Inc., Chicago, IL). Results Response frequencies
Previous testing Never tested Previously tested Previously tested at CHB Regular blood test Free blood test Free cheek swab Rapid test Previously tested elsewhere Rapid test Receipt of latest CHB results Never received Received 1–2 weeks later in person Received ⬎2 weeks later in person Received by phone or letter Rapid results on the same day Unsure Receipt of latest non-CHB results Never received Received 1–2 weeks later in person Received ⬎2 weeks later in person Received by phone or letter Rapid results on the same day Today’s test Boston HAPPENS CTSa Blood test Oral mucosal test Rapid test Reason for visit Appointment Appointment and HIV test Just HIV test a
Characteristics of survey respondents are presented in Table 1. The mean age of respondents was 19.7 years, with a majority (65.6%) female. Approximately one-third (32%) identified as nonHispanic white; 37.6% as non-Hispanic black; 17.6% as Hispanic/ Latino; and 12.8% were classified as Asian-Pacific Islander, Native American, Multiracial, or other. This racial/ethnic distribution is
Table 1 Demographic characteristics of survey participants receiving HIV testing at the CHB’s HAPPENS program (N ⫽ 127) Study clients (N ⫽ 127) % Mean age (range) Legal status Minor (⬍18 years) Adult Gender Male Female Race/ethnicity Non-Hispanic black Non-Hispanic white Hispanic/Latino API/NA/MR/Othera Preferred language English Other Insurance type Private None/public
611
19.7 (14–29) 18.1 81.9 34.4 65.6
68 (53.3) 57 (44.8) 40 (32.0) 6 (15.0) 11 (27.5) 18 (45.0) 10 (25.0) 17 (13.6) 8 (20.0) N ⫽ 39 2 (5.1) 18 (46.2) 8 (20.5) 3 (7.7) 5 (12.8) 3 (7.7) N ⫽ 34 10 (29.4) 11 (32.5) 2 (5.9) 5 (14.7) 6 (17.7) N ⫽ 127 18 (14.4) 2 (1.6) 17 (13.6) 107 (85.6) 39 (31.2) 30 (24.0) 56 (44.8)
HAPPENS’s counseling and testing services.
representative of the community served by the HAPPENS program and of the primary care population of the Adolescent/ Young Adult clinic. Not surprisingly, testers were older than patients served by the primary care practice. Previous testing experiences are depicted in Table 2. More than half of the participants were first-time testers. The majority of previous testers confirmed receiving their most recent HIV test results, with greater follow-up reported among those last tested onsite (87% vs. 70%). Most (85.6%) youth received RHT at their visit, and nearly half presented to our program exclusively for HIV testing. Participants’ attitudes toward testing are presented in Table 3. Willingness to pay for RHT varied widely, with 31.1% of respondents unwilling to pay anything, 11.5% willing to contribute $5 or less, 14.8% willing to contribute $10, another 14.8% willing to contribute $15, and 27.9% willing to pay $20 or more. Ordinal and binary logistic regression
37.6 32.0 17.6 12.8 86.4 13.6 50.5 49.6
CHB ⫽ Children’s Hospital Boston; HAPPENS ⫽ Boston HIV Adolescent Provider & Peer Education Network for Services. a Asian-Pacific Islander/Native American/Multiracial/other.
