Staff Strategies for Improving HIV Detection
Using Mobile HIV Rapid Testing
Oscar Grusky, PhD; Kathleen Johnston Roberts, PhD; Aimee-Noelle Swanson, PhD;
Harmony Rhoades, MA; Marcus Lam, MPP
This paper examines the performance of 13 mobile testing units (MTUs)
and rapid HIV testing technology in Los Angeles County as reflected in the
relationship between the cognitive strategies used by MTU staff regarding
instructions to clients about picking up their test results and returning for test
results, and following up with those clients who did not return, and the spatial distribution of MTUs and AIDS rates in 2003. Maps were created using
geographic information systems (GIS) data on 93 MTU testing locations and
2003 AIDS cases data. MTU staff (N 45) were interviewed and several
themes were identified. MTU testing locations were clustered near high AIDS
rate areas. Staff reports were obtained on 24 clients in the past 6 months who
received HIV-negative test results and 24 clients during the same time period
who received HIV-positive test results. Staff strategies that were used included
keeping clients with them while rapid test results were being processed and
adjusting to clients’ schedules when arranging for picking up test results.
Some staff used tangible incentives such as vouchers for area businesses to
encourage preliminary HIV-positive clients to return for confirmatory test
results. Staff also sought to convince clients who preliminarily tested HIVpositive to convert from anonymous to confidential testing in order to facilitate clients’ linkage to treatment. The GIS findings and client risk data support
the Centers for Disease Control and Prevention policy of implementing MTUs
and rapid testing in large urban communities with high AIDS rates.
Index Terms: conventional HIV testing, failure to return for HIV test results,
geographic information systems (GIS), mobile testing units (MTUs), rapid
HIV testing, staff strategies
24%–27% of these people are unaware of their infection.1,2
HIV counseling and testing have been integral parts of HIV
prevention efforts since 1985, when the first antibody test
became available.3 US research evidence suggests that HIV
counseling/testing substantially reduces risk behavior. Persons unaware of their HIV-positive serostatus are 3.5 times
more likely to transmit HIV to partners than those people
who are aware of their positive serostatus.4 Increased
counseling/testing can reduce the number of HIV-positive
persons (estimated to number between 252,000 and 312,000
individuals) who are unaware of their infection.2
About 50% of all persons aged 18–64 in the United States
have been tested for HIV.5 HIV testing occurs in a variety of
HIV/AIDS continues to be a significant problem in the
United States despite the fact that over 2 decades have
passed since the beginning of the epidemic. Over 1 million
persons in the United States are infected with HIV, and
Dr Grusky is Research Professor in the School of Public Affairs/
Department of Sociology, University of California, Los Angeles
(UCLA), CA. Dr Roberts is a self-employed Research Consultant
in Chicago, IL. Dr Swanson is Project Director in the Department of Family Medicine, Geffen School of Medicine, UCLA.
Ms Rhoades is a Ph.D. student in the Department of Sociology,
UCLA. Mr Lam is a Ph.D. student in the Department of Social
Welfare, School of Public Affairs, UCLA.
Copyright © 2009 Heldref Publications
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STAFF STRATEGIES FOR HIV DETECTION
settings, including medical (eg, emergency departments and
physicians’ offices), community-based (eg, free clinics and thrift
stores), and private (eg, at-home tests) locales. Mobile testing
units (MTUs) are potentially a key venue for testing, because
they are designed to increase access to counseling/testing for
high-risk populations by bringing the service to the clientele.
