HIV Prevention: Clinical Decision Support System to Increase HIV Screening
Findings and Recommendations
The Community Preventive Services Task Force (CPSTF) recommends clinical decision support systems (CDSS) to increase HIV screening based on strong evidence of effectiveness. Evidence shows use of CDSS increases HIV screening for the general population and for people at high risk for HIV infection. Patients who test positive for HIV can be linked with care that would be expected to reduce HIV transmission.
When implemented in healthcare settings for populations who are underserved, CDSS are likely to improve health equity.
The full CPSTF Finding and Rationale Statement and supporting documents for HIV Prevention: Clinical Decision Support System to Increase HIV Screening are available in The Community Guide Collection on CDC Stacks.
Intervention
CDSS encompass a variety of tools to enhance decision making about patient care. These tools include computerized alerts and reminders to healthcare providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; and diagnostic support (Office of the National Coordinator for Health Information Technology, 2018).
To increase HIV screening, CDSS use patient data and current guidelines to identify those eligible for HIV screening and send providers computerized alerts or reminders to order tests. CDC guidelines (Branson et al. 2006) recommend routine screening for all patients aged 13-64 years and all pregnant people, and at least annual screening for people at high risk for HIV. Risk is assessed based on patients’ or their partners’ sexually transmitted disease diagnosis, sexual behavior, or history of injection drug use.
Patients may receive information about HIV transmission and testing prior to screening, and healthcare providers may receive education about HIV transmission, patient eligibility for screening, and how to correctly use CDSS.
About The Systematic Review
The CPSTF finding is based on evidence from a systematic review of 23 studies (search period 1985 to October 2019).
The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to HIV prevention, treatment, and care.
Study Characteristics
- Included studies evaluated interventions implemented in the United States (21 studies) and the United Kingdom (2 studies).
- Studies implemented opt-out (19 studies) and opt-in (3 studies) testing. CDC recommends opt-out testing, which notifies patients they will be tested for HIV as part of their standard preventive screenings unless they decline (Branson et al. 2006).
- Studies relied on active or passive CDSS reminders. Active reminders require providers to address an alert before moving to the next task or closing a patient’s chart (13 studies). Passive reminders can be ignored by providers (4 studies).
- Studies offered HIV screening to all eligible patients who had not been tested previously (12 studies), patients who were at high risk for HIV infection and had not been tested within the previous 12 months (6 studies), or both (5 studies).
Summary of Results
The systematic review included 23 studies.
- When CDSS alerted providers to offer testing to all eligible patients, providers offered testing to a median of 80% of eligible patients (6 studies).
- Compared with no intervention, CDSS increased HIV screening and identified more HIV infections.
- The percent of eligible patients tested for HIV increased by a median of 10.3 percentage points (16 studies).
- The number of eligible patients tested each month increased by a median of 415 (7 studies).
- The number of patients tested positive each month increased by a median of 1.3 (13 studies).
- Patients who tested positive were more likely to be identified at earlier stages of HIV infection (1 study).
- In one study, most of patients who tested positive were linked to care (1 study).
- Greater increases in HIV screening were reported when providers were educated about HIV, HIV testing, and CDSS (10 studies) before the program started, when compared with studies that did not include an educational component (8 studies).
Summary of Economic Evidence
A systematic review of economic evidence has not been conducted.
Applicability
Based on results from the systematic review, the CPSTF finding should be applicable to CDSS used for all eligible patients, independent of age, income, health coverage, race, or ethnicity. Interventions were shown to be effective in urban, rural, or suburban communities, and in a range of healthcare settings (e.g., clinics, hospitals, emergency departments, Veterans Affairs healthcare facilities, managed care settings).
Evidence Gaps
- Most studies reporting on HIV screening among people at high risk did not report effectiveness by specific risk behaviors.
- How effective are CDSS for HIV screening among people who have male-to-male sexual contact or inject drugs?
- How effective are CDSS for HIV screening in rural areas?
Implementation Considerations and Resources
- Current use of electronic medical records (EMR) and electronic health records (EHR) in the United States is very high. This could make it easier for healthcare providers to adopt an additional alert for HIV screening (CPSTF).
- For CDSS to effectively identify patients at higher risk for HIV infection, providers will need to collect and record information about risk behaviors (e.g., sexual behavior, drug use history). Some providers or patients may feel uncomfortable and avoid these topics (CPSTF). CDC offers guidance to providers for discussing sexual health.
- Some risk factors may be recorded in EMR/EHR fields that are not searchable, making it difficult for CDSS algorithms to identify patients eligible for screening (Burrell et al, 2018). Modifications to electronic forms might be needed to ensure complete recording of patient conditions.
- Providers might resist HIV screening in an already busy environment and not offer tests to patients despite CDSS prompts. Steps may be taken to streamline the process or generate prompts at more convenient times (e.g., when emergency departments draw blood for another purpose; Chadwick et al, 2017; Lin et al, 2017).
- Offering training for providers was associated with an increase in HIV screening rates. Training programs might do the following:
- Teach providers how to use the system so daily interruptions are minimized and the perceived burden of HIV screening is reduced (Burrell et al, 2018).
- Provide facts about HIV transmission and prevention, and address biases and stereotypes providers may hold about patients at risk for HIV infection, including those related to age, race/ethnicity, sex, or risk behaviors (CPSTF).
- Although most of the included studies used an opt-out approach to testing, a median of 30% of patients declined an HIV test.
- Providers could ask patients detailed questions about their reasons for declining and offer alternative solutions such as oral testing rather than needles or finger-stick tests (Clarke et al, 2013).
- Providers might offer brief counseling when time and resources allow (CPSTF).
- CDSS interventions for HIV screening identify more patients living with HIV who need to be linked with appropriate follow-up care that is affordable and accessible.
- CDSS algorithms could be established to connect patients to care. Systems could be programmed to automatically order confirmatory tests and submit referrals (Conners et al, 2012), provide direct links to downstream care facilities to set up appointments (Burrell et al, 2018), or report confirmed cases to the local health department for tracking (Sha et al, 2019).
- Outreach workers may be engaged to deliver results to patients who test positive and facilitate linkage to care (Lin et al, 2017). Patients might be more receptive to information and advice offered by community health workers (CPSTF).
Crosswalks
Healthy People 2030 includes the following objectives related to this CPSTF recommendation.