HIV Prevention: Clinical Decision Support System to Increase HIV Screening

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.

Ending the HIV Epidemic: A Plan for America 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 (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.

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).

A systematic review of economic evidence has not been conducted.

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).

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?

• 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).
• 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).

Effectiveness Review

• Logic Model
• Text Description

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

• Summary Evidence Table – Effectiveness Review

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Anaya H, Butler J, Solomon J, et al. Implementation of nurse-initiated rapid HIV testing at high prevalence primary care sites within the US Veterans Affairs health care system. Sexually Transmitted Diseases 2013;40(4):341-5.

Avery AK, Del Toro M, Einstadter D. Decreasing missed opportunities for HIV testing in primary care through enhanced utilization of the electronic medical record. Journal of AIDS and Clinical Research 2012;Suppl 4:10.4172/2155-6113.S4-006.

Burrell CN, Sharon MJ, Davis SM, Wojcik EM, Martin IB. Implementation of a collaborative HIV and hepatitis C screening program in Appalachian urgent care settings. Western Journal of Emergency Medicine 2018;19(6):1057.

Chadwick DR, Hall C, Rae C, Rayment MI, Branch M, et al. A feasibility study for a clinical decision support system prompting HIV testing. HIV Medicine 2017;18(6):435-9.

Clarke E, Bhatt S, Patel R, Samraj S. Audit of the effect of electronic patient records on uptake of HIV testing in a level 3 genitourinary medicine service. International Journal of STD and AIDS 2013;24(8):661-5.

Conners EE, Hagedorn HJ, Butler JN, Felmet K, Hoang T, et al. Evaluating the implementation of nurse-initiated HIV rapid testing in three Veterans Health Administration substance use disorder clinics. International Journal of STD and AIDS 2012;23(11):799-805.

Crumby NS, Arrezola E, Brown EH, Brazzeal A, and Sanchez TH. Experiences implementing a routine HIV screening program in two Federally Qualified Health Centers in the southern United States. Public Health Reports 2016;131(Supp 1):21-9.

Federman DG, Kravetz JD, Vasquez LS, Campbell SM. Improving human immunodeficiency virus testing rates with an electronic clinical reminder. American Journal of Medicine 2012;125(3):240-2.

Felsen UR, Cunningham CO, Heo M, et al. An expanded HIV testing strategy leveraging the electronic medical record uncovers undiagnosed infection among hospitalized patients. Journal of Acquired Immune Deficiency Syndrome 2017;75(1):27.

Goetz MB, Hoang T, Bowman C, et al. A system-wide intervention to improve HIV testing in the Veterans Health Administration. Journal of General Internal Medicine 2008;23(8):1200.

Goetz MB, Hoang T, Knapp H, et al. Central implementation strategies outperform local ones in improving HIV testing in Veterans Healthcare Administration facilities. Journal of General Internal Medicine 2013;28(10):1311-7.

Goetz MB, Hoang T, Knapp H, et al. Exportability of an intervention to increase HIV testing in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety 2011;37(12):553-9.

Golden MR, Duchin J, Chew LD, et al. Impact of an electronic medical record-based system to promote human immunodeficiency virus/hepatitis C virus screening in public hospital primary care clinics. Paper presented at: Open Forum Infectious Diseases 2017.

Hechter RC, Bider-Canfield Z, Towner W. Effect of an electronic alert on targeted HIV testing among high-risk populations. Permanente Journal 2018;22:18-15.

Kershaw C, Taylor JL, Horowitz G, et al. Use of an electronic medical record reminder improves HIV screening. BMC Health Services Research 2018;18(1):14-21.

Lin J, Mauntel-Medici C, Heinert S, Baghikar S. Harnessing the power of the electronic medical record to facilitate an opt-out HIV screening program in an urban academic emergency department. Journal of Public Health Management and Practice 2017;23(3):264-8.

Marcelin JR, Tan EM, Marcelin A, et al. Assessment and improvement of HIV screening rates in a Midwest primary care practice using an electronic clinical decision support system: a quality improvement study. BMC Medical Informatics and Decision Making 2016;16(1):76.

Rodriguez V, Lester D, Connelly-Flores A, Barsanti FA, Hernandez P. Integrating routine HIV screening in the New York City community health center collaborative. Public Health Reports 2016;131(1_suppl):11-20.

