HIV, STIs, Viral Hepatitis and LTBI Routine Screening Toolkit for Community Health Centers and Emergency Departments

Every year, millions of Americans are diagnosed with human immunodeficiency virus (HIV), sexually transmitted infections (STIs), viral hepatitis or tuberculosis (TB) and tens of thousands die from their infection. Guideline adherent screening programs can effectively identify these infections creating opportunities for treatment and prevention. Most of these infections share commonalities, from modes of transmission to demographic, social, and economic conditions that increase risk.

These infections can have an asymptomatic stage which may prevent individuals from seeking the testing needed. For example, not everyone infected with TB bacteria becomes sick. As a result, two TB-related conditions exist: latent TB infection (LTBI) and TB disease. Persons unaware of their health status cannot take advantage of the treatment needed to improve their health and can unknowingly transmit the virus to other individuals.

While significant progress has been made in diagnosing and treating individuals with these infections, routine screening and early detection are critical to ensure individuals receive the appropriate treatment and lower the risk of transmission of these infectious diseases.

Community health centers and emergency departments are uniquely positioned to screen for HIV, STIs, viral hepatitis, and LTBI among under-resourced and disproportionately affected populations. Together we can increase screening and reduce the number of new infections, but first we must understand the scale of the problem.

By routine screening, we mean implementation of the Centers for Disease Control and Prevention (CDC) and U.S. Preventive Services Task Force (USPSTF) evidence-based preventive service guidelines and recommendations, including testing patients without symptoms based on patient characteristics or reported behaviors that would indicate screening is recommended. The American Medical Association (AMA), as reflected in policy, supports the adoption and implementation of evidence-based preventive screening guidelines.

To implement an effective routine screening program, there are several critical considerations that need to be understood and addressed to achieve successful routine screening practices.

• Infectious disease testing is often considered separate from routine care. Community health centers serve communities with a variety of health needs. While screenings for blood pressure and cholesterol may be considered routine, screenings for infectious diseases may not. Conducting infectious disease testing separate from regular routine care may reduce the likelihood people receive needed tests.
• Care is often complaint based. When time pressed and being evaluated on patient satisfaction, oftentimes, it is the patient’s most immediate complaints that drive the appointment. Frequently, routine infectious disease screening is not front of mind when a patient comes in unless the complaint is related to symptoms of HIV, STIs, viral hepatitis or LTBI.
• Confusion over what “routine” means prevails. Clinicians often undertake testing only when a patient presents with certain risk factors associated with HIV, STIs, viral hepatitis or LTBI. While these risk factors may be included in routine screening guidelines, oftentimes other people in need of routine screening are overlooked and not all people recommended for routine screening are being tested. In addition, uncertainty or discomfort over how to link persons diagnosed with HIV and other conditions to medical care may discourage clinicians from screening.
• Stigma and fear profoundly affect patients and clinicians. HIV, STIs, viral hepatitis and LTBI carry a stigma, and screening for these conditions comes with a fear of knowing one’s status—particularly with HIV. Clinicians, while aware of this, sometimes need help communicating and working with patients to normalize screening and counseling on results.

This toolkit was developed with input from health care professionals and was designed for clinicians working in both community health centers and emergency departments, with the focus on those practice leaders and champions who are looking to optimize routine screening practices for these infectious diseases.

The toolkit is organized across the screening continuum and offers helpful resources and best practices for both community health centers and emergency departments from the AMA, CDC and other organizations to overcome the considerations outlined above. The resources include a mix of both implementation and training-related materials for the care team. It is flexible, allowing you to follow along throughout the continuum to help improve your overall screening and testing approach or narrow in and focus on a specific stage where you may need additional guidance and support. While not a specific stage, monitoring and evaluation along the screening continuum is critical and performance outcomes should inform continuous quality improvement efforts.

Given the specific populations recommended by CDC and USPSTF for LTBI screening in primary care settings, LTBI screening is not included in the toolkit recommendations for emergency departments. Emergency departments should continue to consider TB disease in patients with risk factors or positive screening and diagnostic evaluations. For emergency departments who have strong active linkage to care systems established to support LTBI treatment, including staff dedicated to following up with the patient and facilitating confirmed linkage to treatment, and serve a patient population for whom LTBI screening is recommended, please refer to the Community Health Center recommendations for LTBI screening and treatment resources.  

1. Community health center toolkit recommendations

   • Step 1: Community outreach

   • Step 2: Patient intake

   • Step 3: Initiating standard screening protocols

   • Step 4: Testing and diagnosis

   • Step 5: Patient education and post-test counseling

   • Step 6: Linkage to care

2. Emergency department toolkit recommendations

   • Step 1: Patient triage

   • Step 2: Initiating standard screening protocols

   • Step 3: Testing and diagnosis

   • Step 4: Patient education and post-test counseling

   • Step 5: Linkage to care

This effort is supported through a cooperative agreement with the Centers for Disease Control and Prevention’s (CDC) National Center for HIV, Viral Hepatitis, STD, and TB Prevention (CDC-RFA-OT18-1802: Strengthening Public Health Systems and Services through National Partnerships to Improve and Protect the Nation’s Health).