Why test?

If most cases of HIV are concentrated in urban areas, why should health care providers test people in rural areas for HIV? First, according to the CDC, about 25% of those infected with HIV are not aware of their status. There is no reason to think that this is not also true in rural communities. Second, there is evidence that people in rural settings often seek HIV care later than those in urban areas.[1-3] This prevents them from receiving the benefits of early treatment and care and can lead to their unknowingly infecting others. Third, it is essential for the health department to know when and where new infections occur to take steps to prevent HIV from spreading in rural areas.

Screening for other STDs in rural settings is equally important for three reasons. First, untreated infections such as chlamydia and gonorrhea can lead to long-term health consequences in women including pelvic inflammatory disease, infertility, ectopic pregnancy, and chronic pelvic pain. Consequently, the CDC’s Sexually Transmitted Disease Treatment Guidelines, 2006 recommend annual screening of all asymptomatic sexually active females 25 and younger for chlamydia and screening asymptomatic sexually active women of all ages who are engaging in risk behaviors for gonorrhea. Screening asymptomatic men for chlamydia, gonorrhea, and syphilis is recommended when the sexual history reveals risky behaviors such as concurrent partners, unprotected sex, or male to male sex.[4] Second, early detection and treatment of all STDs is a powerful HIV prevention strategy since having one sexually transmitted infection increases the chance of acquiring HIV infection. And third, the process of STD screening provides an opportunity to identify and modify risk behaviors.

There are many challenges and barriers that increase the difficulty of HIV and other STD screening and testing in rural communities. Health care is far less accessible in rural areas than urban settings. People in rural areas often have to travel long distances for care. Even when health care is accessible, HIV and STD testing may not be offered. Provider-reported barriers include cost, lack of time, lack of skills, a belief that HIV or STD infection is not a rural priority, and for some, a reluctance to discuss HIV/STD and sexual or injection drug use risk behaviors. [5,6]

Other factors discourage rural residents from getting tested even when testing is available. Some individuals may not believe they are at risk. They may be embarrassed or afraid that others will find out about their risky behaviors or are afraid to learn that they are infected. They may be worried that treatment and care would not be available, that they could not pay for it, or that they could loose a job or loved one. All of these concerns can be very real, especially concerns about privacy. The overlapping social networks in small towns can make it difficult to get tested and receive results confidentially. For example, the clinic clerk may be a relative, family friend or member of the client’s faith community. In addition there is a real threat of being recognized going into a certain clinic at a certain time or of even having your car parked there on the “STD clinic afternoon.” [5,6]

HIV Testing Options – Routine and Targeted Testing

The 2006 Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings recommend that HIV screening be part of routine clinical care in health care settings with an option for patients to opt out of voluntary participation. This shift in policy from targeted testing coupled with pre and post-test counseling is intended not only to identify those who are unaware that they are infected but also to reduce the stigma associated with getting tested. However, this recommendation may not apply to some rural communities because the CDC does not recommend routine HIV testing in settings with patient populations that have less than 1 person infected out of 1,000 who are tested.[7]

Determining how to respond to the routine testing recommendations in rural areas is not always straightforward. Response will vary depending on local data on HIV/AIDS, syphilis, other STDs, and diseases such as tuberculosis (TB) that may accompany HIV. Rural health care settings must judge whether they can expect 1 positive HIV test among 1,000. The lack of evidence of HIV, syphilis, or TB in a geographic area may point to a plan to continue with targeted testing and periodically review data for any changes. In rural areas that have a few identified cases of HIV/AIDS, new cases of syphilis, or a moderate or high prevalence of TB, it may be reasonable to initiate routine screening at the area’s referral health care facility to determine whether routine HIV testing is warranted. In a rural area, such as the rural South, where HIV/AIDS incidence is on the rise, routine testing in referral health care facilities should be initiated to determine the local positivity rate. When routine HIV testing was implemented in response to the 2006 Revised Recommendations to determine the positivity rate in six mostly rural community health centers in North Carolina, all but one exceeded the 1 in 1,000 threshold.