Rudd S, Gemelas J, Reilley B, Leston J, Tulloch S. Integrating clinical decision support to increase HIV and chlamydia screening. Preventive Medicine 2013;57(6):908-9.

Schnall R, Liu N, Sperling J, et al. An electronic alert for HIV screening in the emergency department increases screening but not the diagnosis of HIV. Applied Clinical Informatics 2014;5(01):299-312.

Schnall R, Sperling JD, Liu N, et al. The effect of an electronic “hard-stop” alert on HIV testing rates in the emergency department. Studies in Health Technology and Informatics 2013;192:432-6.

Sha BE, Kniuksta R, Exner K, Kishen E, Shankaran S, et al. Evolution of an electronic health record based human immunodeficiency virus (HIV) screening program in an urban emergency department for diagnosing acute and chronic HIV infection. Journal of Emergency Medicine 2019;57(5):732-9.

White DA, Todorovic T, Petti ML, Ellis KH, Anderson ES. A comparative effectiveness study of two nontargeted HIV and Hepatitis C virus screening algorithms in an urban emergency department. Annals of Emergency Medicine 2018;72(4):438-48.

Effectiveness Review

The systematic review science team completed a broad search for English-language papers that evaluated the impact of clinical decision support system interventions to increase HIV screening. Searches were conducted in the following databases: Medline, Embase, PsycINFO, Global Health, Scopus, Cochrane Library, and CINAHL. The search period was January 1, 1985 to October of 2019. Two team members independently screened each paper to determine eligibility. Uncertainties and disagreements were resolved by consensus among review team members.

Notes: Duplicates were identified using EndNote automated “find duplicates” function with preference set to match on title, author, and year. There will likely be additional duplicates found that EndNote was unable to detect.

Database: Medline (OVID)

1 exp Decision Support Systems, Clinical/

2 Therapy, Computer-Assisted/

3 Reminder Systems/

4 Decision Making, Computer-Assisted/

5 (clinical decision support system* or computer assisted therapy or reminder system* or computer assisted decision making).ti,ab.

6 ((computer* or electronic) and (alert* or reminder*)).ti,ab.

7 decision support system*.ti,ab.

8 Mass Screening/

9 mass screening*.ti,ab.

10 medical records systems, computerized/ or exp electronic health records/

11 ((electronic or online or on-line) and (record* adj1 (medical or patient or health))).ti,ab.

12 exp HIV/ or exp Acquired Immunodeficiency Syndrome/

13 (sexually transmitted diseases or sexually transmitted infections or acquired immune deficiency syndrome or human immunodeficiency virus).ti,ab.

14 (AIDS or STD or STDs or STI or “STIs” or HIV or HIV testing or HIV test or HIV screen*).ti,ab.

15 12 or 13 or 14

16 or/1-11

17 15 and 16

18 exp Animals/ or exp Nonhuman/

19 Humans/

20 18 not 19

21 17 not 20

22 17 not (animals not humans).sh.

23 limit 22 to (english language and yr=”1985 -Current”)

Database: Embase (OVID)

1 exp Decision Support Systems, Clinical/

2 Therapy, Computer-Assisted/

3 Reminder Systems/

4 Decision Making, Computer-Assisted/

5 (clinical decision support system* or computer assisted therapy or reminder system* or computer assisted decision making).ti,ab.

6 ((computer* or electronic) and (alert* or reminder*)).ti,ab.

7 decision support system*.ti,ab.

8 Mass Screening/

9 mass screening*.ti,ab.

10 medical records systems, computerized/ or exp electronic health records/

11 ((electronic or online or on-line) and (record* adj1 (medical or patient or health))).ti,ab.

12 exp HIV/ or exp Acquired Immunodeficiency Syndrome/

13 (sexually transmitted diseases or sexually transmitted infections or acquired immune deficiency syndrome or human immunodeficiency virus).ti,ab.

14 (AIDS or STD or STDs or STI or “STIs” or HIV or HIV testing or HIV test or HIV screen*).ti,ab.

15 12 or 13 or 14

16 or/1-11

17 15 and 16

18 exp Animals/ or exp Nonhuman/

19 Humans/

20 18 not 19

21 17 not 20

22 limit 21 to (english language and yr=”1985 -Current”)

Database: PsycINFO (OVID)

1 computer assisted therapy/

2 exp Decision Support Systems/

3 (clinical decision support system* or computer assisted therapy or reminder system* or computer assisted decision making).ti,ab.