One study compared clients of an MTU and of a traditional
STD clinic and found that the MTU clients were more likely
than the others to be engaged in prostitution and more likely
to be injection drug users.6 Another study focused on patterns
of HIV testing among a sample of low-income women in Los
Angeles County and found that homeless women were more
likely than others to have been tested for HIV in an MTU.7
Moreover, while providing needed services to high-risk population groups, MTUs are also well-accepted by community members. In 1 study, 97% of respondents thought that neighborhood
mobile STD testing was a “good” or “very good” idea.8
One of the historical challenges of HIV testing efforts has
been encouraging individuals who get tested to return for their
test results. The Centers for Disease Control and Prevention
(CDC) estimate that only about two-thirds of the 2 million
persons who get tested for HIV each year receive their test
results, and that approximately 25% of those people who test
positive for HIV never receive their test results.9
Failure to return (FTR) for HIV test results has been a pervasive problem for MTUs. In an earlier study on this topic, a
return rate of only 20% for MTU clients was found.10 Molitor
and colleagues11 examined predictors of FTR for HIV test
results for a sample of 366,280 clients. Results showed that the
most significant predictor of FTR was testing site type. Mobile
testing clients were over 3 times more likely than other alternative test site clients to fail to return for test results. Another study
examined the posttest counseling rates for clients of a mobile
STD/HIV screening clinic and found that only 66% of infected
and 46% of uninfected clients received their results. The
authors concluded that their “mobile STD/HIV screening clinic
[was] limited in its effectiveness.”12 A recent study examined
time trends of failure to return for HIV test results among an
MTU population in Los Angeles, California. Results showed a
statistically significant worsening time trend between 1997 and
2004 for the percent of MTU clients who failed to return.13
There are various possible explanations for the high rate
of FTR among clients testing at MTUs. For instance, MTUs
typically serve disadvantaged populations (eg, homeless
individuals and/or active drug users). Such populations are
often unstable and may lack resources such as bus fare to
return to a testing location. Also, because MTUs are, by
definition, mobile, clients may be unsure of how to locate
the MTU on any given day, or clients may be in a different
location than the MTU on the day that results are ready.
102
The increasing availability of rapid HIV testing, which
eliminates the need for HIV–negative clients to return to
the HIV testing site to receive test results, has improved
the FTR problem in MTUs.14 For example, Liang and
colleagues15 examined the use of OraQuick rapid HIV-1
testing for clients tested in a mobile unit and found a posttest
counseling rate of 89% for infected and 93% for uninfected
clients. However, rapid testing cannot solve all the problems
associated with FTR. Rapid tests are still not available in
all locales, so some persons still get tested conventionally.
Moreover, seropositive rapid test results are considered
preliminary. Those people who test positive must undergo
confirmatory testing and clients may fail to return for confirmatory test results. A study of rapid testing in a hospital
emergency department found that 13 of 26 patients with a
preliminary positive screen failed to return.16
This study was designed to examine HIV counseling and
testing prevention strategies. Strategies are defined as choices that managers and staff make regarding the use of their
organization’s technology, structure, markets, clients, and
domain.18 The study strategies of concern involve the use of
MTUs and rapid HIV testing. This study addresses 2 issues.
First, are MTUs selecting appropriate locations (eg, locations that are the most likely to attract and serve individuals
at elevated risk for contracting HIV)? Geographic information systems (GIS) methods have been used to examine the
spatial relationship between MTU locations and high AIDS
rates in Los Angeles County. Second, what cognitive strategies are MTU providers employing to encourage clients to
return for their test results? Our study contrasts MTUs using
rapid and conventional testing and explores the instructions
staff members give clients regarding picking up their test
results, the methods of encouragement staff members use to
urge clients to return for their test results, and strategies staff
members use to follow up with clients who fail to return.
METHODS
We collected 3 types of data: MTU location (GIS) data,
MTU testing data, and computer-assisted personal interview data from MTU staff, including data on clients who
were tested for HIV.
MTU Location (GIS) Data
We first created a map of AIDS rates in Los Angeles
County based on the number of AIDS cases recorded in
2003.19 AIDS cases were distributed by census block
(2,000 divisions), with only blocks that reported 6 or more
AIDS cases included. Using a unique census block identifier, we joined this AIDS rate data with GIS data for Los
Angeles County using the Environmental Systems Research
Behavioral Medicine
GRUSKY ET AL
Institute (ESRI) 2000 Tiger/Line Data Web site in Shapefile
format.20
MTU testing locations were geocoded based on addresses,
street intersections, or landmarks given by survey respondents. Follow-up calls were made to staff in cases for which
locations were vague. Ninety of the 93 (96.8%) specific
MTU locations were successfully geocoded. Only 3 locations were omitted from the final dataset, 2 of which were
“don’t know” responses. The other omitted response was
too vague to be coded.