Even when prevalence is too low to prompt or continue a routine testing program in a rural healthcare setting, the recommendations do advocate HIV testing for certain patients including anyone seeking treatment for an STD, diagnosed with TB, or receiving routine prenatal care. In addition, testing targeted to those with identified risk behaviors continues to be recommended for low prevalence rural populations. Statutes and regulations governing routine and targeted testing vary from state to state. More information on state policies that impact HIV screening are summarized in the NASTAD publication, 2007 Report on Findings from an Assessment of Health Department Efforts to Implement HIV Screening in Health Care Settings. [8]

Which HIV Test to Use

The choice of HIV test depends on factors including laboratory requirements, how easy the test is to administer, how accurate it is, and how much it costs. Often, state health department policy dictates which test will be used. The state health department HIV division and state laboratory are excellent sources of additional information about testing. In turn, NASTAD publications offer guidance to state health departments to help them develop testing policies.[8, 9]

Most HIV tests look for the presence of HIV antibody, which usually appears within weeks of infection but can take up to three months to develop after exposure to the virus. Once present, the antibody remains and can be detected in blood (serum and plasma) and in oral fluid (oral mucosa transudate which is different from saliva). Despite a possible delay in the development of HIV antibody levels of several weeks, testing for HIV within weeks of exposure is recommended to ensure the earliest possible detection and treatment of HIV as well as other STDs. The traditional EIA (enzyme immunoassay) tests for the presence of HIV antibody in a sample of blood or oral fluid and must be processed in a lab. The test is relatively inexpensive and may be offered for no charge by some state health department labs. Drawbacks to the EIA for rural testing include the need for a trained person to draw the blood and the one to two week delay in getting results back. This delay can be a problem since many rural clients cannot readily return for test results or may change their mind about learning their status during the wait. On the other hand, this waiting period gives rural providers time to organize treatment referrals and assemble a support network if there is a positive test result. Telephone notification of negative results may be an option for rural settings, especially for clients who are not engaged in ongoing high-risk behaviors such as injection drug use or unprotected sex.[10]

There is a trend toward using rapid HIV tests that provide results in 30 minutes or less, are minimally invasive, and can be done in the field. These tests can be performed using oral fluid, whole blood (can be from a finger stick), serum, or plasma. Although a blood draw is not required, adequate training is still essential to ensure accurate results by following precise procedures for storing and transporting test kits, conducting control tests, correctly performing the test, and interpreting the results. Unlike at-home pregnancy tests that are clearly positive or negative, rapid test results are more subtle and reading them accurately requires a good light source and some experience on the part of the tester. Rapid oral tests can be confusing to clients who erroneously think that it is the saliva being tested. It is important to explain that the test is for HIV antibodies (not the virus) found in the oral fluid obtained from the gums and cheeks of the mouth. In contrast, saliva is excreted into the mouth by the salivary glands and contains insufficient amounts of HIV antibody to test for HIV infection.

Another concern is whether the results from rapid testing are as valid as those for conventional EIA. Clinical studies show rapid tests are as valid as EIA tests to identify HIV antibody in true HIV cases and the lack of any HIV antibody for true negative cases. There is a probability of getting from two to five false positives for every 1000 tests administered, depending on the particular brand of rapid test used. False negatives can also occur. False positives from rapid tests may be minimized slightly by testing blood from a finger stick rather than using the oral fluid swab but they cannot be eliminated with any HIV test. Indeed, all reactive (preliminary positive) results from a rapid test must have a secondary confirming test. Counseling from the health care provider or other trained counselor can be important to minimize the negative impact of a false positive test result on the individual and on the community.

Who Should Be Tested for STDs?

Understanding who should be tested or screened for which STD and how frequently can be complicated. Some groups require routine screening such as sexually active asymptomatic women aged 25 or younger being screened annually for chlamydia and pregnant women being screened for chlamydia, syphilis, and hepatitis B. Similarly, MSM who have had unprotected sex with a casual partner require annual screening for chlamydia, gonorrhea, and syphilis. Conducting a thorough sexual history that asks about specific sexual behaviors, the gender and risk behaviors of partners, and correct use of condoms is essential to decide when to test for STDs such as gonorrhea or when to repeat a test more often than once a year. Early diagnosis and treatment of chlamydia, gonorrhea, syphilis, and HIV prevents potentially serious health consequences and further transmission of the infection. Vaccinating for hepatitis A and B and human papillomavirus (HPV) can reduce morbidity as well. Click here for CDC's recommendations on STD testing and vaccination.

Who Should Do HIV and STD Testing and Where?

