Adolescent AIDS Program: ACTS

ACTS
(Assess, Consent, Test, Support)
Despite concern in key public health communities about the growing incidence of HIV, many providers continue to miss crucial opportunities to identify HIV-positive patients. Our research has identified two factors that inhibit routine HIV testing of sexually active teens. After consulting with public health officials and clinicians it was determined that these same factors can be applied to all populations at risk for HIV.

1) The need for an effective educational program to inform providers that HIV counseling and testing is now a standard of care for all sexually active youth and adults; and

2) The need for a simpler HIV counseling and testing protocol that puts the procedure on par with other diagnostic tests.
With ACTS, the AAP plans to meet these needs, helping providers close the gap between those who are unaware that they are infected with HIV and those who have been identified and linked to care. ACTS fosters the routine offering of HIV counseling and testing to all patients in high prevalence areas and to at-risk patients in areas with a prevalence of less than 1 percent.

ACTS (Assess, Consent, Test, Support)

Goal
To make HIV counseling and testing a more routine part of primary care practice in high prevalence areas.

Background
• For more than a decade the number of new HIV infections has remained steady at 40,000 each year. In primary care settings, many opportunities are missed to identify HIV+ patients and many of those infected are still unaware of their status and/or not linked to care.

• Monumental advances in HIV treatment have not yet spurred similar advances in case finding. An evolution in counseling and testing is needed to identify the more than 300,000 people in the U.S. who are HIV+ but unaware of their infection or not linked to care.

• HIV counseling and testing has been separated from primary care, a development that has created barriers to successful case finding. Providers need to be engaged and empowered to take advantage of the opportunities they have with patients to test for HIV.

• Because half of all new HIV infections are in young people, and because they are dangerously under screened by their health care providers for STDs including HIV, we are advocating for special attention to screening and testing this population.

• The recent approval of a rapid HIV test makes it timely to introduce a new paradigm that may include rapid pre-test counseling, same day testing or delivery of test results by phone.

• The billing ramifications of practicing ACTS are advantageous. Primary care visits that include ACTS can bill for a separate counseling and testing visit, and the NYS DOH is drafting a new reimbursement rate for same day testing that promises to include fees for pre- and post-test counseling.

• Research shows the majority of providers aren’t offering HIV counseling and testing routinely to their at-risk patients because:

	- Providers underestimate or don’t assess their patients’ risk
	- Providers find the counseling and testing process too complicated and time-consuming
	- Providers do not think they are qualified to deliver HIV counseling
	- However, providers report that they are eager for training and materials that can facilitate their involvement

Program
• The Adolescent AIDS Program at Montefiore has created a rapid new system for simplified HIV counseling and testing, which codifies critical elements in a memorable acronym: ACTS (Assess, Consent, Test and Support) and provides tools for implementation.

• The ACTS approach, which incorporates all essentials for effective counseling and testing, is estimated to take no more than 5–10 minutes.

• Elements of the ACTS system include:

	- A meeting with the HIV coordinator, clinic administrator and medical director to address the challenges and solutions to implementing routine counseling and testing
	- An academic detailing session to train clinic staff about the importance of case finding and the use of ACTS
	- Toolkit for ACTS implementation (for use in appropriate places in clinic) • Patient Risk Evaluation (PRE) screening form • New York State Department of Health consent form • Patient information (sexual health/HIV information flyer and The Deal, a lifestyle magazine that incorporates HIV education and prevention )
	- Laminated pocket reference card on ACTS steps
	- ACTS manual with detailed information on its elements and use: • Sample scripts for pre-test and post-test counseling • Prevention plan materials • Resources for additional information

Evaluation
• Conduct a randomized trial of ACTS in community health clinics where HIV testing is currently under utilized.

• Match clinics, randomize to immediate or 6-month delayed intervention.

• Assess provider beliefs and practices pre- and post-intervention via questionnaire.

• Utilize existing database to determine number of patient visits and number of HIV/STD tests.

Next Steps
• Begin implementation of the ACTS trial in community health centers in the Bronx, NY.