MTUs and Testing Outcomes
MTUs were identified as part of our larger study of 159
HIV testing organizations and 621 staff in LA County from
2003–2007. Chief executive or medical officers provided
consent for organization participation. Staff participation
was completely voluntary and accompanied with separate
informed consent. A sampling frame was constructed from
4 publicly available listings.21–24 These 4 listings represent
the best collection of known and recognized HIV testing
venues in Los Angeles County and are widely referenced
by community-based organizations, medical professionals,
and Los Angeles County agencies. In order to comprehensively identify all HIV MTUs active in Los Angeles County,
including those units not identified by other sources, we
contacted Los Angeles County public health administrators
and prominent HIV organizations such as the LA Department of Health Services (LADHS) Office of AIDS Program
and Policy (OAPP) to obtain a list of MTUs in Los Angeles
County that are funded through this office. We contacted
all 3 public health departments in the county: the Pasadena
Public Health Department, the LADHS Sexually Transmitted Disease Program, and the Long Beach Department
of Health and Human Services HIV & STD Testing and
Treatment Services. Additional sources with local expertise were also contacted to ensure that all prominent and
widely recognized HIV testing sites were polled, yielding
a sample of 14 MTUs in the county connected with a total
of 11 organizations. However, 1 MTU in an organization
with 2 MTUs had no unique providers and no unique data
collection and had visited only 1 site in the prior t3 months.
Hence, data was collected from 13 MTUs situated in
11 organizations. Ten MTUs from 9 organizations offered
rapid HIV testing.
Data on HIV testing outcomes was gathered from
12 MTUs in 10 organizations. One unit was not able to
provide this information, and 1 unit was not in operation
during the requested period. Data was obtained from the
Los Angeles County OAPP for 9 organizations that reported
to this office. Data for the other 2 organizations was less
Vol 35, Winter 2009
complete. Data apply to the MTU as a whole and do not
differentiate between testing locations.
Staff Interview Data
Staff participants were recruited from 13 MTUs identified between February of 2005 and December of 2006. A
total of 45 MTU staff participated in the project, including
29 front-line (HIV test counselors) and 16 managerial-level
workers. In addition to their managerial duties, managers engaged in HIV testing and counseling with clients,
although not as frequently as front-line staff whose jobs
were devoted to these tasks.
Research assistants conducted face-to-face computerassisted interviews. Participants were asked questions
about the policies/procedures regarding HIV testing at
their sites; specific encounters with both HIV-negative
and HIV-positive clients within the past 6 months; and the
issue of returning for HIV test results. Interviews lasted
approximately 45 minutes. Participants’ responses were
immediately typed into computers. Both closed-ended and
open-ended questions were included in the interviews. In
the case of the open-ended questions, the research assistants typed participants’ responses verbatim or summarized
responses.
Client Data
Information on clients was obtained from front-line
providers, who were asked about their most recent HIVnegative and HIV-positive test sessions conducted over the
prior 6 months. Providers were permitted to consult their
clients’ charts. A total of 24 front-line MTU staff provided
information on 48 clients, 24 of whom tested HIV-negative
and 24 of whom tested HIV-positive.
The text from all open-ended questions was loaded into Ethnograph (Version 5.07, Claris Research Associates, Colorado
Springs, CO), a software program for computer-based text
search and retrieval. Multiple readings of these data were
performed to identify key themes.25 A line-by-line review
of the data was performed and first-level codes (descriptors
of important components of the interviews) were noted in
the margins. All codes were then tagged to associated text
segments in Ethnograph. Data corresponding to each of the
first-level codes were printed and reviewed, and subcodes
were established to divide the first-level codes into smaller
categories. The results correspond to the emergent categories. All quotations are drawn from the transcripts.
RESULTS
Findings from the study included: (1) descriptive
data on MTU HIV testing outcomes and staff and client
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STAFF STRATEGIES FOR HIV DETECTION
characteristics; (2) results from maps showing the relationship between the location of the MTUs and AIDS rates in
LA County in 2003; (3) instructions MTU staff members
gave to clients regarding returning for test results; (4) how
MTU staff members encouraged clients to return; and (5)
how MTU staff members followed up with clients who
failed to return for test results. Our findings highlight the
advantages of using rapid testing. Although only a small
number of MTUs used conventional HIV testing, discussions of areas 3, 4, and 5 are divided into rapid and conventional HIV testing sections, because the instructions,
encouragement, and follow-up protocols often differed
depending on testing technology.
Data were unavailable regarding the number of false HIVpositive and false HIV-negative rapid HIV tests. In 2005, the
media reported aberrant rates of false positives from the oralbased rapid HIV test in San Francisco and New York. Very few
similar occurrences were reported in Los Angeles. Currently,
CDC still supports the use of the rapid oral fluid HIV test,
although HIV rapid testing with blood or serum is considered
slightly more accurate. As pointed out later, following CDC
protocol, rapid HIV-positive tests are considered preliminary
and are routinely confirmed by using the Western blot.
mean percentage of seropositive tests in which results
were given to clients (N 9 MTUs) was 70.3 (range 48.9100.0, SD 15.8).