Results of univariate and multivariate analyses are shown in Table 4. In univariate analysis, younger age was significantly associated with testing barriers, including fear of needles, lesser knowledge of different testing methods, and preference for free testing. Multivariate analysis suggested that preference for free testing was not related to age, but fear of needles (OR: .84; 95% CI: .71, 1.00) and lack of knowledge about testing methods (OR: .80; 95% CI: .66, .96) remained barriers for younger adolescents. Moreover, multivariate analysis suggested that older youth had significantly higher odds of planning to receive medical
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Table 3 HIV testing attitudes of survey participants receiving HIV testing at the CHB’s HAPPENS program (N ⫽ 127) HIV testing attitudes
Strongly disagree (%)
Disagree (%)
Neutral (%)
Agree (%)
Strongly agree (%)
“I want results as soon as possible” “I plan to discuss my results with my doctor or nurse” “I hate needles or having my blood drawn” “I do not want my parents to know I got tested today” “I will only get tested if it is free, even if it means waiting 2 weeks for results” “It is okay if my insurance is billed for this test” “I did not know there were different ways to get tested” “I am nervous waiting for my results” “I would rather come back for results than have to wait here longer today”
.0 2.5 14.2 20.0 22.0 35.1 30.4 9.7 55.3
.0 4.2 20.5 18.3 26.0 10.8 23.2 13.7 23.6
7.1 21.0 31.5 22.5 23.6 21.6 13.6 19.4 11.4
9.4 26.1 14.2 7.5 16.3 15.3 22.4 21.8 4.1
83.5 46.2 19.7 31.7 12.2 17.1 10.4 35.5 5.7
follow-up (OR: 1.43; CI: 1.14, 1.81), as did youth of “Other” ethnicity (OR: 13.94; CI: 1.55, 125.84). Our multivariate models revealed no other predictors of testing barriers or facilitator by race, ethnicity, gender, or language preference. In both univariate and multivariate models, private insurance predicted a desire for rapid results (OR: 11.31; CI: 2.06, 61.87). Although univariate analysis suggested that black and Latino youth were less likely to value rapidity than their white peers, these results were not significant in the multivariate model. In univariate analyses, females were more likely than males and Latinos were more likely than whites to say that they were okay with their insurance being billed for the test, whereas in the multivariate model, rapid testers had higher odds of agreement (OR: 3.62; CI: 1.04, 12.54). Having chosen RHT was the most frequent and strongest independent predictor of youth testing attitudes because rapid testers had significantly higher odds of valuing rapidity (OR: 5.0; CI: 1.24, 20.19), planning for medical follow-up (OR: 7.92; CI: 2.24, 28.05), and preferring to wait for results (OR: 16.6; CI: 4.54, 50.0). Age, gender, race/ethnicity, language preference, and insurance status were not associated with willingness to contribute to RHT costs. However, experienced testers (44.8%) were more
likely than first-time testers (53.3%) to value rapid results over free tests and to express willingness to contribute to testing costs (OR: 3.89; CI: 1.29 –11.72). Discussion Acceptability and feasibility This study revealed strong support for prompt results of HIV testing among youth at an urban adolescent/young adult clinic. Only one-third of participants were unaware of different testing methods, with younger adolescents significantly being less knowledgeable. These results mirror international findings that younger adolescents have lower rates of voluntary HIV testing [22]. Because younger teenagers may face greater structural, emotional, and psychological barriers to HIV testing, education and outreach are particularly important for this age group. Routine testing may help alleviate age discrepancies, but would cost more per testing result [23,24]. With routine testing, clinicians should heighten their awareness of vulnerable subgroups to ensure adequate follow-up because younger teenagers in our study were less inclined to discuss test results with medical providers.
