摘要：Objectives. We examined patterns of rapid HIV testing in a multistage national random sample of private, nonprofit, urban community clinics and community-based organizations to determine the extent of rapid HIV test availability outside the public health system. Methods. We randomly sampled 12 primary metropolitan statistical areas in 4 regions; 746 sites were randomly sampled across areas and telephoned. Staff at 575 of the sites (78%) were reached, of which 375 were eligible and subsequently interviewed from 2005 to 2006. Results. Seventeen percent of the sites offered rapid HIV tests (22% of clinics, 10% of community-based organizations). In multivariate models, rapid test availability was more likely among community clinics in the South (vs West), clinics in high HIV/AIDS prevalence areas, clinics with on-site laboratories and multiple locations, and clinics that performed other diagnostic tests. Conclusions. Rapid HIV tests were provided infrequently in private, nonprofit, urban community settings. Policies that encourage greater diffusion of rapid testing are needed, especially in community-based organizations and venues with fewer resources and less access to laboratories. The Centers for Disease Control and Prevention’s (CDC’s) 2006 recommendations for HIV testing of adults, adolescents, and pregnant women encouraged routine HIV screening in all public and private health care settings, including nonprofit community health clinics that provide medical care for under-served populations. 1 These recommendations supplemented 2001 CDC guidelines that recommended HIV testing of at-risk individuals in community-based organizations (CBOs; e.g., nonclinical AIDS service organizations) and outreach settings, and superseded 2001 CDC guidelines that recommended HIV testing of at-risk individuals in public and private health care settings. 2 The CDC’s goal is to decrease the number of people in the United States who are unaware of their HIV status (about 25% of infected persons). 3 Awareness of serostatus increases the likelihood that seropositive individuals will reduce transmission risk behaviors and allows HIV test providers to facilitate linkages to medical care. 1 , 4 , 5 Although traditional HIV tests can be used for HIV screening, these tests require that clients return 1 or 2 weeks after the test to receive their results and prevention counseling. Approximately one third of clients do not return for results of traditional HIV tests across settings, with larger proportions not returning in CBOs and outreach settings. 4 , 6 The CDC therefore recommended expansion of the use of single-session rapid HIV tests, which do not require a return visit for results. 1 , 2 Since 2002, 6 rapid HIV tests with high sensitivity (99.3%–100%) and specificity (99.1%–100%) have been approved by the US Food and Drug Administration. 5 , 7 – 12 As of November 2007, 4 rapid tests—OraQuick Advance (Orasure Technologies, Bethlehem, Pa), Uni-Gold Recombigen (Trinity Biotech PLC, Wicklow, Ireland), and Clearview HIV 1/2 STAT-PAK and COMPLETE HIV 1/2 (Chembio Diagnostic Systems, Medford, NY)—were waived for point-of-care use under the Clinical Laboratory Improvement Amendments and can be used by trained staff in nonclinical settings. Rapid HIV tests have advantages over traditional HIV tests in community health settings (including community clinics and CBOs), including high posttest counseling rates, feasibility, cost-effectiveness, and client and staff acceptability. 13 – 22 Rapid tests allow HIV-negative individuals to learn their serostatus 10 to 40 minutes posttest; reactive (“preliminary positive”) rapid test results require confirmatory testing. 23 Rapid tests are ideal for community settings in which clients may not have ongoing relationships with HIV test providers and may be unlikely to return for counseling. The scope of rapid HIV testing in US community health settings outside the public health system, including community clinics and CBOs, is unknown. Researchers have suggested that, although rapid HIV testing is feasible and cost-effective, some barriers may need to be overcome in community settings, including psychological costs to testers (e.g., anxiety resulting from a lack of sufficient preparation time for delivering peliminary positive results), counseling-related costs, and difficulties in linking seropositive individuals into care. 24 , 25 Staff may be apprehensive about the potential for false-positive results and about learning rapid testing procedures. 19 Rapid test protocols require larger blocks of time than traditional tests to perform counseling, conduct testing, document the test, and report results in 1 session. 20 Regulations for HIV testing vary by state 26 ; strict regulatory environments may make CDC recommendations difficult to implement. We examined the scope of rapid HIV testing in the United States from 2003 to 2006 in a multistage national random sample of private, nonprofit, urban community health settings (i.e., community clinics and CBOs). We provide a baseline study of rapid HIV test availability in private community settings before the CDC’s 2006 statement on HIV screening in health care settings (including community clinics), but after the CDC’s 2001 recommendations for CBOs and community clinics. We used the diffusion of innovation theory 27 as a framework to describe the trajectory of rapid HIV testing. According to diffusion of innovation theory, innovations are likely to be adopted to the extent that they appear advantageous over existing methods; are compatible with existing infrastructure, resources, and norms; and are relatively easy to use. Organizations with greater resources and fewer barriers are more likely to adopt innovations. 27 Diffusion is predicted to follow an S-shaped curve that represents the cumulative percentage of adopters divided into 5 chronological categories: rising slowly initially (innovators and early adopters), accelerating steeply until about half of the population has adopted the innovation (early majority), and leveling off as fewer non-adopters are available with whom to share the innovation (late majority and laggards). Following the diffusion of innovation theory, 27 we hypothesized that larger community clinics and CBOs would have greater resources to implement rapid HIV testing, and hence would be more likely to be offering rapid tests. We also hypothesized that community clinics and CBOs located in areas of higher AIDS prevalence, as well as areas with high concentrations of subgroups in which HIV is increasing (i.e., Black, Hispanic, and high-poverty areas) would perceive a greater need for rapid HIV testing and, thus, would be more likely to offer rapid tests. Further, we predicted that HIV test provision would differ by geographic region because of state variations in test regulations.