Spatial Data (GIS) Findings
Figure 1 shows MTU locations based on units that offer
rapid testing only and for all units. As noted previously,
10 of 13 MTUs (76.9%) offered rapid testing. Figure 1
indicates that rapid and conventional MTU locations were
clustered in areas with high AIDS rates. Specifically, MTU
locations were clustered in the Hollywood, downtown Los
Angeles, and Long Beach areas, where AIDS rates were
recorded as between 31 and 192 cases per block. Most of
the locations in areas with high AIDS rates were visited
by MTUs that offered rapid testing. Figure 2 reveals that,
in general, MTU locations were found along existing bus
routes and therefore were presumably accessible to those
people without personal means of transportation. However, we found that areas with high AIDS rates in 2003
remained which rapid testing MTUs did not adequately
serve, such as the San Pedro area and parts of Central Los
Angeles.
Instructing Clients to Pick Up HIV Test Results
Staff, Client, and MTU Characteristics
As shown in Table 1, the average age of staff participants
was 40 years, and 16% were White, 49% Hispanic, and 20%
African American (SD 11.3). The remainder identified as
Asian, more than 1 race, or other. Most staff either completed high school (36%) or had some college or graduated
(42%). 60% were male. The average length of time staff had
worked at their current job was 4.9 years (range 0.2–20.9,
SD 5.02). About 7 out of 10 staff were either African
American or Hispanic, 2 groups with comparatively high
incidences of HIV/AIDS, in both LA County and the United
States. Clients are grouped in Table 1 into those persons
with HIV-negative results and those persons with HIVpositive test results. HIV-positive clients were disproportionately male (92%); Hispanic (46%) or African American
(38%); men who have sex with men (58%) or men who
have sex with men/women (25%). A total of 18 of 24 (75%)
clients who were HIV-positive and 16 of 24 (67%) clients
who were HIV-negative received rapid tests.
With regard to the MTUs, the mean number of HIV
tests given in 2003 (N 12 MTUs) was 1,377 (range 4922,740, SD 842). The mean percentage of seropositive tests given in the same year (N 11 MTUs) was 1.99
(range 0.953.17, SD 0.73). The mean percentage
of overall tests in which results were given to clients (N 9 MTUs) was 78.4 (range 56.399.6, SD 14.7). The
104
Conventional HIV testing
MTU workers’ instructions to clients regarding returning for HIV test results after conventional testing differed
depending on whether clients opted for anonymous or
confidential conventional HIV tests. MTU staff members
collected no identifying information from clients who
tested anonymously. Instead, staff collected certain types
of information (eg, zip code, gender, initials) from clients
and used these data to create unique identifiers. The type of
identifier information collected varied by site. Regardless
of the nature of the identifiers, MTU workers gave anonymous testers similar instructions regarding picking up their
results. At the conclusion of the testing session, the MTU
staff gave clients slips of paper that had their unique identifiers and instructed the clients to bring the paper back to
receive their test results. Clients who tested confidentially
were told to return at a later date and provide their identifying information (eg, name and address) to receive their
result. The amount of time between the testing sessions
and when clients were told to come back varied from 1 to
2 weeks.
