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Rochelle P. Walensky, MD, MPH, Elena Losina, PhD, Laureen Malatesta, MHP, PA-C, George E. Barton, BA, Catherine A. O’Connor, MSN, ACRN, Paul R. Skolnik, MD, Jonathan M. Hall, BA, Jean F. McGuire, PhD and Kenneth A. Freedberg, MD, MSc

Rochelle P. Walensky and Kenneth A. Freedberg are with the Divisions of Infectious Disease, General Medicine, and the Partners AIDS Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Mass. Elena Losina and Kenneth A. Freedberg are with the Departments of Biostatistics and Epidemiology, Boston University School of Public Health, Boston, Mass. At the time of the study, Laureen Malatesta, George E. Barton, Catherine A. O’Connor, and Jean F. McGuire were with the Massachusetts Department of Public Health AIDS Bureau, Boston. Paul R. Skolnik and Jonathan M. Hall are with Boston Medical Center, Boston, Mass.

Correspondence: Requests for reprints should be sent to Rochelle P. Walensky, MD, MPH, Division of General Medicine, Massachusetts General Hospital, 50 Staniford St, 9th Floor, Boston, MA 02114 (e-mail: rwalensky{at}partners.org).

	ABSTRACT

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Think HIV offered HIV counseling, testing, and referral to patients at 4 Massachusetts urgent care centers from January to September 2002. We compared the positive diagnosis yield of Think HIV with that of state-funded HIV counseling, testing, and referral sites. Think HIV found an HIV prevalence of 2.0% compared with 1.9% identified by self-referral testing. Urgent care center–based routine HIV counseling, testing, and referral programs are feasible, can have high positive diagnosis yields, and should be the standard of care in high HIV prevalence areas.

	INTRODUCTION

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An estimated 180000 to 280000 people in the United States have undiagnosed HIV infection despite Centers for Disease Control and Prevention (CDC) guidelines that advise routine HIV counseling, testing, and referral in hospitals where HIV prevalence exceeds 1.0%.^1–3 In 2003, the CDC began promoting "New Strategies for a Changing Epidemic" to make "HIV testing a routine part of medical care."⁴ We designed "Think HIV" to provide routine, voluntary HIV counseling, testing, and referral at Massachusetts hospital-associated urgent care centers in high prevalence areas.

	METHODS

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Program Overview
The Massachusetts Department of Public Health AIDS Bureau identified 3 hospital-associated urgent care centers and 1 emergency department with an expected HIV seroprevalence of 1.0% or greater. Three of the 4 sites were at urban not-for-profit hospitals, and 1 was at an urban public authority hospital. All hospitals had at least 182 beds (mean = 468).

All patients presenting to each of the 4 urgent care centers for any reason were offered confidential HIV counseling and testing with the OraSure HIV-1 antibody detection system (Epitope Inc, Beaverton, Ore), which uses oral mucosal transudate (i.e., cheek swab) with later serological confirmation. Patients returned within 14 days for test results and posttest counseling. Patients failing to return received at least 4 telephone calls and a letter encouraging follow-up. For patients identified as having HIV infection, staff also contacted homeless shelters and offered transportation vouchers for follow-up. Patients informed of their HIV diagnosis were introduced to a linkage nurse from the HIV care clinic who arranged a clinic appointment within 10 days and ensured clinic follow-up.

Data Collection and Analysis
The counselor collected information on a standardized Massachusetts Department of Public Health HIV Counseling and Testing Form (available on request from Eduardo Nettle, HIV counseling, testing, and referral coordinator, Massachusetts Department of Public Health). Think HIV data were compared with data from the Massachusetts Department of Public Health collected at state-funded HIV counseling, testing, and referral sites located within a 10-mile radius of the 4 Think HIV sites. These state-funded sites provide HIV counseling, testing, and referral to patients attracted via outreach, self-referral, or physician referral. Demographics and prevalence were compared with ² tests (a 2-sided P < 0.05 value was used for statistical significance).

	RESULTS

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From January through September 2002, the Think HIV program offered routine HIV counseling, testing, and referral to 7026 patients; 2620 (37.3%) accepted testing, and 2444 (93.3%) of these patients had completed HIV test results at the time of this analysis. During the same period, HIV counseling, testing, and referral sites within 10 miles of the Think HIV sites, hereafter referred to as the self-referral sites, completed 13 890 tests. Think HIV identified 48 new HIV diagnoses (2.0% undiagnosed HIV prevalence) compared with 262 at self-referral sites (1.9% undiagnosed HIV prevalence).

