HIV, STIs, Viral Hepatitis and LTBI Routine Screening Toolkit: Initiate standard screening protocols

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

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 STD 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 are 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 feel seen and heard by 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
• Time constraint of patient encounters

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 about the benefits of routine screening

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

   2. Related resources

   • Care team resources to help healthcare providers educate patients on the importance of sexual health: These tools from the National Coalition for Sexual Health can help health care providers and clinical staff cultivate a clinical environment that delivers inclusive, patient-centered, and accessible sexual health services for all patients.
     • Inclusive Sexual Health Services: Practical Guidelines for Providers & Clinics
     • Sexual Health and Your Patients: A Provider’s Guide
     • Compendium of Sexual & Reproductive Health Resources for Healthcare Providers
   • CDC’s status-neutral approach to prevention and care: This webpage from the CDC provides resources about how routine screening benefits your patients as well as outlines the CDC’s status-neutral approach to prevention and care which ensures that all patients can benefit from quality HIV prevention and care, regardless of their HIV status.
   • Care team training on LGBTQ, transgender and gender nonconforming essentials: The AMA Ed Hub offers a series of training modules developed by Howard Brown Health, SAGECare, The Fenway Institute and more that can help provide education to your care team on sex-positive and gender appropriate language and methods to incorporate best practices into your organization.
     • Patient Care Education from Howard Brown Health
     • SAGECare Education
     • LGBTQIA+ Health Education from The Fenway Institute
     • AMA Ed Hub CME Course: LGTBQ Health, Diversity & Inclusion
   • Telementoring session video clip: During this telementoring session focused on sex-positive, status neutral messaging, Jason Zucker, MD talks about the many benefits of sex-positive, status-neutral messaging in HIV care.  

3. Implement automated EHR reminders, prompts and orders 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. Tools that could be standardized include automated risk assessment, automated prompt reminders to initiate screening, clear and specific order sets, hard stop alerts and subsequent pop-ups. 

   2. EHRs that automatically flag patients in need of screening as well as EHR reminders to initiate screening takes the pressure off the health care professional to remember who to screen. Alerts can automatically prepopulate test orders, further reducing the clinician’s responsibilities. Auto-orders in the EHR that are connected to algorithms to identify who is recommended for routine screening will reduce time in the EHR and additional steps for clinicians. Positive and indeterminant results can also be linked to auto-orders for confirmatory testing.

   3. Related resources

   • Clinical Decision Support System to Increase HIV Screening: This webpage outlines CPSTF recommendations and considerations for clinical decision support systems, which evidence shows 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