In many rural communities, there are not enough health care providers to conduct HIV/STD testing. From the health care provider’s perspective, barriers to testing include lack of time, discomfort with the topic, and inadequate or outdated skills. State health departments, AIDS Education and Training Centers, and regional STD/HIV Prevention Training Centers can help reduce these barriers by training clinicians and non-traditional community helpers in risk assessment, HIV testing, STD screening, and risk-reduction counseling. CDC recommendations in 2006 that remove the requirement for counseling as part of routine testing in health care settings may also reduce provider barriers.

Although HIV/STD testing sites can vary from community to community depending on their resources and needs, traditional testing sites generally include medical care sites with clinical professionals doing the testing. Counseling may or may not be offered for routine HIV screening prior to surgery, childbirth, or emergency treatment, depending on state law and institutional policies. However, counseling should be provided to everyone who receives a positive or preliminary positive test result.

The advent of non-invasive testing procedures enables HIV/STD testing in rural areas to expand beyond traditional health care providers and traditional testing sites. Before embarking on a non-traditional HIV/STD testing program, though, it is wise to check applicable state laws that may limit who can conduct HIV testing (National HIV/AIDS Clinicians’ Consultation Center). Where state law allows, rapid HIV tests enable well-trained non-licensed individuals to take testing and counseling to those who are at heightened risk for infection. Chlamydia and gonorrhea screenings are easy to do by simply collecting a urine specimen, making it feasible to screen for these common STDs during annual exams and in conjunction with rapid HIV testing in non-traditional settings.

Although rapid HIV test results are available in 30 minutes or less, chlamydia and gonorrhea test results from nucleic acid amplification technology (NAAT) are not available for several days. When rapid HIV and NAAT tests are performed at the same time, a plan is needed for getting results and treatment, if needed, to those screened.

Another concern is that testing for primary and secondary syphilis requires a sample of blood drawn from a vein, making it more difficult to test for syphilis using non-traditional testers and outreach sites. In some states, disease intervention specialists (DIS) collaborate with rural testing programs to draw blood for syphilis, HIV, and other STD testing while conducting field epidemiology to identify potentially exposed sexual partners.

Ensuring that professional and non-traditional testers are adequately trained in testing, counseling, and referral can be challenging in rural settings. The time and cost of travelling to urban training sites may stop rural providers from getting training, especially training on HIV/STD prevention practices that may not seem that urgent in a rural area. Rural providers or non-traditional testers may not be able to leave their jobs for training if they have no back-up coverage. As a result, HIV/STD testing and counseling training may need to go to providers and non-traditional testers. Providing training locally may motivate rural providers to attend and simultaneously help to normalize HIV/STD testing within the local provider network. Distance learning technology such as Internet video seminars can be an option to augment face-to-face training in a cost-effective and acceptable way.

Expanding testing to non-traditional sites can work in rural settings but may require innovative approaches. Testing in non-traditional sites requires clarification of who is at risk for HIV/STD, identification of places where those at risk congregate, consideration of community and target audience values, ways to protect confidentiality, and available resources. State laws and health department policies may govern who may do what, in what venues, with what funds, and with what outcomes in mind. If the goal is to detect cases of HIV or STDs, targeted testing events and outreach may be a wise use of resources. Community-wide events, on the other hand, may be better for increasing HIV/STD awareness. Combining HIV rapid testing with urine-based NAAT testing for chlamydia and gonorrhea may also be a good rural strategy.

Special events are useful to increase public awareness of HIV/STD risks and sites where they and their partners can get tested and treated. Special events are often part of a larger community event, which can help decrease stigma and cost of marketing the event. Rapid HIV testing and urine-based STD testing can be offered and may be less stigmatized when other health screening is being provided as well. However, testing at community events requires planning to decide how to deal with those who wish to be tested despite having low risk and how to deliver results of urine-based STD tests. Trained volunteers can act as community educators and may conduct HIV/STD testing and counseling if allowed by state law.

Targeted Outreach Testing Programs identify specific at-risk groups and try to take prevention education and testing to those groups at places where they naturally gather. The following are examples of non-traditional rural HIV/STD outreach testing programs currently being implemented.

Targeted Outreach - Men Who Have Sex with Men

Adult Bookstore
Outreach worker in popular adult bookstore offers educational materials and confidential rapid HIV testing and counseling. Being on-site frequently increases trust to promote interaction between customers and the outreach worker.

Public Sex Venues
Outreach workers take education and confidential HIV testing to known public environments where men meet male sexual partners. These locations are often advertised on the Internet. Outreach workers should partner for safety. Information on how to assess whether sexual activity in public places should be targeted for intervention is available at www.popcenter.org/problems/illicit_sex/1.

