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HIV Prevention: Clinical Decision Support System to Increase HIV Screening

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What the CPSTF Found

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 23 studies (search period 1985 to October 2019).

The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to HIV prevention, treatment, and care.

Context

Ending the HIV Epidemic: A Plan for America External Web Site Icon is the operational plan developed by agencies across the U.S. Department of Health and Human Services (DHHS) to pursue the goal to reduce new HIV infections by 75% in 5 years and 90% in 10 years. The National Strategic Plan: A Roadmap to End the Epidemic for the United States, 2021-2025 External Web Site Icon (The Plan), also developed by DHHS, is closely aligned with, and complements, the Ending the HIV Epidemic. The Plan covers the entire United States with a focus on collaboration between all sectors of society to prevent new HIV transmission, improve health outcomes of people with HIV, and reduce HIV-related disparities and health inequities. Testing for HIV is the first step for both plans. Identifying interventions that increase HIV screening, especially among population groups with the highest rates of diagnosis, can facilitate testing.

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The systematic review included 23 studies.

  • When CDSS alerted providers to offer testing to all eligible patients, providers offered testing to a median of 80% of eligible patients (6 studies).
  • Compared with no intervention, CDSS increased HIV screening and identified more HIV infections.
    • The percent of eligible patients tested for HIV increased by a median of 10.3 percentage points (16 studies).
    • The number of eligible patients tested each month increased by a median of 415 (7 studies).
    • The number of patients tested positive each month increased by a median of 1.3 (13 studies).
  • Patients who tested positive were more likely to be identified at earlier stages of HIV infection (1 study).
  • In one study, most of patients who tested positive were linked to care (1 study).
  • Greater increases in HIV screening were reported when providers were educated about HIV, HIV testing, and CDSS (10 studies) before the program started, when compared with studies that did not include an educational component (8 studies).

Summary of Economic Evidence

A systematic review of economic evidence has not been conducted.

Applicability

Based on results from the systematic review, the CPSTF finding should be applicable to CDSS used for all eligible patients, independent of age, income, health coverage, race, or ethnicity. Interventions were shown to be effective in urban, rural, or suburban communities, and in a range of healthcare settings (e.g., clinics, hospitals, emergency departments, Veterans Affairs healthcare facilities, managed care settings).

Evidence Gaps

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

  • Most studies reporting on HIV screening among people at high risk did not report effectiveness by specific risk behaviors. How effective are CDSS for HIV screening among people who have male-to-male sexual contact or inject drugs, and people who are transgender?
  • How effective are CDSS for HIV screening in rural areas?

Study Characteristics

  • Included studies evaluated interventions implemented in the United States (21 studies) and the United Kingdom (2 studies).
  • Studies implemented opt-out (19 studies) and opt-in (3 studies) testing. CDC recommends opt-out testing, which notifies patients they will be tested for HIV as part of their standard preventive screenings unless they decline (Branson et al. 2006 External Web Site Icon).
  • Studies relied on active or passive CDSS reminders. Active reminders require providers to address an alert before moving to the next task or closing a patient’s chart (13 studies). Passive reminders can be ignored by providers (4 studies).
  • Studies offered HIV screening to all eligible patients who had not been tested previously (12 studies), patients who were at high risk for HIV infection and had not been tested within the previous 12 months (6 studies), or both (5 studies).