Identifying who to screen for what infection(s) and when is a critical consideration for how to implement an effective routine screening program. Community health centers continue to face challenges with individual biases about sexual health and infectious disease, both from patients and the clinical staff. This sense of vulnerability, compounded by socialized stereotypes and stigma, makes testing consent conversations emotional and complex. Implementing an opt-out approach to screening can help simplify these conversations and normalize screening as a standard of care.

Guidance from the EHR, including automated reminders and prompts, as well as straightforward, demographic-based routine screening criterion have proven to be effective tools for increasing screening and time and energy savers for a busy care team. Patients feel more comfortable if routine screening is offered as a clinical standard of care, and they can feel seen and heard by their health care professionals. 

• The more complex the criteria, the harder it is to reliably execute routine screening
• Screening conversations can take time while moving through the EHR making the interaction less personal and more transactional 
• Implicit bias carried by care team staff members 
• Lack of EHR support and optimized structure for routine screening 
• Relying on clinicians to remember to screen for all diseases without alerts or reminders 

1. Implement the “opt-out” approach 

   1. Training health care professionals to implement opt-out language helps normalize routine screening as standard of care. Opt-out screening reduces the subjectivity of the decision on behalf of the patient where consent is not legally required. 

   2. Related resources

   • Explanation of opt-out screening approach for HIV: This resource link from the CDC provides an explanation of an opt-out approach to screening and why it is effective at increasing screening.
   • Sample opt out script for clinicians during HIV screening encounter: Pages 4-5 of the Guidance for Delivering HIV Pre-Test and Post-Test Results resource from the Reproductive Health National Training Center outlines samples scripts that clinicians can use when conducting an opt-out approach to HIV screening.
   • Discussion Guide: Using normalizing and opt-out language for chlamydia and gonorrhea: This resource from the Reproductive Health National Training Center is designed to build the confidence of clinic staff to use normalizing and opt-out language for chlamydia and gonorrhea screening.
   • State Laws that address High-Impact HIV Prevention Efforts: This resource from the CDC is a summary of state specific laws on a minor’s autonomous consent for HIV and/STI services, and laws that address HIV prevention efforts.

2. Stick to sex-positive, status-neutral messaging 

   1. Equipping care team members with training and resources on sex-positive, non-judgmental messaging about risk, transmission, treatment, outcomes and benefits of screening can help overcome initial patient refusal. 

   2. Related resources

   3. Care team training on LGBTQ, transgender and gender nonconforming essentials: This series of three training modules on the AMA Ed Hub™ developed by Howard Brown Health can help provide education to your care team on sex-positive and gender appropriate language and methods to incorporate best practices into your organization.

      • Transgender and Gender Nonconforming Essentials
      • LGBTQ Essentials: Foundations of Care  
      • Creating Trans Affirming Spaces–Using Gender Appropriate Language  

3. Implement automated EHR reminders and prompts to increase screening 

   1. There is evidence to support that EHR reminders and prompts are effective tools for increasing screening for HIV when compared with no intervention. Based on a systemic review of evidence, the Community Preventative Services Task Force (CPSTF) recommends the use of clinical decision support systems to increase HIV screening for both the general population and for people at higher risk for HIV infection.

   2. Related resources

   • Clinical Decision Support System to Increase HIV Screening: The resource outlines new recommendations and considerations for implementation from the CPSTF that the use of clinical decision support systems increases HIV screening both for the general population as well as those at higher risk for HIV infection.
   • Tips to Leverage Your Electronic Health Record to Implement Opt-Out HIV: This resource from Health Information Technology Evaluation and Quality Center outlines best practices and strategies for implementing opt-out HIV screening in your organization using the electronic health record.

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.

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