摘要：Objectives. We assessed routine HIV testing in Indiana community health centers (CHCs). Methods. CHC medical directors reported HIV services, testing behaviors, barriers, and health center characteristics via survey from April to May 2013. Standard of care testing was measured by the extent to which CHCs complied with national guidelines for routine HIV testing in clinical settings. Results. Most (85.7%) CHCs reported HIV testing, primarily at patient request or if the patient was symptomatic. Routine HIV testing was provided for pregnant women by 60.7% of CHCs. Only 10.7% provided routine testing for adolescents to adults up to age 65 years. Routine testing was reported by 14.3% for gay and bisexual men, although 46.4% of CHCs reported asking patients about sexual orientation. Linkage to care services for HIV-positive patients, counseling for HIV treatment adherence, and partner testing generally was not provided. Conclusions. Most CHCs reported HIV testing, but such testing did not reflect the standard of care, because it depended on patient request or symptoms. One approach in future studies may be to allow respondents to compare current testing with standard of care and then reflect on barriers to and facilitators of adoption and implementation of routine HIV testing. Community health centers (CHCs) have been important providers of primary and preventive care since the late 1960s for communities with uninsured or underinsured patients. 1 The importance of CHCs is heightened for the millions who remain without insurance coverage because of the varied implementation of the Affordable Care Act, because almost half of US states have opted not to expand Medicaid, 2 and because the federal government has delayed the implementation of the employer health insurance mandate until 2015. 3 It has been argued that CHCs are uniquely positioned to provide community-based, nonstigmatized access to specialty services, such as HIV testing. 1,4 Recent HIV testing recommendations by the US Preventive Services Task Force call for routine testing among adolescents and adults in clinical settings, 5 echoing the 2006 Centers for Disease Control and Prevention recommendation. 6 Such recommendations imply that testing services likely will be reimbursed—an important point for resource-constrained environments and a financial incentive to improve practitioner compliance around HIV testing. CHCs themselves have been the target of additional efforts to increase HIV testing to help fulfill the National HIV/AIDS Strategy to reduce new HIV infections. 7–9 Understanding HIV testing in CHCs is important because it is now known that 20% of those living with HIV in the United States do not know their status, 10 and 40% of those who learn it do so within a year of an AIDS diagnosis. 11,12 Delayed HIV testing is particularly acute in rural populations, 13,14 because barriers to testing such as stigma and fear of anonymity loss are more pronounced. 15,16 Publicly funded HIV testing, while helpful to some communities, may not be sufficient to improve early HIV testing in all communities. A recent evaluation of HIV testing sites in a state with moderate HIV incidence found several important problems related to access: 20% of test attempts failed to result in a test, 48% of sites had reported confidentiality issues, and a little fewer than half of the sites received a “no return” rating by test visitors (meaning that those evaluating the test site would not return for an HIV test if they needed one in the future). 17 Given the delays in testing and the troubles experienced in some publicly funded testing sites, a tremendous need exists to understand whether and how routine HIV testing is offered in other public health settings such as CHCs. Despite the emerging federal interest in HIV testing in CHCs and the public health importance of understanding testing in these environments, not much is known about the level of services in CHCs, particularly in areas with moderate HIV incidence and in Midwestern settings. Studies evaluating routine HIV testing in CHCs have focused on patient acceptance of testing 18,19 or on provider testing behavior. 20–23 Implementation studies provided participating CHCs with training and HIV rapid test kits to facilitate participation and success. The most recent studies occurred in urban areas: one among patients in a Houston, Texas, CHC serving a predominantly Hispanic population 21 and the other, the largest of extant studies, comparing the views of clinicians in 31 Boston, Massachusetts, health centers. 23 Notably, the Boston CHCs were rated as high performing in a recent national review of performance and may not reflect the performance of CHCs in other communities. 24 Studies of HIV testing in CHCs have not yet included moderate HIV incidence states or focused on rural and urban areas. These communities tend to have lower levels of HIV prevention and public health investment, which heightens the need for strong HIV testing services in CHCs. The objective of this study was to identify the extent to which CHCs in Indiana implement routine HIV testing. Indiana is a Midwestern, moderate HIV incidence state with low public health investment. In 2014, Indiana ranked 50th in per capita funding from the Health Resources and Services Administration (federal funding source for HIV treatment and also for CHCs) and from the Centers for Disease Control and Prevention (the primary federal funding source for HIV prevention). Indiana ranked 37th for state per capita public health investment. 25
