Public Health

HIV, STIs, Viral Hepatitis and LTBI Routine Screening Toolkit: Community outreach


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

A successful routine screening program begins with outreach strategies rooted in engagement outside the community health center’s walls, forming long-term bonds with the community and delivering educational messages that stick.

  • Health care is not a priority compared to income, housing or food insecurity
  • Distrust of institutional health
  • Lack of awareness in the community about the need for routine screening
  • Lack of knowledge on costs and affordability of screening
  • Shortage of access to sites that provide screening
  • Lack of adequate transportation to clinics
  • Misconceptions about disease transmission
  • Fear of finding out one’s status and the associated stigma in the community
  1. Build strong community partnerships

    1. Building trusted relationships is critical to normalizing routine screening. Establishing a referral program through network of affiliates and community, medical and social service organizations, including those organizations who may already be doing community-based testing, will link more patients to your community health center for screening and care.

    2. Related resources

    • Tool for Tracking Partners and Partnership Activities: Pages 81-88 from the Health Resources and Services Administration’s (HRSA) Integrating HIV Care, Treatment & Prevention Services into Primary Care–A Toolkit for Health Centers guide includes a Partnership Toolkit that provides a comprehensive list of key considerations, steps and templates to help guide your organizations’ community relationship building and tracking.
    • Partnership Mapping Template (PDF): This template provides a framework to help your organization keep track of relationships with non-clinical services and outpatient clinics that will support both community outreach and a sustainable linkage to care program.
    • AMA telementoring session video clip: During this telementoring session focused on building strong community partnerships, Jennifer Brumfield, RN shares how Express Personal Health in Jackson, MS built relationships with other providers to improve patient experiences and outcomes.
  2. Increase local and digital visibility

    1. More traditional approaches such as on-the-street flyers and targeted social media ads help establish visibility of a clinic’s services and notify the public of its accessibility and affordability.

    2. Related resources

  3. Establish an integrated approach to care

    1. Employ a holistic social determinants of health (SDOH) approach to your care, offering wrap-around services such as mental health care and non-clinical support with employment or housing, to initiate screening and ensure longer term care.

    2. Related resources 

    • Tools for Putting Social Determinants of Health into Action: This CDC webpage compiles a series of tools and resources that health care practitioners can review in order to embed strategies to address social determinants of health in their organization.
    • Health-Related Social Needs Screening Tool: This resource from the Centers for Medicare and Medicaid Services can help clinicians find out patients’ needs in five core domains including housing instability, food insecurity, transportation problems, utility help needs and interpersonal safety.
    • PRAPARE Screening Tool and Implementation Toolkit: Developed in partnership between the National Association of Community Health Centers, the Association of Asian Pacific Community Health Organizations, and the Oregon Primary Care Association the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) is a national standardized patient risk assessment protocol designed to engage patients in assessing and addressing social determinants of health.
    • Care team training on the SDOH:
    • AMA telementoring session video clip: During this telementoring session focused on establishing an integrated approach to care, Jacky Bickham describes how the Louisiana Department of Health's STD, HIV, and Hepatitis Program approaches addressing the needs of community members.
  4. Meet patients where they are

    1. Expanding or building partnerships for testing outside of the clinical setting—and bringing it to local clubs, bars, rehab centers or on-the-street mobile clinics—helps overcome transportation barriers and normalize screening in the community.

    2. Related resources

    • HIV Testing in Non-Clinical Settings: This CDC webpage compiles a series of guidelines, recommendations and job aids that supports HIV testing in non-clinical setting.
    • Implementing HIV Testing in Nonclinical Settings: A Guide for HIV Testing Providers:​​ The purpose of this guide from the CDC is to familiarize clinicians with key programmatic issues that impact delivery of HIV testing services in nonclinical setting. 
    • AMA telementoring session video clip: During this telementoring session focused on meeting patients where they are, Jacky Bickham shares examples and an approach to how the Louisiana Department of Health's STD, HIV, and Hepatitis Program provides testing outside of the clinic.
  5. Provide patient-centric education materials

    1. Patient education materials that are linguistically and culturally reflective of populations disproportionately affected (such as Baby Boomers for HCV or refugees for LTBI) help patients overcome shame and understand the need for routine screening. 

    2. Related resources

    3. Patient Education Materials from the CDC: These links compile downloadable patient education materials from the CDC with resources targeted to different patient demographics and available in multiple languages.  
    1. JAMA Network™ Patient Pages: JAMA Patient Pages are free patient resources designed to distill high-quality evidence and updated guidance from USPSTF into a more accessible patient friendly format to help guide patient decisions. These resources can also be helpful to reference as your clinic or institution develops their own patient-friendly educational resources.
    2. HIV
    3. Viral hepatitis
    4. STIs
    5. LTBI

Disclaimer: This page contains resources supplied by third party organizations. Inclusion of these materials on this page does not imply endorsement of these resources or corresponding organization.

The HIV, STIs, Viral Hepatitis and LTBI Routine Screening Toolkit is organized across the screening continuum and offers helpful resources and best practices for the care team.