摘要：Objectives. We examined the efforts of the US network of AIDS Education and Training Centers (AETCs) to increase HIV testing capacity across a variety of clinical settings. Methods. We used quantitative process data from 8 regional AETCs for July 1, 2008, to June 30, 2009, and qualitative program descriptions to demonstrate how AETC education helped providers integrate HIV testing into routine clinical care with the goals of early diagnosis and treatment. Results. Compared with other AETC training, HIV testing training was longer and used a broader variety of strategies to educate more providers per training. During education, providers were able to understand their primary care responsibility to address public health concerns through HIV testing. Conclusions. AETC efforts illustrate how integration of the principles of primary care and public health can be promoted through professional training. In 2006, the Centers for Disease Control and Prevention (CDC) published revised recommendations for HIV testing that encouraged routine, voluntary, and opt-out testing for all individuals aged 13 to 64 years regardless of perceived HIV risk. 1,2 Supporting the recommendations were estimates that 21% of HIV-infected people in the country are unaware of being infected, 3 the need for infected people to receive care as early as possible, 4,5 and the sexual transmission prevention benefits of timely HIV diagnosis. 6 HIV testing benefits the individual patient by providing an opportunity to enter care, receive antiretroviral therapy, and reach therapeutic goals of an undetectable viral load and functional CD4+ T cell count levels. HIV testing also benefits public health because individuals who know they are infected are less likely to engage in transmission risk behaviors and are more likely to achieve lower viral load levels, decreasing transmission potentials and leading to fewer new infections. 7 Despite the release of the 2006 testing recommendations, however, the CDC has reported that an estimated 55% of adults in the United States have never been tested and that 32% of HIV diagnoses still occur late in the disease process, when treatment is more complicated, less effective, and more expensive. 8 Expanding testing to primary care settings, where a greater proportion of the population is likely to be seen, allows these sites to better support the public health response to HIV. The major primary care contributions to this effort should include earlier HIV diagnosis, improved linkage to care, and reduced transmission of HIV infection. We have presented the first, to our knowledge, overview of the HIV testing education, training, and technical assistance that the federally funded AIDS Education and Training Centers (AETCs) program provided between September 1, 2008, and August 31, 2009—a period during which the CDC offered supplemental funding to accelerate the integration of the public health practice of HIV testing into primary care settings in light of the 2006 guidelines. We have presented data on the characteristics of training and technical assistance focused on integrating HIV testing into primary care settings relative to AETC efforts not focused on testing. We also used case studies from AETC regions to illustrate organizational- and system-level changes that support the ability of individual clinicians to provide HIV testing in primary care clinics, labor and delivery departments, and emergency departments. The importance of primary care and the need for it to be fully integrated into community and public health systems were codified at the International Conference on Primary Health Care at Alma-Ata in the former Soviet Union in 1978. The conference, sponsored by the World Health Organization, resulted in the “Alma-Ata Declaration,” a landmark document that explored health care disparities, the need for universal health care, and the critical role of primary care in the process. 9 More than 30 years after the release of the declaration, nations, communities, and individual health care providers are still struggling to develop integrated systems to achieve the goal of health for all. In the United States, the complex nature of care systems and lack of capacity to rapidly recognize community health risks, incorporate proactive responses, and establish the fiscal infrastructure to support a response have hampered progress toward this goal. 10 Grumbach and Mold 11 have suggested that an approach to help integrate the very different primary and community care systems in the United States would be to develop a health care cooperative extension service derived from the agricultural model that transformed American farming in the last century. They advocated extension agents, linked to academic centers, that would disseminate information about evidence-based practices, develop collaborations, and enhance the speed at which health care innovations would be adopted in rural and hard-to-reach areas. Fortunately, numerous programs designed to do just this are already in existence, including the AETC program, which is part of the federal Ryan White HIV/AIDS Treatment Extension Act, 12 a unique program that improves the availability of care for low-income, uninsured, and underinsured people with HIV infection and their families by supporting a comprehensive set of services from HIV primary care to professional education and workforce development support. The AETCs were established in 1987 when the Health Resources and Services Administration funded 5 regional centers to provide education about HIV infection to health care providers. In 1988, additional regional centers were added to the program to cover all 50 states, the District of Columbia, the US Virgin Islands, Puerto Rico, and the Pacific Jurisdictions. 13 By 2011, the program had expanded to 11 regional AETCs, which are housed in academic health institutions and supported by 5 national AETCs and 1 international center. The regional AETCs coordinate education and consultation services through more than 130 local performance sites that provide community-based needs assessments and timely delivery of cutting-edge training and technical assistance to health professionals. The AETC mission is to increase the number of health care professionals in the US workforce who are qualified and willing to offer effective HIV prevention and treatment services to individuals and communities. Between July 2008 and June 2009, the AETCs and their local performance sites presented more than 50 000 hours of education, consultation, and technical assistance to more than 71 000 health care providers in disparate geographic areas of the country. 13 For more than 25 years, the AETCs have supported efforts to contain the HIV epidemic in the United States by focusing on training initiatives in the areas of HIV prevention, diagnosis and testing, clinical management and treatment, mental health care, substance abuse treatment, and case management, with an emphasis on reducing health care disparities, 14 all of which support the National HIV/AIDS Strategy 15 and contribute to cost savings and improved care values as outlined by the Affordable Care Act. 16 The AETCs have been delivering training about HIV testing since 1987, but the 2006 testing recommendations created a stimulus to more intensively focus on testing and to expand AETC efforts into clinical settings that did not specialize in HIV care, such as community health centers. Since the CDC released the 2006 HIV guidelines, the AETCs have worked to increase awareness of the new recommendations and improve capacity among health professionals working in primary care settings to conduct routine HIV screening. In fact, in 2008, the CDC provided supplemental funding to the AETC program to enhance delivery of intensive, clinic-based education, training, and technical assistance activities to support the integration of HIV testing into primary care settings. AETC efforts have, for example, helped clinics develop policies and procedures for HIV testing, worked with clinics to develop tailored models for routine HIV testing, established quality assurance programs for rapid test interpretation, and taught clinicians to deliver prevention counseling for individuals found to have HIV infection. 17