Targeted Outreach - Substance Users

A health educator trained in HIV testing and counseling rides a 600 mile circuit through the mountains and plains in rural Colorado to provide HIV education and free, confidential HIV testing. The program reaches people in substance abuse treatment, court mandated programs for driving under the influence or domestic violence, and those attending a monthly free testing evening in a resort community with many immigrant workers. The circuit rider goes to homes to deliver positive results in person.

Targeted Outreach - Latinos/as

Promotores de Salud
This approach uses natural helpers or “promotores” from the community to provide HIV/STD testing, prevention education, and condom distribution to migrant workers. Promotores talk with workers, offer testing, and provide opportunities to try different styles of condoms. Promotores talk to farm workers where they gather or they get permission from supervisors to talk with workers during short breaks in the fields. Promotores take along trained HIV testers after the initial contact to offer oral fluid collection on the spot. Some programs collect urine specimens for NAAT at the same time. The promotores and testing and counseling team return together to give results. They also educate and test female sex workers living near the male worker camps. [11, 12]

US-Mexico Border Truck Stop Outreach
At border truck stops, Spanish speaking outreach workers reach people in transit by approaching them at truck stops and border crossings where people are waiting for long periods. This provides opportunities to talk at length or conduct rapid testing and counseling.12

House Parties
House parties are a way to engage Latinas in conversations about HIV and other STDs in a safe and comfortable setting and offer them confidential testing for HIV, chlamydia and gonorrhea. A public health professional and promotora join together to present information and facilitate discussion. House parties are bilingual or in Spanish depending on the group of women gathered. [12]

Migrant Workers
In Kentucky, HIV testing strategies extend far beyond the mandated provision of testing and counseling in each of the 120 local health departments, most of which are rural. Kentucky Cabinet of Health and Family Services contracts with community-based organizations and local health departments to literally take testing “into the field” meaning fields of tobacco, corn, soybeans, and other common crops. Rapid testing is most often used so results can be provided in the same session, eliminating the need for the client to come back for results.

Targeted Outreach - Incarcerated Males

Testing individuals serving time in prison or jail for HIV and other STDs is ideally done on admission and discharge. Inmates receive HIV/STD education and are treated for STDs. HIV-infected inmates receive case management and discharge planning such as providing transportation assistance for the first doctor’s visit after release. In rural areas, jail programs have been directed by DIS, local public health nurses, or correctional facility staff. This outreach effort requires developing a solid working relationship with prison officials who may be reluctant to identify new cases, pay for care, and address inmate sexual activity. Practices developed in more urban institutions have been implemented in rural jails and detention centers. Model programs for HIV/STD prevention in prisons are described online at www.nmac.org/index/prison-initiative and www.caps.ucsf.edu/projects/Centerforce/.

Targeted Outreach - Long-Haul Truckers

There are 3.2 million over the road truckers in the US and 1.4 million are long haul drivers covering the 48 states and Canada. A project in Spokane, Washington, found that 88% of truckers would participate in confidential rapid HIV testing at truck stops, weigh stations, or rest stops. The report identifies the risk behaviors that put truckers at risk for HIV/STD, the specific ways truckers would want to know about testing sites, and how they want to receive follow-up test results. This report is available online at www.srhd.org/documents/PublicHealthData/TruckerHealthReport.pdf.

Targeted Outreach - American Indian Youth

Circle of Health is a culturally appropriate HIV, STD, and substance abuse prevention education and testing program tailored for American Indiana/Alaska Native youth attending tribal colleges in Montana. HAWK (Honoring Ancient Wisdom and Knowledge) is a California program in which trained Native Peer Advocates deliver education and risk prevention awareness to teens in the community through information booths, small group workshops and event presentations at Pow-Wows. HAWK advisor provides HIV/STD education and testing materials in the local jail.

Targeted Outreach - Workplace

This community-level intervention has been implemented successfully in food processing plants to bring HIV/STD education, free HIV and other STD testing, and medical services to large groups of workers in the community. After getting support from plant management, a 2-person outreach team schedules HIV educational presentations at all orientation sessions for new workers and at quarterly sessions with a question and answer table set up for several hours during each shift. Having the same outreach workers over time increases rapport and trust so that workers feel increasingly comfortable asking questions. This program has been successful using bilingual/bicultural outreach workers in plants with a large proportion of Spanish-speaking migrant workers. HIV testing has increased 100% for agencies that have initiated this program. One challenge is getting worksite management to support HIV/STD prevention education and to acknowledge that HIV exists in the community.