4 ((computer* or electronic) and (alert* or reminder*)).ti,ab.

5 decision support system*.ti,ab.

6 mass screening*.ti,ab.

7 medical records systems, computerized/ or exp electronic health records/

8 ((electronic or online or on-line) and (record* adj1 (medical or patient or health))).ti,ab.

9 exp HIV/ or exp Acquired Immunodeficiency Syndrome/

10 (sexually transmitted diseases or sexually transmitted infections or acquired immune deficiency syndrome or human immunodeficiency virus).ti,ab.

11 (AIDS or STD or STDs or STI or “STIs” or HIV or HIV testing or HIV test or HIV screen*).ti,ab.

12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8

13 9 or 10 or 11

14 12 and 13

15 limit 14 to (english language and yr=”1985 -Current”)

Database: Global Health (OVID)

1 exp decision support systems/

2 (clinical decision support system* or computer assisted therapy or reminder system* or computer assisted decision making).ti,ab.

3 ((computer* or electronic) and (alert* or reminder*)).ti,ab.

4 decision support system*.ti,ab.

5 mass screening*.ti,ab.

6 ((electronic or online or on-line) and (record* adj1 (medical or patient or health))).ti,ab.

7 or/1-6

8 exp HIV/

9 exp acquired immune deficiency syndrome/

10 (sexually transmitted diseases or sexually transmitted infections or acquired immune deficiency syndrome or human immunodeficiency virus).ti,ab.

11 (AIDS or STD or STDs or STI or “STIs” or HIV or HIV testing or HIV test or HIV screen*).ti,ab.

12 8 or 9 or 10 or 11

13 7 and 12

14 limit 13 to (english language and yr=”1985 -Current”)

Database: Scopus

(( INDEXTERMS( “Decision Support Systems” OR “Reminder Systems” OR “electronic health records”) OR TITLE-ABS(“decision support system” OR “decision support systems” OR “computer assisted therapy” OR “computer assisted therapies” OR “reminder system” OR “computer assisted decision making” OR “mass screening” ) OR TITLE-ABS(( computer* OR electronic” ) AND (alert* OR reminder*” )) OR TITLE-ABS( record* W/1 (medical OR patient* OR “health” )) ) AND ( INDEXTERMS( “HIV” OR “Acquired Immunodeficiency Syndrome” ) OR TITLE-ABS( “sexually transmitted diseases” OR “sexually transmitted infections” OR “acquired immune deficiency syndrome” OR “human immunodeficiency virus” OR AIDS OR STD OR STDs OR STI OR STIs OR HIV))) AND LIMIT-TO ( PUBYEAR) 1985 2019

AND ( LIMIT-TO ( LANGUAGE , “English” ) )

Database: Cochrane

#1 (“clinical decision support system*” or “computer assisted therapy” or “reminder system*” or “computer assisted decision making”):ab,ti

#2 ((computer* or electronic) and (alert* or reminder*)):ab,ti

#3 decision support system*:ti,ab

#4 mass screening:ti,ab

#5 ((electronic OR online OR on-line) AND (record* NEAR/1 (medical OR patient OR health))):ti,ab

#6 (“sexually transmitted diseases” OR “sexually transmitted infections” OR “acquired immune deficiency syndrome” OR “human immunodeficiency virus”):ti,ab

#7 (AIDS or STD or STDs or STI or “STIs” or HIV or HIV testing or HIV test or HIV screen*):ti,ab

#8 #1 OR #2 OR #3 OR #4

#9 #5 OR #6 OR #7

#10 #8 AND #9 with Cochrane Library publication date Between Jan 1985 and Oct 2019

#11 #10 with Publication Year from 1985 to 2019, in Trials

Database: CINAHL

S18 S12 AND S17

S17 S13 OR S14 OR S15 OR S16

S16 TI ( AIDS or STD or STDs or STIs or HIV or HIV testing or HIV test or HIV screen* ) OR AB ( AIDS or STD or STDs or STIs or HIV or HIV testing or HIV test or HIV screen* )

