Table 1.

Implementation Plan for Rapid HIV Testing Adapted from the NACHC Model

Essential Steps	Key Elements	Implementation Plans
Step 1: Pre-Work	Choose a rapid HIV testing method. Establish key personnel for managing kits. Solidify referral arrangements for HIV care.	The Uni-Gold ™ Recombigen® HIV rapid test chosen for its reliability; specificity = 100% (99.5100, 95% CI), sensitivity = 99.7% (99-100, 95% CI; Greenwald, Burstein, Pincus, & Branson, 2006). Kits obtained free of charge from the NC Rapid HIV Testing Program in exchange for data reporting to the CDC. PCC medical assistant is designated to manage kit inventory, maintain test/control logs, and ensure that kits are current and that those closest to their expiration dates are used before those with later expiration dates. Patients with positive rapid HIV test and positive confirmatory WB are referred to the NOC for comprehensive medical care and case management. NOC Bridge Counselor and Case Manager are responsible for ensuring linkage to other facilities if necessary.
Step 2: Set up the Framework	Finalize data collection and documentation plans. Prepare test logs. Prepare patient education materials and draft staff tools.	Electronic medical record is used to document demographic data, test acceptance or rejection, and test results. A reactive tracking tool from NACHC model is used to collect data regarding follow-up of any reactive rapid HIV test result. Rapid HIV test results logs and test control results logs from NACHC model are used to document test lot numbers, tester names, test date/times, and internal/external test controls. NACHC patient brochures (English and Spanish) describing HIV testing in simple language are placed in patient waiting areas. Scripts from NACHC model are utilized to help guide nurses and providers in the use of appropriate language for offering/ performing rapid HIV tests, and delivering the results.
Step 3: Design the Patient Visit Process to Include HIV Screening	Develop a patient visit process for integrating HIV screening into existing work flow. Define the process for responding to test results (see algorithm, Figure 1).	After check-in and vital signs, the patient is offered a rapid HIV test by a medical or nursing assistant in the privacy of the exam room, and verbal consent is obtained (sufficient per NC law). If the test is accepted, a blood sample is obtained by finger stick and the Uni-Gold™ rapid HIV test is performed. The HIV test kit is kept in the exam room for the 10 minutes required to obtain results. Negative test results are delivered to the patient by the tester in the exam room, and the patient is given an information sheet that addresses HIV risk reduction and explains the negative result. The patient is informed that antibodies to HIV may not be detected early in infection, and that if there is concern that the patient may have been infected within the previous 3 months, he or she should be tested again in 3 months. Reactive test results are delivered to the patient by the provider, who explains that the WB test is necessary to confirm the HIV status. The provider explains the HIV seroconversion window period, gives the patient a handout explaining the reactive result, orders the WB test (performed same day on site), and ensures that a follow-up appointment is scheduled to deliver the WB results. For any patient with a reactive rapid HIV test and a positive WB, a NCDIS is notified to follow up with the patient. The staff of the NOC are also notified, and the newly diagnosed HIV-infected patient is immediately linked to clinical care and counseling. If the WB result is indeterminate, the test is repeated and if the second WB test is negative, the patient is asked to return in 3 months for repeat testing.
Step 4: Plan for Tracking Reactives	Identify a point person to track reactives	The PCC nursing supervisor is responsible for tracking reactive results utilizing a reactive tracking tool adapted from the NACHC model and for ensuring linkage to the NOC.
Step 5: Adopt HIV Screening Codes for Reimbursement	Establish billing and coding guidelines	HIV testing is offered free of charge; however, billing and coding information is available from Coding Guidelines for Routine HIV Testing in Health Care Settings, a resource for guidance in reimbursement issues developed jointly by the American Academy of HIV Medicine and the American Medical Association (http://www.ama-assn.org/ama1/pub/upload/mm/36/hiv_cpt_guidance.pdf).
Step 6: Commit	Convene staff forums. Convene profession-specific training.	PCC leadership and key staff and NOC staff meet to discuss the project in detail and to state their joint commitment to the project. Planning meetings are held with the PCC nursing supervisor, the QI point person, and the information technology manager. Experienced testers from the NOC lead training sessions for the nursing assistants and medical assistants performing rapid HIV testing. Lectures regarding HIV pathophysiology, transmission, and prevention are provided prior to rapid HIV test training, and all trainees are required to demonstrate proper technique in test administration. NOC medical providers and staff guide PCC providers in diagnosing HIV infection and delivering and discussing HIV test results, with emphasis on how to manage reactive results.
Step 7: Launch	Set a target date to begin testing, and arrange for troubleshooting during launch.	The initial target date is set for December 1, 2011. Scheduling and completing staff training and obtaining rapid test kits from the state delay the launch date to February 1, 2012. The NOC staff is available when the testing project is launched to troubleshoot and respond to problems.
Step 8: Realignment	Ongoing evaluation and process improvement	After the testing project is launched, a schedule is developed for meetings between key players to discuss any problems with the testing project and to develop new ideas, tools, and methods to improve service delivery.

Note. CDC = Centers for Disease Control and Prevention; PCC = primary care clinic; NOC = Northern Outreach Clinic (HIV clinic); WB = Western blot; NC = North Carolina; NCDIS = North Carolina Disease Intervention Specialist; NACHC = National Association of Community Health Centers; QI = quality improvement.