Clinic to community

The key to this intervention Access to HIV testing - and other testing interventions - in the community has become common over the last few years. Testing is often available immediately, and clinics are open after-hours and with no appointment necessary. Where HIV testing is the goal it is essential to have clear and swift referral pathways into mainstream HIV out-patients services.

What is the activity?

Clinical (NHS) interventions have been undertaken in community settings almost as long as the NHS has existed - for example, blood donation sessions in workplaces. However, since the publication of the National Strategy for Sexual Health and HIV (Department of Health 2001) they have become much more common in HIV and sexual health promotion.

Many charitable organisations now host clinical sexual health interventions, including chlamydia screening, hepatitis B vaccination, HIV testing and other screening for sexually transmitted infections. Others provide fast-tracked referrals into HIV testing services, or even chaperone their clients into standard NHS environments and provide informal interpretation.

Of particular interest here, are HIV testing services coordinated by community or charitable organisations. The actual counselling and testing in these interventions is often provided by staff from local genito-urinary medicine (GUM) or sexual health services, with the charitable organisation collaborating to provide the venue, the reception staff and promoting the intervention to potential users. Effectively clinical governance usually remains with the organisation providing the nursing and health advising staff, and they also provide the bridge back into mainstream HIV services, which is especially important when someone receives a positive HIV diagnosis.

Testing and counselling should be undertaken by fully qualified staff in rooms appropriately equipped and adequate supervision, clinical governance and insurance should be in place. While it is feasible for charitable organisations to directly employ staff qualified to provide HIV testing and other clinical interventions, there will rarely be sufficient demand for the services to make such appointments worthwhile.

Community-based HIV testing services frequently use rapid testing technologies, also commonly know as point-of-care testing (or POCT). Testing kits usually require a finger-prick of blood applied directly to a small disposable testing device. These kits are also used in clinical environments where rapid testing is the goal and are considered sufficiently sensitive and specific for a preliminary HIV diagnosis. The kits themselves are relatively inexpensive (usually less than £10), and give an antibody test result in about ten minutes. Where HIV infection is indicated by the rapid test kit, a full blood test is required to provide confirmation.

When we describe Clinic to Community interventions, we are talking about interventions that deliver HIV testing, not just those that encourage or give information about testing.

Strengths and limitations

People who are wary of interacting with standard NHS services - such as GP surgeries, or hospitals - may feel more comfortable in a community setting where there is a pre-existing relationship of trust.

Making HIV testing - or any other clinical intervention - easily accessible in community venues increases their acceptability to many users. Evaluation data (Weatherburn et al. 2006, Weatherburn et al. 2006) suggests users particularly welcome services that are accessible outside core hospital hours (9am-5pm) and where no appointment is necessary. Clinical sessions can be used as a means of referring individuals to other services, as well as a means of promoting written interventions and distributing HIV prevention resources (such as leaflets and condoms). Further evaluation of expanded opportunities for testing in eight pilot cities has been undertaken by the Health Protection Agency. Their interim report, Time to test for HIV (HPA 2010), describes findings indicating that testing carried out in the community may carry a higher positivity rate (more HIV positive diagnoses per test undertaken) than HIV tests performed in clinics.

Because of the relatively high cost of staffing, sessions tend to be short (typically 2-3 hours during which 8-12 people might be tested) and only occur once a week. However, substantial effort might be needed to ensure service uptake, so service promotion will be required.

Most clinical interventions in the community test for one specific infection (eg. HIV). People attending standard genito-urinary medicine (GUM) services might expect to receive a battery of screening tests that could identify a larger range of infections.

Where does it happen?

Clinical interventions can occur in public, private and commercial spaces where African people socialise or use other services, including clubs, places of worship, schools, colleges, universities, businesses and community centres. In reality, clinical interventions in the community tend to occur in the offices of the host charities themselves, because of the specific demands of a clinical intervention.

The host charity must provide a waiting or reception area; at least one private room and ideally two, each with comfortable seating for up to 3 people; a sink (for hand-washing); a hard floor (in case sample spillage); and sharps boxes for the safe disposal of clinical waste. There should be a secure area for keeping confidential records, and rooms should be equipped with a panic button system to be used if there is a physical danger.

Centre-based interventions lack the immediacy and coverage of outreach interventions. The self-referral demanded by such services means that individuals have identified a need (knowledge), decided to act to get it met, found out where to go, planned a time to attend, and had the capacity to act on it. People using such services demonstrate motivation (will) and the capacity to seek support in meeting their needs (power).

Frequently delivered alongside ...