Rapid Testing
When conducting rapid HIV tests, clients received their
results in about 20 minutes. Such results are considered
Behavioral Medicine
GRUSKY ET AL
TABLE 1. Staff, Client, and Mobile Testing Unit Characteristics
Characteristics
Staff
Race
Asian
African American
White
Hispanic
More than one race
Other*
Education
Less than high school
High school
Some college or college graduate
Post-graduate degree
Other*
Gender
Male
Female
Client negative test results
Race
Asian
African American
White
Hispanic
More than one race
Other*
Gender
Male
Female
Transgender
Behavioral risk group (BRG)
Men who have sex with men (MSM)
Men who have sex with men and women (MSM/W)
MSM/intravenous drug user(IDU)
IDU
Women at sexual risk (WSR)
Transgender
Other
Clients—positive test results
Race
Asian
African American
White
Hispanic
More than one race
Other*
Gender
Male
Female
Transgender
N
%
2
9
7
22
3
2
4.4
20
15.6
48.9
6.7
4.4
2
16
19
7
1
4.4
35.6
42.2
15.6
2.2
27
18
60
40
1
7
5
10
1
—
4.2
29.1
20.8
41.7
4.2
—
16
7
1
66.7
29.1
4.2
9
1
—
5
2
1
6
37.5
4.2
—
20.8
8.3
4.2
25
—
9
3
11
—
1
—
37.5
12.5
45.8
—
4.2
22
1
1
91.6
4.2
4.2
(Continues)
Vol 35, Winter 2009
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STAFF STRATEGIES FOR HIV DETECTION
TABLE 1. (Continued ) . Staff, Client, and Mobile Testing Unit Characteristics
Characteristics
N
%
Behavioral risk group (BRG)
Men who have sex with men (MSM)
Men who have sex with men and women (MSM/W)
MSM/intravenous drug user(IDU)
IDU
Women at sexual risk (WSR)
Transgender
Other
14
6
1
1
—
1
1
58.2
25
4.2
4.2
—
4.2
4.2
Mean
76.9
1377
1.99
78.4
70.3
Std. Dev.
Min.
Max.
842
0.73
14.7
15.7
492
0.95
56.3
48.9
2740
3.17
99.6
100
Mobile Testing Units (as of 9/18/03)
Percent with Rapid Testing
Total HIV Tests (N 12 MTUs)
Percent of Positive Tests (N 11 MTUs)
Percent of Tests Given (N 9 MTUs)
Percent of Pos.Test Results Given (N 9 MTUs)
*
Includes “refuse to answer.”
Note. Staff M age 40.3 y, SD 11.3 y; M years at organization 4.9, SD 5.02. For clients—negative test results, M age 32 y, SD 12 y.
For clients—positive test results, M age 33.7 y, SD 10.2 y.
preliminary and, following CDC recommendations, positive
(reactive) results must be confirmed by an HIV Western
blot. Some MTU staff stated that it was not necessary to
give clients any instructions regarding picking up their
preliminary test results. Instead, they kept the clients occupied talking about HIV prevention and/or the clients’ risk
behaviors during the waiting period. In contrast, other staff
opted to not keep the clients with them during this waiting
period. (If the MTU testing site was busy, staff needed to
see other clients in the interim.) In this circumstance, they
instructed rapid testers to wait outside. Staff provided further instructions to clients who tested positive for HIV at
the preliminary stage. Workers instructed these persons that
they needed to undergo confirmatory testing. The methods
used to set up a time to return for the confirmatory results
varied. Some respondents set an actual date and time for
the client to return, while others offered clients a choice of
locations to pick up their confirmatory results. One respondent emphasized “whatever [location] is easier for the
client.” The time period between undergoing the confirmatory testing and returning to receive results ranged from 1
to 2 weeks.
Some staff did not set a specific appointment for clients to
return for their confirmatory results. Instead, they instructed
clients to call the MTU to make arrangements. In several
instances, clients failed to follow up in this manner. One
respondent reported:
106
[The client] got initial OraQuick test then and there, but
[client] had to come back in a week to get the confirmatory
results. . . .Client was instructed to call in a week to make
arrangements. Client did not do so, so [we] had to chase him
down.
Encouraging Clients to Return for HIV Test Results
Conventional HIV Testing
Respondents stated that they offered 2 main types of
encouragement to both anonymous and confidential conventional testers regarding returning for their HIV test
results: verbal and tangible. Of the 26 respondents who
discussed encouragement strategies during their interviews,
9 mentioned strategies for encouraging clients to return for
conventional results. Four respondents specifically mentioned using verbal encouragement that took several forms.
Some staff emphasized the importance of knowing one’s
HIV status for health reasons. One respondent explained
that he had told a previous client, “It’s important . . . to
get a form with status so he can get treatment.” Another
respondent told the client “it was very important for his
health.” Other respondents verbally encouraged clients to
return by pointing out the futility of testing without receiving results.
Staff members also offered tangible incentives to clients
to encourage them to return for their HIV test results. The
Behavioral Medicine
GRUSKY ET AL
FIGURE 1. MTU Testing Locations (Rapid and Nonrapid) and AIDS rates, Los Angeles County, 2003.
Sources: AIDS rate data for Los Angeles County is from LA County Department of Public Health’s Semi-Annual Surveillance Summary, July 2005; Los Angeles County Census Tract Shapefile and city boundary files are from the US Census 2000 Tiger/Line Data
downloaded from Environmental Systems Research Institute.