Table 4 Results of univariate and multivariate logistic regression models examining associations among sociodemographic characteristics and testing attitudes of survey participants receiving HIV testing at the CHB’s HAPPENS program (N ⫽ 127)
1 2 3 4 5
“I want results as soon as possible”
“I plan to discuss my results with my doctor or nurse”
“I hate needles or having my blood drawn”
“I do not want my parents to know I got tested today”
OR (95% CI)
OR (95% CI)
OR (95% CI)
OR (95% CI)
AOR (95% CI)
AOR (95% CI) a
Older age 1.09 (.91, 1.30) .77 (.57, 1.04) 1.12 (.98, 1.27) 1.43 (1.14, 1.81) Young adult vs. minord 2.13 (.70, 6.52) — 1.96 (.81, 4.76) — a c c Rapid test vs. oral 5.12 (1.78, 14.78) 5.00 (1.24, 20.19) 3.04 (1.18, 7.83) 7.92b (2.24, 28.05) Female vs. male 2.08 (.81, 5.32) 3.71 (.95, 14.56) 1.32 (.65, 2.69) 1.22 (.47, 3.19) Preference for non-English .60 (.10, 3.45) .37 (.03, 5.45) .61 (.14, 2.69) .57 (.08, 4.01) language 6 Private vs. none/public 6.99a (1.86, 26.23) 11.30a (2.06, 61.87) .96 (.43, 2.11) .45 (.16, 1.25) insurance 7 Previous testing experience 1.17 (.46, 3.03) 1.51 (.41, 5.64) .89 (.45, 1.76) .51 (.20, 1.27) vs. never tested 8 Other vs. non-Hispanic .76 (.07, 8.82) .84 (.04, 20.49) 1.86 (.58, 6.01) 13.94c (1.55, 125.84) white .18 (.01, 2.48) .75 (.33, 1.69) 1.21 (.38, 3.86) 9 Non-Hispanic black vs. .15c (.03, .71) non-Hispanic white c .14 (.01, 2.01) .97 (.36, 2.64) 1.59 (.42, 6.03) 10 Latino/Hispanic vs. non.13 (.02, .72) Hispanic white
b
.82 (.73, .92) .44 (.19, 1.04) .68 (.28, 1.61) 1.46 (.75, 2.84) .51 (.13, 2.00)
AOR (95% CI)
AOR (95% CI)
.84 (.71, 1.00) .93 (.83, 1.04) .96 (.80, 1.14) — .45 (.18, 1.10) — .74 (.26, 2.10) 1.35 (.55, 3.31) .90 (.31, 2.66) 1.49 (.63, 3.50) .82 (.41, 1.62) 1.06 (.44, 2.58) .44 (.08, 2.46) 1.67 (.41, 6.71) 1.72 (.30, 9.83)
.61 (.29, 1.28)
.95 (.40, 2.29)
.97 (.45, 2.08) 1.04 (.42, 2.60)
1.08 (.57, 2.04)
.96 (.44, 2.12)
.77 (.40, 1.49)
1.90 (.67, 5.35)
2.33 (.54, 9.97) 1.72 (.59, 5.01) 2.71 (.55, 13.44)
2.54c (1.17, 5.52) 1.74 (.59, 5.12) 1.63 (.65, 4.31)
.80 (.35, 1.84)
.69 (.31, 1.51) .100 (.19, 1.89)
1.33 (.39, 4.54) 1.23 (.46, 3.26) .812 (.21, 3.61)
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Despite the testing barriers associated with younger age, we found that age was not significantly associated with valuation of common facilitators like noninvasiveness, rapidity, confidentiality, or lower cost. These findings contrast previous research suggesting that noninvasive (oral) testing was preferred by older youth [20]. A sizeable minority (39%) of participants expressed confidentiality concerns, which may pose a larger barrier among younger populations. Using alternate Current Procedural Terminology (CPT) codes (the standardized codes used for billing patients or third-party insurers for medical procedures) may allow clinicians integrating routine testing to ensure patient confidentiality. Hospitals and clinics might explore confidential testing through funding mechanisms similar to family planning services. Moreover, minor consent laws can and should include HIV testing in the STD services package to which minors may consent without parental notification. Although these results suggest acceptability and feasibility of clinical RHT, implementing routine testing requires creative solutions to potential testing barriers, particularly for younger adolescents. The CDC’s routine screening recommendations have been met with widespread medical, public health, and political support, and endorsed by at least 35 national professional societies [25,26]. Routine testing may be difficult in pediatric and adolescent clinical settings because of parental presence and insurance requirements, but rapid testing may reduce testing barriers. Despite concerns over routine testing, sites implementing CDC recommendations have demonstrated significant testing rate improvements [26].