Issues to consider

Providers should be familiar with a range of sexual health issues such as the transmission, prevention and treatment of sexually transmitted infections (including HIV). Beyond this, they also require familiarity with services to which they can make appropriate referrals. Workers providing information and advice should have proven listening and communication skills.

Agencies will need to have procedural and boundary guidelines for one-to-one workers, and will need to ensure that these are built into staff inductions and are regularly revisited. These should aim to maximise the physical safety and comfort of workers while also ensuring a standardised service. The providers’ credibility is paramount to the success of these interventions, therefore workers will need training about personal, professional and social boundaries during work (and about contact with clients outside of work). The Sigma Research evaluation of Terrence Higgins Trust’s fasTest pilots of HIV testing in the community (Weatherburn et al. 2006, Weatherburn et al. 2006) concluded that the success of the fasTest interventions was a function of: their promotion; a need to establish HIV status in the local population; and pre-existing service provision in the locality of the site (ie. the availability and accessibility of comparable HIV testing services). The evaluation demonstrated that it was feasible to recruit black African migrants into fasTest services, though promotion to African and other black and minority ethnic populations needed specific interventions. This same evaluation demonstrated:

  • More than half of all service users reported that their main reason for choosing fasTest over other options for HIV testing was because the test result was available at the same visit.
  • Another third stated that it was more convenient because of the after hours nature of the service and the absence of any need for an appointment.
  • None of the clinics ran at full capacity for the entire pilot period but managing (over)demand was problematic at times in all sites. Overall, on average one HIV test was delivered for every 41-53 minutes of clinical staff time.
  • Promotion of the service affected uptake but more expensive methods of promotion (including outreach) did not have a large impact on uptake.

Outcomes

  • Clinic to community interventions are primarily a means of increasing HIV diagnoses. In particular they should reduce the length of time between HIV infection and diagnosis (see associated needs here and here).
  • The shared governance and hosting structures in place should also lead to an increased organisational understanding of interventions and services offered by others (see section on partnership working), and therefore increased referral capacity.

A variety of other claims are made about the utility of clinical interventions in community settings – most common among these are the assertion that the population of people testing for HIV in community settings is different from those that test at GUM clinics, GP surgeries or elsewhere. Most commonly it is claimed that the population using community testing sites will be younger, more recent migrants and / or more recently infected with HIV. None of these claims are proven but none are necessary to justify the intervention since HIV testing in community environments expands HIV testing capacity in a locality and improves patient choice, so long as it does not replace pre-existing HIV testing services.

Monitoring and evaluation

Clinical interventions in community environments are generally subject to monitoring and access evaluation exercises which collate information about service users’ basic demographics (age, ethnicity, gender, geographical location etc.) and their expected and actual test results. These details will enable some assessment of whether the intervention is reaching the desired target populations. Evaluating the impact of such interventions will require specific funding and research expertise.

Page last updated: 22 July 2013

Case study

Know Your HIV Status football tournament

Leicestershire AIDS Support Service (LASS)

The LASS ‘Know Your HIV Status’ football tournament in July 2011 achieved more than the expected outcomes. The focus of the tournament was to raise awareness of HIV, ‘kick out’ stigma and promote rapid HIV testing , in particular among African men, because LASS statistics over the past 2 years highlight a reluctance to be involved in HIV issues and HIV testing. HIV was a topic of conversation across the ground – with a queue for rapid HIV tests at the LASS outreach van. Twenty nine African men and three African women were tested for HIV during the day. Click here for a press release with photos of the event.

Case study

African Testing Outreach and Mentoring (ATOM)

Metro Centre

MAC (through TIDES Foundation) funded Metro to undertake the ATOM project.The premise is that an integrated approach is best. So Metro provides culturally-appropriate and proactive one-to-one information and advice and interactive small media distribution to encourage African people to test for HIV, accompanied by the offer of a rapid HIV test in a community setting (in this case a GP surgery in Woolwich). Referrals follow on after BOTH negative and positive test results. People diagnosed positive are referred to local GU and/or SLHP, and people diagnosed negative are referred immediately to counselling, mentoring, or groups, mostly offered locally. This approach recognises that HIV testing is not an isolated event.
 

Case study

Time to know

Embrace UK

The Pan African and Caribbean Sexual Health (PACSH) Project at Embrace UK undertakes Time to Know (T2K) to enable easy access to HIV testing. PACSH staff make clinic appointments at the Sexual Health Clinic at St. Anne's Hospital in Haringey on behalf of their service users whom they issue with T2K cards. Showing a T2K card at the clinic means clients are fast-tracked to HIV counselling and testing. PACSH workers are able to monitor uptake by collecting cards back from the clinic regularly. Combining T2K with chaperoning  results in 6 to 7 successful referrals for testing per month.