Abstract
Summary:
HIV counselling and testing has traditionally been performed by highly trained professionals in clinical settings. With HIV rapid testing, a reliable and easy to use diagnostic tool, paraprofessionals can be trained to administer on-site HIV testing in a variety of non-traditional settings, broadening the HIV detection rates. Our objective was to create a robust and sustainable paraprofessional training module to facilitate off-site HIV rapid testing in non-clinical settings. Trainees attended a series of training sessions involving HIV education, rapid test instructions and communication techniques. After these sessions, trainees competently carried out HIV rapid testing in homeless shelters throughout the Los Angeles county. Agencies motivated to expand HIV screening programmes may use trained paraprofessionals to administer a full range of services (recruitment, pretest counselling, test administration, interpretation of results, post-test counselling and documentation) through this training model and enabling more highly trained healthcare providers to focus efforts on patients identified as HIV-positive.
Introduction
Many studies have provided evidence as to the feasibility and acceptability of HIV rapid testing when compared with conventional counselling and testing.1,2 Recent testing advances involve simple oral-swab procedures, with results available in approximately 20 minutes, obviating the need for either a blood draw or return visit.
Rapid testing in non-clinical settings, although effective, places a high level of responsibility on field staff; they act as HIV educators, pre and post-test counsellors, test administrators and interpreters, all rolled into one. We detail the educational series that was created which trained paraprofessionals to offer and administer HIV oral testing at homeless shelters throughout the Los Angeles County. 3 This paper also provides recommendations for techniques and protocols pertaining to the field implementation of such services.
Methods
Field staff consisted of two recent college graduates; neither had any previous experience working in health care settings.
Training
Session 1. Administering the test
The OraQuick® Advance™ rapid test (OraSure Technologies, Inc.) was selected for its reliability and ease of use. The manufacturer provides a 15-minute detailing of proper storage and test administration of DVD. Trainees were coached to provide simple step-by-step verbal instructions to patients while using a cotton swab on themselves to demonstrate.
Session 2. HIV education
Along with the traditional HIV education, we needed our field staff to explain the functionality of the HIV test to patients, specifically the timeframe factor in relation to HIV exposure. This session emphasizes that the OraQuick® device is not a direct HIV test, rather this ELISA test reacts to antibodies produced in response to HIV exposure. In order to help patients understand a negative result, workers were trained to explain that it can take up to three months for antibodies to be detected by this test, thus setting the stage for effective post-test counselling for negative outcomes and the recommended follow-up confirmatory testing.
HIV informed consent forms were distributed and discussed thoroughly. HIV field testing should adhere to the laws pertinent to each locality. This was followed by a demonstration of an optimum pretest briefing dialogue wherein the corresponding paperwork is completed. Next, trainees were paired-up to practice the pretest counselling procedure. The session concluded with guidelines for assessing the patient's capacity to give an informed consent (e.g. orientation, judgement and general state of mind).
Session 3. Emotional aspects of HIV testing
It is expected that any rational person would welcome an HIV test as a useful method to achieve early detection. However, as there is no way to eliminate the emotional factors from human contact, feelings must be recognized, respected and effectively dealt with. Saying ‘yes’ to HIV testing, even anonymously, can precipitate emotional risks. Understanding the array of negative feelings associated with HIV testing can help staff to create an environment conducive to a patient's unique emotional needs, thereby facilitating the process. Consequently, field workers may expect to encounter feelings, including anxiety, guilt or embarrassment.
Fundamental communication skills.
It is essential to create a compassionate and trusting setting, wherein the patient can feel confident that their test outcome and feelings will be handled competently. This can be facilitated through the use of several therapeutic communication skills
Positive regard. An outlook that this person's life is intrinsically worthy. Rapport. The quality of the (professional) relationship between you and the other person. Non-judgemental attitude. Unconditional acceptance. Normalizing. Helping the person to understand that what they are experiencing is not atypical. Empathy. Demonstration of awareness and respect of the other person's feelings. Attentiveness. Listen, observe, make eye contact; reflect your perception of their facts (paraphrasing) and feelings (empathy). Focus. Limit discussion to the topic at hand. When working with vulnerable populations, allow for some extra latitude for them to process additional issues. This can provide valuable opportunities to build rapport and trust in light of their difficult position. Scope of practice. Expect to be asked questions that go beyond your education/experience level. Do not be afraid to say ‘I don't know.’ Use referrals as needed. Boundaries. You are there to offer HIV testing, not to become personally involved with others. Maintain appropriate emotional and physical boundaries. 4
Session 4. Script for proposing an HIV test
The following script can be customized to suit your needs
Hello, we're offering (free) confidential/anonymous HIV oral testing that is >99% accurate.
HIV is a sexually transmitted disease, so anyone who's ever had sex with anyone, male or female, should think about having an HIV test.
As with any advancing disease process, early detection is better than late.
Someone with HIV can look and feel completely healthy for years - the only way to detect HIV is with a test.
