In this national survey of general internists, many with responsibility for supervising residents, approximately 15% reported having rapid HIV testing available in their practices. Similarly, a study about the barriers to adoption of rapid HIV testing found that while 50% of hospital clinics had rapid HIV testing available, only 15% of respondents from clinics and community-based organizations did.25
In our study focused on primary care settings, rapid testing appeared to be offered more commonly in community health centers and public hospital-based clinics, in settings with a higher prevalence of minority and uninsured patients, and in the northeastern US. Having rapid testing in these settings may have been influenced by CDC funding of rapid testing in certain types of communities and settings,8
but our study did not assess source of funding for rapid testing. One individual provider characteristic related to rapid testing, race/ethnicity of the physician, is consistent with another study showing Black and Asian physicians being more likely to provide HIV testing than white physicians.26
Providers with more time since completing training were also more likely to practice in settings with access to rapid testing. Otherwise, system issues and characteristics associated with the surrounding community appeared to be more important in predicting rapid HIV testing availability.
Our study and others suggest more HIV testing is done in settings where rapid testing is available, although causality is difficult to determine. Recent evidence from Washington, DC, shows a 335% increase in the number of persons who were tested after the CDC recommendations and rapid testing were widely distributed; 27
however, several additional public health measures were simultaneously implemented, making it difficult to attribute testing changes to any single intervention. Studies suggest that consumers more often choose rapid testing when both rapid and standard tests are available.7,20,28
A primary rationale for placing rapid HIV testing in episodic care settings is the greater chance for patients to be lost to follow-up compared to primary care practices. While rapid testing may be perceived to have less benefit when physicians and patients have ongoing relationships, outpatient internal medicine practice frequently involves urgent care visits.
A greater proportion of providers with access to rapid testing reported no structural, clinical, or patient-related barriers to provision of HIV testing. It is not clear whether this finding means rapid testing actually reduced these barriers to testing or whether rapid testing is more often present in practice locations where barriers to HIV testing have already been addressed. Two of the three individual barriers that were lower in settings with rapid HIV testing were related to perceptions of patients’ high-risk behaviors, whereas the third specific barrier relates to priorities at the time of patient visit. In contrast, rapid testing availability did not appear to impact several other common barriers, including patient refusal, language issues, cultural issues, or consent issues regarding HIV testing. In general, primary care providers rated HIV testing a lower priority than many other common screening tests or inquiries; and this finding was supported by “other priorities at the time of visit” being the most frequently cited individual barrier to screening. Improved understanding of the reasons for the low prioritization of HIV testing may be needed to improve HIV testing rates in primary care settings.
We are just beginning to see efforts at offering HIV testing in rural29
primary care settings. Recent data from community care clinics suggest that implementing rapid HIV testing, together with a systematic method to encourage HIV testing, resulted in an increased number of persons being tested.10
However, few new HIV infections were identified.10
Reports indicate rapid testing is viewed favorably by patients; however, we are not aware of studies that have focused on physicians offering HIV testing or having access to rapid HIV testing, as was done in this study. Challenges with rapid HIV testing also need to be considered, including higher initial cost,9,31
although rapid testing could save money over time if it improves overall detection and treatment rates.32
Another potential downside to rapid testing is a higher proportion of false-positive results compared to standard testing,10,11,33
which can result in additional counseling time for the providers10
and may result in psychological stress.34
Several study limitations should be noted. First, although the results suggest an association between availability of rapid HIV testing and decreased barriers to HIV testing, the cross-sectional nature of the study precludes establishing causality. Second, primary outcome measures were based on self-report and could not be validated. Although our study focused on provider-related issues that may impact access to rapid HIV testing, it may be that the decisions to offer rapid HIV testing occur at the level of the practice or university setting, and the internist has little influence on this decision. Our sampling strategy targeted members of an organization that includes a high proportion of general internists in academic settings practicing in diverse settings, but may not be representative of all practicing general internists. However, one of our goals was to evaluate those training the next generation of internists, an influential sample in the field of general internal medicine.
Although meeting all prevention and care needs is a challenge in primary care, both the 2010 Institute of Medicine (IOM)’s report regarding HIV prevention and the US President’s National HIV/AIDS strategy prioritize early intervention in order to treat and prevent further spread of HIV. These are consistent with the CDC's 2006 Recommendations to increase routine HIV testing.1,35,36
The IOM report identifies rapid testing as one method to increase HIV testing. If rapid HIV testing is seen as a tool in the effort to increase testing rates in the US, the findings of this study provide some guidance. Our study suggests that rapid HIV testing is currently available to a minority of general internists and is more prevalent in settings serving minority and uninsured communities where there is a higher HIV prevalence. Clinic- and systems-based factors may have a greater relationship to rapid testing utilization than individual provider characteristics. Future research should evaluate whether offering rapid HIV testing, rather than standard HIV testing, is effective at increasing the detection and treatment of persons with HIV in primary care settings.