613
reimbursement guidelines to support CDC recommendations [28]. California has modeled one potential solution by requiring insurers to cover HIV testing costs in healthcare settings [25]. Given some adolescents’ willingness to contribute to RHT costs, clinics might consider subsidizing youth testing. In our study, free testing was an important facilitator for first-time testers, whereas repeat testers were significantly more likely to be willing to contribute to RHT costs (and to value rapidity over cost). A graduated payment model may make RHT feasible for non-grant-funded settings. Our findings suggest that older individuals may not pay more for RHT, suggesting that age-based subsidization may not be an ideal model of cost sharing. For point-of-care testing, there exist manufacturer- and state-dependent mandated guidelines for how often staff must verify the accuracy of test results by running the RHT on purchased “control specimens,” whose results are known as positive or negative. Moreover, external proficiency testing is required, using a service that periodically sends blinded controls for staff interpretation. The product cost of RHT (approximately $27, including controls) is compounded by requisite staff time, staterequired consent and counseling, quality assurance, and documentation. Adolescent clinics may consider hiring ancillary staff, accepting co-location of staff from publicly funded sites, or crosstraining existing staff to provide RHT. Cost concerns are compounded by the diminishing federal HIV prevention budget [25]. Policy research, political support for HIV prevention, and strong school-based HIV education may help influence the reach of routine screening [29].
Costs of rapid testing Study limitations and strengths Overall, although one-third of youth preferred completely free testing, most (57.8%) were willing to contribute at least $10 to RHT cost. Providers can now bill for RHT by adding a coding modifier to the standard HIV testing codes within the CPT system [27]. Although Medicaid covers RHT, most state guidelines do not address routine testing and few private insurers have updated their
Strengths of this study include its use of a diverse, urban, hospital-based adolescent clinic with a high survey response rate. Our study also focused on youth attitudes toward specific dimensions of RHT because this method’s popularity and utility are likely to expand HIV testing in both clinical and community-
Table 4 Continued “I will only get tested if it is free, even if it means waiting 2 weeks for results”
“It is okay if my insurance is billed for this test”
“I did not know there were different ways to get tested”
“I am nervous waiting for my results”
“I would rather come back for results than have to wait here longer today”
OR (95% CI)
OR (95% CI)
OR (95% CI)
OR (95% CI)
OR (95% CI)
AOR (95% CI)
AOR (95% CI)
b
AOR (95% CI)
AOR (95% CI)
c
1 .95 (.85, 1.06) .93 (.79, 1.10) .93 (.82, 1.05) .94 (.79, 1.13) .79 (.70, .90) .80 (.66, .96) .92 (.82, 1.03) .96 (.81, 1.14) 1.01 (.90, 1.14) 2 .42c (.17, .99) — 1.32 (.52, 3.40) — .28a (.12, .68) — .46 (.19, 3.78) — .97 (.39, 2.40) 3 .52 (.21, 1.29) .34 (.11, 1.04) 1.53 (.58, 4.03) 3.62c (1.04, 12.54) 1.46 (.59, 3.59) 1.49 (.50, 4.42) 2.02 (.84, 4.86) 2.05 (.71, 5.92) .09b (.03, .24) .77 (.39, 1.49) .90 (.38, 2.16) .92 (.46, 1.80) .76 (.31, 1.84) .94 (.45, 1.95) 4 1.31 (.67, 2.56) 1.38 (.57, 3.30) 2.39c (1.16, 4.95) 1.28 (.51, 3.24) 5 2.11 (.54, 8.22) 5.02 (.87, 29.14) 1.77 (.41, 7.69) 1.80 (.28, 11.73) .86 (.22, 3.36) .51 (.09, 2.97) 8.67c (1.04, 72.30) 5.34 (.51, 55.87) 2.77 (.70, 11.03) 6
.56 (.25, 1.26)
.59 (.22, 1.59)
1.06 (.54, 2.11)
1.26 (.52, 3.05)
8 2.71 (.35, 2.89) 1.60 (.35, 7.23)
1.86 (.36, 3.18)
.30 (.06, 1.58)
9 1.54 (.63, 2.96) 1.04 (.34, 3.19)
2.05 (.88, 4.74)
2.33 (.70, 7.77)
2.86c (1.05, 7.81)
1.67 (.44, 6.33)
7
.95 (.45, 2.01) 1.01 (.41, 2.53) c
.75 (.39, 1.43) .40 (.17, .92)
10 2.30 (.43, 2.83)
.75 (.21, 2.67)
.40c (.19, .86)
AOR (95% CI) 1.40 (.74, 1.10) — .06b (.02, .22) .75 (.28, 1.98) 2.52 (.42, 15.04)
.55 (.22, 1.35)
.71 (.33, 1.51)
.83 (.33, 2.06)
.97 (.43, 2.18)
1.42 (.51, 3.95)
.83 (.37, 1.88)