Removing Individual Barriers to Testing

Perhaps the most significant barriers to HIV/STD testing are from the individual’s perspective. Barriers include lack of perceived risk; fear of adverse emotional, social, and physical consequences; concerns about access to treatment and support; confidentiality concerns; and cost. These individual level concerns are much more difficult to address than provider concerns. This is particularly true in rural communities where access to affordable and confidential care is a real issue and disclosure of HIV status could have disastrous consequences to the individual and his or her family.

However, individual level barriers to testing can be addressed in a number of ways, including strategies involving the community. Community level educational efforts can address the value and need for testing (see Chapter 3 for examples). These efforts need to address the availability of treatment and care services for those who test positive (see Chapter 6). Health care facilities can improve confidentiality and reduce stigma by following some of the suggestions outlined in the document Fighting Stigma and Denial, distributed by the National Rural Health Association (NRHA).[5] Providing testing at locations that are not easily identifiable as HIV testing sites may be one of the most practical suggestions. For example, a community center, WIC center, counseling center, faith-based organization, bar, college dormitory, truck stop, park, adult bookstore all would provide locations and that do not necessarily disclose one’s HIV/STD status. Planning for reliable and confidential ways to get information to individuals who have tested positive will enable people to begin care as early as possible. This is important since many rural people go outside their community where they are not known to receive more confidential testing. Unfortunately, there are no comprehensive solutions that will motivate every individual at increased risk to seek testing or to relieve their concerns about testing issues.

Adapted from Vermund and Wilson (2002) [13]

A final but important individual barrier to testing is cost and access to health care. System level barriers such as access to care and cost are very difficult to address. However, there are some approaches that communities have used to increase access to care and funding for testing which may be suitable for a variety of other communities. Some rural areas that do not have enough HIV/AIDS cases to qualify for state or federal funding programs have joined together to create a consortium to buy HIV testing supplies and seek consortia funding. Other rural areas with few HIV+ cases rely on DIS from the state health department to test partners of those known to be infected. As of late 2007, Medicaid law permits coverage of routine HIV screening as an option if a state opts to include it. Medicare does not cover HIV testing unless medically indicated for symptoms suggesting HIV infection. To date, Ryan White CARE Act funding can fund HIV testing for population-based screening although screening funded by this act has been minimal and has largely been conducted in urban areas. [14]

Counseling and Testing Issues

There has been some confusion over how the 2006 CDC revised recommendations for routine opt-out HIV testing in health care settings pertain to rural settings. The revisions allow routine HIV testing in health care settings to occur without the previously recommended pre and post-test prevention counseling. Removing the counseling requirement is intended to increase the number of tests conducted in health care settings such as emergency departments where traditional prevention counseling is perceived as a barrier.[7] Post-test counseling for those identified as HIV positive is still indicated in all circumstances. Eliminating prevention counseling is not intended to apply to community-based non-health care testing and is an option not a mandate for health care settings. Some rural providers consider HIV testing as a “teachable moment” to discuss risk reduction. However, evidence suggests that a reduction in frequency of unprotected sex occurs after a positive HIV test result, not a negative test result.[15] On the other hand, there is evidence that brief messages from a physician can change risk behaviors such as tobacco use. Knowing this, rural communities may want to focus on increasing the frequency of sexual health risk assessment in medical and mental health settings to create teachable moments that would serve a broader population and possibly intervene earlier in the primary prevention process. All individuals at heightened risk of infection should be provided with or referred to HIV risk-reduction services such as drug treatment, STD treatment, and/or behavior change counseling.

Summary

Rural communities should use public health recommendations and local data to guide development of a community-tailored HIV and STD screening and testing plan that provides ongoing surveillance through routine and targeted testing using traditional and non-traditional venues and testers. Testing plans should reflect the HIV and STD epidemiology, values, available resources, identified high-risk groups, and confidentiality concerns of the community. The planning process can create community acceptance regarding the implementation of the testing and screening plan from community leaders, health professionals, advocates (e.g., advocates for migrant workers), men and women revered in the community, leaders in the faith community, and other interested and pivotal community members. Although testing appears to only involve individuals, in reality it does take the entire community to support the need for testing through anti-stigma campaigns. With community support in place, HIV testing can detect previously unidentified cases, and those individuals can begin care as soon as possible to ensure the best individual and community outcomes.

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