S15 TI ( sexually transmitted disease* or sexually transmitted infection* or acquired immune deficiency syndrome or human immunodeficiency virus ) OR AB ( sexually transmitted disease* or sexually transmitted infection* or acquired immune deficiency syndrome or human immunodeficiency virus )

S14 (MH “HIV Infections+”)

S13 (MH “Human Immunodeficiency Virus+”)

S12 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S9 OR S10 OR S11

S11 TI ( ((electronic or online or on-line) and (record* N1 (medical or patient or health))) ) OR AB ( ((electronic or online or on-line) and (record* N1 (medical or patient or health)))

S10 TI computerized medical records system* OR AB computerized medical records system*

S9 (MH “Electronic Health Records+”)

S8 computerized medical record systems

S7 TI mass screening* OR AB mass screening*

S6 TI decision support system* OR AB decision support system*

S5 TI ( ((computer* or electronic) N3 (alert* or reminder*)) ) OR AB ( ((computer* or electronic) N3 (alert* or reminder*)) )

S4 TI ( (clinical decision support system* or computer assisted therapy or reminder system* or computer assisted decision making) ) OR AB ( (clinical decision support system* or computer assisted therapy or reminder system* or computer assisted decision making) )

S3 (MH “Reminder Systems”)

S2 (MH “Therapy, Computer-Assisted”)

S1 MH “Decision Support Systems, Clinical+”)

Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Morbidity and Mortality Weekly Report: Recommendations and Reports 2006;55(14):1-17.

U.S. Office of the National Coordinator for Health Information Technology. Clinical Decision Support; 2018. Available from URL: https://www.healthit.gov/topic/safety/clinical-decision-support. Accessed: 1/12/21.

The following considerations for implementation are drawn from studies included in the existing evidence review, the broader literature, and expert opinion from the CPSTF, as noted below.

• Current use of electronic medical records (EMR) and electronic health records (EHR) in the United States is very high. This could make it easier for healthcare providers to adopt an additional alert for HIV screening (CPSTF).
• For CDSS to effectively identify patients at higher risk for HIV infection, providers will need to collect and record information about risk behaviors (e.g., sexual behavior, drug use history). Some providers or patients may feel uncomfortable and avoid these topics (CPSTF). CDC offers guidance to providers for discussing sexual health.
• Some risk factors may be recorded in EMR/EHR fields that are not searchable, making it difficult for CDSS algorithms to identify patients eligible for screening (Burrell et al, 2018). Modifications to electronic forms might be needed to ensure complete recording of patient conditions.
• Providers might resist HIV screening in an already busy environment and not offer tests to patients despite CDSS prompts. Steps may be taken to streamline the process or generate prompts at more convenient times (e.g., when emergency departments draw blood for another purpose; Chadwick et al, 2017; Lin et al, 2017).
• Offering training for providers was associated with an increase in HIV screening rates. Training programs might do the following:
  • Teach providers how to use the system so daily interruptions are minimized and the perceived burden of HIV screening is reduced (Burrell et al, 2018).
  • Provide facts about HIV transmission and prevention, and address biases and stereotypes providers may hold about patients at risk for HIV infection, including those related to age, race/ethnicity, gender, or risk behaviors (CPSTF).
• Although most of the included studies used an opt-out approach to testing, a median of 30% of patients declined an HIV test.
  • Providers could ask patients detailed questions about their reasons for declining and offer alternative solutions such as oral testing rather than needles or finger-stick tests (Clarke et al, 2013).
  • Providers might offer brief counseling when time and resources allow (CPSTF).
• CDSS interventions for HIV screening identify more patients living with HIV who need to be linked with appropriate follow-up care that is affordable and accessible.
  • CDSS algorithms could be established to connect patients to care. Systems could be programmed to automatically order confirmatory tests and submit referrals (Conners et al, 2012), provide direct links to downstream care facilities to set up appointments (Burrell et al, 2018), or report confirmed cases to the local health department for tracking (Sha et al, 2019).
  • Outreach workers may be engaged to deliver results to patients who test positive and facilitate linkage to care (Lin et al, 2017). Patients might be more receptive to information and advice offered by community health workers (CPSTF).

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce the number of new HIV infections HIV-01
• Increase knowledge of HIV status — HIV‑02
• Increase the proportion of adults who get recommended evidence-based preventive health care — AHS‑08