We can do an oral test today, which uses no needles and gives the answer in 20 minutes.
If it is negative, then you get a sense of relief.
If it is positive, then we can give you referrals for confidential care; the medications available are highly effective in preserving length of life and quality of life.
If the patient refuses, then courteously accept this; you may wish to state your availability (e.g. ‘We'll be here Wednesday evenings from 6:00 to 9:00 through the end of the month if you change your mind.’)
Role plays
Role plays help staff build proficiency and comfort in interacting with (simulated) patients, wherein do-overs are possible without consequence. For the first role play, the trainer should act as the field worker, using a trainee as a potential patient. The trainer may pause to provide educational commentary. The trainer then demonstrates appropriate debriefing wherein both participants engage in emotional ventilation, followed by constructive feedback.
Next, exchange roles and repeat the role play. For the first round, the trainer should portray a co-operative client. During the role play, the trainer may provide feedback and prompt the trainee to ‘rewind and retry’ selected parts of the role play, facilitating performance improvement. Experienced field staff may be used as additional role play trainers. Role plays should include practice scenarios involving each of the three possible test outcomes.
Negative - Explain to the patient that HIV is not detected in their system at this time, but that it can take up to three months after exposure for antibodies to be detected. Review safe behaviour and suggest retesting in three months for confirmation.
Indeterminate - Explain that the test outcome is unclear, meaning that the test needs to be repeated. Repeat with a new kit and consider the second test as the proper finding. If the second test also reads as indeterminate, explain that it may be too early to detect HIV or that there may be some other (possibly unrelated) disease/biological process confounding the results. Review safe behaviour and provide a referral for the patient to get an HIV blood test from a qualified provider.
Positive - Explain that the test indicates a provisional positive result, which requires confirmation. Empathetically tend to their needs using the skills detailed in Session 3. Provide referrals for the patient to receive a confirmatory HIV blood test from a qualified provider in order to substantiate the findings. Review safe behaviour.
It is important to assess their state of mind in terms of potential risk. Ask them how they feel. Ask whom they might share this news with; this may suggest the extent of their support system. If the patient feels hopeless or has no support system, this could indicate increased risk. Ask what they intend to do after leaving. If the patient's response to any of these questions is vague, unclear or negative, it is important to ask if they are thinking of killing/hurting themselves. If they are unable to affirm that they will not hurt themselves, then provide support. Confer with your supervisor; you may be instructed to contact 911 or an emergency hotline in order to facilitate the patient's safety.
For positive disclosures, several role plays should be carried out, characterizing clients who present with (1) acceptance, (2) denial, (3) depression and (4) anger. Encourage trainees to partner-up and practice role plays between sessions.
Implementation
Staffing
Field workers should have flexible hours with an adequate number of trained backup personnel available for instances such as illness, vacation or being otherwise unavailable.
Field Kit
Hardware
Prior to deployment, staff should use a checklist to verify that their field kit is properly stocked. Our field kit consisted of: 20 rapid tests in an ice chest with a thermometer and cold packs (storage temperature for the OraQuick® is 35°-80°F; 2°-27°C), two stopwatches, 20 consent forms, two clipboards, pens, a lock box for signed consent forms, cell phones, waterless hand sanitizer, disposable gloves, post-test referral materials, cotton swabs and taxi vouchers for transportation to facility for (positive) confirmatory testing. Owing to concerns about potential voucher abuse, the vouchers were preprinted, indicating the home institution only as being valid. Used vouchers were billed to our account.
Information security
If patient names are collected, then proper protocol must be followed in terms of protecting patient information. Our field staff used a portable lock box to protect identifiable media when in the field.
General referrals and materials
If your outreach involves confidential testing, then it is advisable that referrals for anonymous testing be available to patients who are unwilling to reveal their identity as a prerequisite to testing. Our field staff frequently encountered enquiries regarding sexually transmitted diseases (STDs); referrals to local STD clinics or brochures detailing such information can be useful. In addition, referrals for substance or alcohol abuse recovery centres may also be valuable. Depending on the policies and practices of your organization, field workers may provide proven HIV risk-reduction resources such as condoms or referrals to needle exchange programmes. 5 9
Post-test card
A two-sided card detailing information for negative and positive outcomes helps facilitate test result confidentiality - anyone else who might encounter this card in the patient's possession would not be able to determine their status. This model card can be customized to suit your needs
Negative side
HIV antibodies were not currently detected.
It can take up to three months to develop antibodies after exposure.
It is recommended that you be re-tested in three months.
You can reduce HIV risk by: abstinence, condom usage upon any sexual contact (oral, anal or vaginal), limiting number of sexual partners and never sharing needles or paraphernalia. 10
Appropriate phone numbers (e.g. STD clinic)
Positive side
Preliminary findings suggest that there are HIV antibodies in your system.
Today's findings need to be confirmed with a blood test. Please contact Acme Healthcare at (555) 555-5555 to schedule a confidential appointment.
The use of medication, lifestyle adjustment and emotional support can facilitate good length and quality of life - this is a disease that you live with, not die from.