.66 (.35, 1.28)
.66 (.29, 1.50)
.77 (.38, 1.56)
.93 (.37, 2.32)
.84 (.29, 2.42) 1.21 (.26, 5.51)
.95 (.34, 2.70)
1.66 (.38, 7.22)
1.37 (.44, 4.23)
.49 (.07, 3.26)
.97 (.45, 2.10)
.72 (.33, 1.56)
1.20 (.40, 3.58)
1.35 (.58, 3.11)
1.10 (.33, 3.70)
2.09 (.57, 7.65)
.88 (.40, 2.51)
.91 (.23, 3.64)
.86 (.45, 1.64)
.96 (.32, 2.90)
1.78 (.69, 4.57) 1.19 (.34, 4.13) 2.90c (1.02, 8.23)
OR ⫽ odds ratio; AOR ⫽ adjusted odds ratio; CI ⫽ 95% confidence interval. a p ⱕ .01. b p ⱕ .001. c p ⱕ .05. d Multivariate models excluded because of colinearity with age.
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based settings. Our analysis adjusted for numerous potential covariates in the relationship among youth characteristics, testing barriers, and facilitators. Several limitations are important to consider. First, small sample size limits statistical power of our findings. Answers to these questions may suffer from recall and social desirability bias, although this was mitigated by querying most recent experiences and by ensuring anonymity. Because this survey was conducted anonymously, we could not gather demographic data on nonrespondents; thus, the role of self-selection bias remains unknown. Finally, generalizability of these findings may be limited because participants were sampled from a clinic setting rather than the general population. Although we believe that the conclusions from this study are applicable to most clinical settings, our sample might be biased toward youth who are more comfortable testing through a dedicated, confidential, and free HIV program with trained counselors rather than a routine medical setting. Conclusion Our study revealed strong support for RHT among adolescents, with a minority desiring confidentiality from parents and insurance providers. Younger adolescents were significantly less knowledgeable about testing options and less likely to follow-up with healthcare professionals after testing— both significant barriers to knowledge of status. Younger adolescents were also more likely to prefer noninvasive methods, although this association was marginally significant in multivariate analysis. Overall, the value of key testing facilitators such as rapidity, noninvasiveness, confidentiality, and lower cost did not vary significantly by age, gender, or race. These findings suggest that RHT is an acceptable and feasible option for a diverse range of adolescents and young adults. Routine testing is most likely to be acceptable among youth if it is free or of low cost, and designed to respect confidentiality, privacy, and rapidity. The cost of RHT remains problematic, and partial support of testing costs may be a feasible funding strategy. Future research should address potential barriers, such as price and confidentiality, among diverse youth samples while exploring funding possibilities. Acknowledgments This research and rapid testing pilot program was supported by the Aerosmith Endowment Fund at CHB and by the Massachusetts Department of Public Health. The funding sources provided financial support for the costs of rapid testing and had no role in the study design; the collection, analysis, or interpretation of data; the writing of this manuscript; or the decision to submit for publication. Selin Tuysuzoglu, M.D., M.P.H., developed and designed the data analysis plan, analyzed and interpreted the data, and drafted and coordinated subsequent revisions of the manuscript; Heather Corliss, M.P.H., Ph.D., analyzed and interpreted the data and assisted with critical revisions of the manuscript; Susan Fitzgerald, M.S.N., C.P.N.P., assisted in the study design, survey design, and administration of the study; Brian Abascal, M.F.A., supervised the collection and entry of study data, designed data collection tools, and assisted with critical revisions of the manuscript; Cathryn Samples, M.D., M.P.H., served as the study PI, secured the funding, designed the study, acquired IRB approval, interpreted the data, and assisted with critical revisions of the manuscript. All authors read and approved the final manuscript.
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