Vol 35, Winter 2009
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STAFF STRATEGIES FOR HIV DETECTION
FIGURE 2. MTU Testing Locations (Rapid and Nonrapid) and High AIDS Rate Areas, Los Angeles County, 2003.
Sources: AIDS rate data for Los Angeles County by city/area is from Los Angeles County Department of Public Health’s SemiAnnual Surveillance Summary, July, 2005; Los Angeles County Census Tract Shapefile and city boundary files are from the Census
2000 Tiger/Line Data downloaded from Environmental Systems Research Institute; Bus line data are from Los Angeles County
Metro GIS Data Project (http://developer.metro.net/ Accessed 12/2/2007).
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Behavioral Medicine
GRUSKY ET AL
specific incentives mentioned included $5.00 vouchers
for area businesses and bathhouse passes. For confidential testers, staff members offered the tangible incentive
of a piece of paper with the client’s name and negative
result. One respondent said: “Told her she needs results
and could show partners she tested negative.” This incentive was not available to anonymous testers, who were
told that they would not receive a personalized copy of
their results.
Rapid HIV Testing
Respondents stated that no encouragement was needed
for rapid testers to return for their preliminary test results.
In many cases, staff remained with the clients while the
results were being processed, thereby eliminating the likelihood of clients leaving before receiving their preliminary
results. However, as previously noted, in some cases, staff
instructed clients to wait outside while results were being
processed. In these cases, the respondents still believed no
encouragement was necessary for clients to return because,
as 1 respondent noted, “people don’t usually leave.”
Regarding providing encouragement to clients who
received a preliminary positive reading to return for confirmatory results, MTU workers stated that no encouragement,
either verbal or concrete and incentive-based was given for
returning.
Overall, 14 respondents discussed using strategies for
encouraging clients to return for confirmatory results after
initially testing HIV-positive following a rapid test. Of
these, 6 staff members mentioned using tangible incentives
and 2 mentioned using both verbal and tangible incentives.
Respondents noted that in some cases, clients really wanted
or needed to know their confirmatory results. Hence, they
did not require encouragement to return. Respondents
explained that they verbally encouraged clients to return
for their confirmatory test results by explaining all the
benefits of receiving such results, including (1) eliminating
the psychological uncertainty that a preliminary positive
result induced; (2) facilitating a linkage to medical care/
social services; and 3) taking responsibility for one’s own
health by being proactive. The following responses are
illustrative:
• “Best thing to do is to come back. Don’t be so paranoid.
Only way to know is to come back.”
• “We could get her involved in clinic services; she would
need blood work done, t-cell count, viral load, etc.”
• “Client is sleeping on the streets. Told him if he is HIVpositive he could get emergency housing through this
agency.”
Vol 35, Winter 2009
• “Told him he had a responsibility. It was his life. [He]
needed to be proactive. If you care about yourself, need
to come back.”
Finally, some respondents mentioned that they used
tangible incentives to encourage clients to return for their
confirmatory test results. The type of incentives mentioned
included tickets to local entertainment and vouchers for fast
food restaurants.
Following up with FTR Clients
Conventional HIV Testing
Whether or not and how the MTU staff followed up with
FTR clients who had received a conventional HIV test depended on whether the client tested anonymously or confidentially.
Regarding anonymous clients, the most common theme of
responses was that nothing could be done to get in touch
with them. One respondent explained: “Anonymous person,
we cannot follow up, [because we have] no information.”
However, some staff did find creative ways to follow up. One
respondent stated that she gave such clients a card with the
testing site’s name and phone number. The idea was that if
MTU staff could not call the client, maybe the client would
call the MTU staff.
In regard to confidential FTR clients, respondents stated
that they attempted to contact these persons via some
combination/schedule of phone calls, mailings (eg, letters/
postcards), e-mail messages, in-person visits, and “looking”
for such “no-shows” at testing venues. The exact combination of these methods, as well as the schedule of their use,
varied. A respondent said: “We follow a 3 phone-call protocol and if no response, [send] a postcard.” Another test
counselor stated that staff members “make weekly phone
calls indefinitely.” Other respondents explained their site’s
policy: “Use [the] phone” and “[make] visits…72 hours
after call.”