You can reduce HIV risk by: abstinence, condom usage upon any sexual contact (oral, anal or vaginal), limiting number of sexual partners and never sharing needles or paraphernalia. 10
It's normal to feel sad, scared, angry or confused. If you feel that you might hurt yourself, please call 911 or local emergency hotline immediately.
Out to the Field
Preinitial visit
Prior to deploying field staff, arrange for an in-person meeting at the facility with the manager/director. Take the time to answer questions and gather information regarding such things as the best time(s) and place(s) to encounter clients. The testing area should be well lit, quiet and private without being isolated; it should be in close proximity to other staff members or security. The staff should know who you are, what you are doing and what areas you will be occupying.
Initial visit
Upon arrival at each shift, check in with the site staff. In addition, notify the staff when you are done.
The supervisor should set up the testing area, verifying that field workers understand where everything is (e.g. tests, consent forms, gloves, etc.). Workers should be seated far enough apart to facilitate confidentiality and positioned such that they have an unobstructed path to the door in the event of an emergency; never place the patient between you and an exit.
Establish a waiting area that is separate from the testing area to accommodate those awaiting testing or test results.
The field supervisor should make it clear to the workers that they are there for questions, and also emotional support. Post-shift debriefings should be conducted upon departure from the facility, while the facts, feelings and events of the experience are still fresh.
Subsequent visits
Depending on the proficiency and comfort of the field workers, the field supervisor need not accompany them to subsequent shifts. Field staff can be supervised remotely via cell phone. Before each shift, each field workers should contact the supervisor for a preshift briefing. The supervisor should assess the readiness of each of the field workers. If a field worker is tired, emotionally stressed or feeling otherwise unfit, then this person should be excused. A practical ‘yardstick’ for making this determination is to consider if the worker is prepared to effectively cope with a positive disclosure at this time. The supervisor should assess the coping status of the workers on each call during shifts as well as on any mid-shift calls. The supervisor should exercise the right to cancel or cut a shift short in the interest of the field worker's welfare/safety. Field workers should feel free to contact their supervisor, for any reason during a shift.
Field workers should contact their supervisor to debrief after each (preliminary) positive finding is rendered, regardless of how the encounter went and at the end of each shift for debriefing wherein the supervisor speaks with each staff member.
Weekly staff meetings
Staff meetings should be held weekly in order to process feelings, experiences, questions, concerns, progress, agency changes and procedural issues. In addition, field staff should have access to their supervisor for individual consultations on an as-needed basis. Field workers should be encouraged to use these (confidential) meetings in the event that they find themselves obsessing about an encounter, uncertain about a particular case, or if they have any personal questions, concerns or issues that may influence their field performance.
As emotional issues are involved, the leader should set ground rules that serve to facilitate an open and supportive environment wherein feelings and possible errors can be discussed in a non-punitive, problem-solving fashion. Each meeting is an opportunity to validate the field worker's efforts, thoughts and feelings.
The following is a sample meeting agenda:
Progress to date (recruitment efforts, number of tests administered, etc.).
Changes in the worksites.
Openly discuss successes and challenges encountered.
Engage in problem-solving (build/modify field practice guidelines as needed).
Provide support.
Provide ongoing education (solicit field workers regarding their needs/wishes for further education subjects; consider selective review per field workers request).
Discussion
HIV rapid testing has been shown to be a highly flexible and reliable point-of-care diagnostic tool.1,2 Previous research has mentioned the significance of using HIV rapid tests in resourceconstrained settings, although this may increase the potential for differential levels of effectiveness, due to poorly or nontrained staff. 11 For example, the World Health Organization has developed guidelines for country-based implementation of HIV rapid testing; however, these guidelines focus exclusively on the administration of the test itself, and do not cover the training of staff in providing counselling of any kind nor field deployment guidelines. 12
Although this training module was designed for a specific type of outreach effort, it is flexible enough so that it can be customized to fit a variety of testing settings.
Conclusions
As the use of HIV rapid testing becomes more widespread and the variety of testing settings expands, so will the pool of people charged with test administration. It follows that training and deploying paraprofessionals to administer these tests is a cost-effective means of meeting the need for broader testing, particularly in resource-limited settings, such as developing countries where the HIV/AIDS epidemic is rampant and highly trained healthcare professionals may be scarce. Under such conditions, paraprofessionals can be charged with detection, thereby enabling higher trained health-care staff to concentrate exclusively on providing care to those who are positive.
Footnotes
Acknowledgements
The authors wish to thank Rini Rajan and Mark Frank for their assistance with the project from which this work derived. This project was funded through a US Department of Veteran's Affairs grant (Implementing an HIV Rapid Testing Pilot Project among Homeless Veterans: RRP: 06-129) awarded to the second author. The OraQuick® Advance™ Rapid Tests used in this project were donated by OraSure Technologies, Inc. All views are expressly those of the authors and do not necessarily reflect those of the US government or of OraSure Technologies.