Patient Characteristics and HIV Prevalence
Gender, race/ethnicity, previous HIV testing, and risk behaviors of Think HIV patients differed significantly from those of self-referral patients (Table 1) but HIV prevalence stratified by these characteristics did not (Table 2). The distribution of patients who were HIV infected differed by risk of transmission between the 2 types of counseling, testing, and referral programs (P < .0001).

HIV Among Think HIV Patients Who Had Been Tested Previously
HIV prevalence among Think HIV patients who reported testing in the previous year was 2.2%, similar to the prevalence among those tested more than 1 year earlier (1.9%, P = .77). According to the reported date of the most recent negative test result, the estimated incidence of HIV infection was 4.1 infections per 100 person-years.

Return for Results and Referral to Care in Think HIV
Overall, 1382 of 2444 (56.5%) people tested in Think HIV returned for results (56% among patients who were HIV negative and 88% among patients who were HIV infected [P = .002]). Of the 48 patients identified as having HIV infection, 42 were informed of their results; all had documented linkage to care defined as at least 1 outpatient HIV primary care visit.

Program Costs
Program costs for the first 9 months totaled $232 000 and included (1) an HIV counselor, (2) an HIV clinical nurse specialist for program infrastructure and training, (3) a part-time HIV linkage nurse, (4) OraSure test kits and processing, and (5) serum enzyme immunoassay and Western blot for confirmation of positive results. Think HIV costs were $95 per test performed, $170 per result given, $4850 per positive test result, and $5500 per each person who had HIV infection and was linked to care. Costs for the self-referral program during the same time were estimated at $105 per test performed and $5550 per positive test result.

	DISCUSSION

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Think HIV identified 48 new cases of undiagnosed HIV infection (HIV prevalence = 2.0%). Routine HIV counseling, testing, and referral through this program was as successful at HIV case identification as was self-referral screening. Think HIV reached a higher proportion of African Americans and risk behavior categories (other than men who have sex with men) than did self-referral programs but yielded a higher prevalence of HIV positive men who have sex with men than did self-referral programs. Think HIV costs totaled less than $5000 per each newly identified HIV-infected patient.

Programs such as Think HIV will be most efficient in areas of highest HIV prevalence. In 2000 to 2001, at least 6 states reported 2 to 6 times more cases than Massachusetts.⁵ An extension of routine HIV counseling, testing, and referral programs similar to Think HIV in high HIV prevalence settings may have substantially higher positive diagnosis yields than our already successful program.

	Acknowledgments

 
This research was funded by the Massachusetts Department of Public Health, AIDS Bureau; National Institute of Allergy and Infectious Diseases (K23 AI01794, K25 AI50436); Center for AIDS Research (P30 AI42851); and National Institute of Mental Health (R01 MH65869-01).

The authors are indebted to the HIV counselors at each of the urgent care centers (Boston Medical Center, Baystate Medical Center, University of Massachusetts Medical Center, and Cambridge and Whidden Hospitals), who are dedicated to patient care and HIV case identification. We appreciate the support of the hospital and urgent care center staff without whom this program would not have been possible, and we also thank Heather E. Smith for her technical assistance.

Human Participant Protection
This work was approved by the Partners human research committee (Protocol 2002-P-002041/1).

	Footnotes

 
Contributors
All authors contributed significantly to the origination and design of the study and to the writing of the brief. R. P. Walensky, E. Losina, L. Malatesta, J. F. McGuire, and K. A. Freedberg designed and initiated the study. J. F. obtained funding. R. P. Walensky, E. Losina, and K. A. Freedberg interpreted the data and prepared the manuscript. R. P. Walensky, E. Losina, and J. F. McGuire supervised implementation. G. E. Barton, C. A. O’Connor, P. R. Skolnik, and J. F. McGuire compiled the data.

Peer Reviewed

Accepted for publication February 3, 2004.

	References

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

 
1. Recommendations for HIV testing services for inpatients and outpatients in acute-care hospital settings. Centers for Disease Control and Prevention. MMWR Recomm Rep. 1993;42(RR-2):1–6.[Medline]

2. Centers for DiseaseControl and Prevention. Revised guidelines for HIV counseling, testing, and referral. MMWR Recomm Rep. 2001;50(RR-19): 1–57.[Medline]

3. Fleming PL, Wortley PM, Karon JM, DeCock KM, Janssen RS. Tracking the HIV epidemic: current issues, future challenges. Am J Public Health. 2000;90: 1037–1041.[Abstract/Free Full Text]

4. Advancing HIV prevention: new strategies for a changing epidemic—UnitedStates, 2003. MMWR Morb Mortal Wkly Rep. 2003;52:329–332.[Medline]

5. Diagnosis and reporting of HIV and AIDS in states with HIV/AIDS surveillance—United States, 1994–2000. MMWR Morb Mortal Wkly Rep. 2002; 51:595–598.[Medline]

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