Rapid Testing
Rapid tests eliminated the FTR problem for seronegative
clients. The significant exception was the case of those persons who received a preliminary positive result. In this case,
respondents used the same methods described previously
for conventional tests, depending on whether the client was
tested anonymously or confidentially.
Some respondents stated that they tried to “convert”
anonymous HIV-positive clients to confidential testing.
Respondents’ beliefs regarding how successful “conversion” was varied widely, ranging from 50% to 90% (meaning that they reported they were able to convince between
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STAFF STRATEGIES FOR HIV DETECTION
50% and 90% of positive anonymous testers to become
confidential testers). Respondents stated that they stressed
the advantages of confidential testing to HIV-positive
clients, such as earlier access to treatment/services, support
regarding follow up, and reminder calls for confirmatory
results. One respondent explained:
We try to convert them to be a confidential client. We
encourage them that it can expedite treatment and we can
encourage them to follow up with treatments. Conversion is
often successful. Fifty percent conversion from anonymous
to confidential.
When clients refused to be “converted,” several respondents explained that they used various “unofficial” means
to keep in touch. One respondent explained that he tried
to get anonymous HIV-positive clients’ names and phone
numbers, just for himself: “I try to get their name and their
number—if they’re testing anonymously, at the time of
disclosure, I’ll try to get [that] information for myself, to
contact them later, if they don’t want to convert.” Another
respondent explained that he gives HIV-positive clients his
name and direct phone number:
If they don’t want to convert … [I say,] “I want to see how
you’re doing. If you have questions, you can contact me.”
A lot of them are worried about the criminal justice system,
immigration, if they’re people who don’t have any papers.
They can . . . call and ask for me.
COMMENT
This study investigated strategic choices MTU staff made
that presumably influenced the performance of their mobile
HIV testing sites. Results indicated that both testing locations and MTUs offering rapid and conventional testing
were concentrated near areas with the highest AIDS rates
in 2003. Hence, the spatial data and data on client behavioral risk groups suggest that, consistent with CDC policy,
MTUs effectively targeted areas where clients at elevated
risk for contracting HIV were located. The data also suggest
that the MTUs successfully recruited Hispanic and African
American front-line staff.
Regarding HIV staff cognitive behavioral strategies, our
study found that there was no one standard way of instructing or encouraging clients to receive their results or following up with those persons who failed to do so. Variations
in these themes existed at many levels, including organizational (eg, site policies about following up with phone calls
vs postcards, returning for results in 1 week vs 2) and individual (eg, only some counselors gave clients their name
and phone number if clients refused to provide theirs).
Variation also probably occurred because of different test-
110
ing technologies (rapid vs conventional tests) and client
choices for privacy (anonymous vs confidential tests).
Several strategies seemed to help the FTR problem at
MTUs that provided rapid testing. First, when HIV test
counselors chose to keep clients with them while their test
results were being processed, clients had no opportunity to
leave before receiving their results. In contrast, if clients
were told to wait outside, they had an opportunity to leave
before getting their results. Next, setting specific dates,
times, and locations while trying to offer limited choices to
suit clients’ schedules, rather than relying on clients to telephone and make appointments to pick up results seemed to
ease the FTR problem. Making an appointment may be too
challenging for some persons who are emotionally upset
from receiving a preliminary positive test result. Finally,
regarding those clients who preliminarily test positive,
when staff convince such clients to convert to confidential
testing, staff are able to obtain the information needed to
contact these persons, should they FTR. When staff are
unable to convert such clients, they have few follow-up
options. An approach to the FTR issue that proposes changing the national rapid HIV testing algorithm so that an HIV
diagnosis is based on the results of 2 matching rapid tests
has recently been proposed.17 This method would permit
prompt feedback to patients regarding their HIV status and
could greatly reduce the loss to follow-up of those persons
who are seropositive.
MTU workers used verbal as well as tangible methods of
encouragement to urge clients to return for their test results
at both rapid- and conventional-style testing. sites At issue
are ethical concerns regarding: (1) how much pressure or
encouragement is appropriate for providers to use in their
attempts to convert anonymous testers to confidential testing and (2) their use of unofficial means to keep in touch.
Future studies should also systematically investigate which
strategies are most effective for particular testing conditions
and whether different strategies work best with different
population subgroups.
NOTE
For comments and further information, address correspondence to Dr. Oscar Grusky, Department of Sociology, University
of California, 264 Haines Hall, Los Angeles, CA 90095-1551
(e-mail: [email protected]).
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