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Routine testing for all (RTFA): U.S. HIV prevention innovation proposal

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Routine testing for all (RTFA): U.S. HIV prevention innovation proposal

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Content ROUTINE TESTING FOR ALL (RTFA):
U.S. HIV PREVENTION INNOVATION PROPOSAL
by
Monique M.C. Worrell
_________________________________
A Capstone Project Presented to the
SUZANNE DWORAK-PECK SCHOOL OF SOCIAL WORK
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF SOCIAL WORK
(SOCIAL WORK)
October 2019
Copyright 2018 Monique M.C. Worrell
Running head: ROUTINE TESTING FOR ALL 1

Routine Testing For All
(RTFA)

2018
U.S. HIV PREVENTION INNOVATION PROPOSAL
MONIQUE M.C. WORRELL, LICSW-C, BCD

ROUTINE TESTING FOR ALL 2
Acknowledgements
Giving honor to God who is the head of my life, I could not have made it this far without your
grace and mercy. My magical daughter Cambridge, you are the constant motivating factor in my
life. You consistently surprise and inspire me to be and do better. My unborn “sun,” Baldwin,
each kick and nauseous moment has reminded me of the world I want you to inherit. To my
husband, Olawale Oriola, thank you for your unwavering support. My mom and dad, who
migrated to the U.S. in the 1970s in search of the opportunity to provide the proving ground to
raise children who would take full advantage of the American Dream as they deferred theirs,
“thank you” seems woefully and utterly inadequate. And to my friends and family members who
have rooted for me along the way, I am appreciative of your support and guidance.

ROUTINE TESTING FOR ALL 3
The Social Work Grand Challenge Closing the Health Gap: Executive Summary
The foundation of the United States of America has been structured and shaped by
inequality and disproportionality. The roots of the nation manifest in every facet of American
life, including the healthcare system. The Social Work Grand Challenge of closing health gaps in
the United States seeks to highlight the disproportionately poorer health outcomes people of
color consistently experience (Walters et al., 2016). The American Academy of Social Work
and Social Welfare Close the Health Gap work group urges policy makers to make explicit
commitments to eliminating health disparities at individual and population levels by eliminating
negative social determinants that have become foundations to health conditions and outcomes
(Walters et al., 2016). People of color experience disease at much higher rates and at deadlier
rates than their White counterparts, which requires the public health community to view U.S.
prevention and care strategies through an innovative and transformative lens.
The U.S. Human Immunodeficiency Virus (HIV) Gap
People of color account for 74% of all new human immunodeficiency virus (HIV)
infections, shouldering the greatest burden in the United States despite making up 41.8% of the
population (Centers for Disease Control and Prevention [CDC], 2017; U.S. Census Bureau,
2017). HIV is disproportionately affecting communities of color and changing the landscape in
these communities at high rates. Also, while the United States has made significant medical
strides and policy advances that have quelled the overt discrimination and imminent fatality that
once came along with an HIV diagnosis, people of color living with HIV are less likely to be
virally suppressed, less likely to be in appropriate HIV care and treatment, and more likely to die
due to complications of HIV/AIDS (Center for HIV Law & Policy, n.d.). Generally, people of
color are not reaping the benefits of the HIV/AIDS battles waged in the 1980s and 1990s despite
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the public health infrastructure’s targeted responses to the disease’s prevalence (Pellowski,
Kalichman, Matthews, & Adler, 2013; U.S. Department of Health & Human Services [DHHS],
2018a). Current public health approaches to preventing the spread of HIV are stale and lack the
innovation and audaciousness needed to eliminate HIV in a generation.
HIV Care and Treatment and Prevention Barriers
The historical development and reaction to HIV/AIDS in the United States led to overt
stigma and discrimination, which can be described as the negative attitudes, prejudice and abuse
towards people living with HIV/AIDS (PLWHA) (Joint United Nations Programme on
HIV/AIDS, 2015). The introduction of HIV/AIDS to the U.S. population has also brought on
significant misinformation, as the disease was associated with stigmatized groups: gay men and
injection drug users (Herek, Capitanio, & Widaman, 2002). The general public was afraid and
the federal government fumbled in its response to and actions regarding the epidemic (Axelrod,
2011).
HIV/AIDS stigma has a negative impact on the health of PLWHA and has been cited as a
barrier to medical care (Sayles, Wong, Kinsler, Martins, & Cunningham, 2009). The stigma’s
power lies in the perceived belief that PLWHA will experience discrimination if their status is
revealed and in internalized shame and poor self-imagery among the diagnosed. Research
demonstrates that perceived and internalized stigmas have a negative impact on retention in care
(Mills et al., 2006), HIV testing (Rintamaki et al., 2006), mental health (Kempf et al., 2010), and
treatment adherence (Park et al., 2008).
Of the estimated 1.2 million PLWHA in the United States, the CDC (2016a) estimates 1
in 8 are unaware they are infected with the disease. It is also estimated that almost all newly-
ROUTINE TESTING FOR ALL 5
infected contracted the disease from PLWHA who are unaware of their status or not engaged in
adequate healthcare (Fauci, 2016).
Opportunities for Innovation
The U.S. public health infrastructure continues to target populations most affected by
HIV in an effort to turn the changing tide on disease in the nation. This approach is equitable and
intuitive; however, the approach also deepens HIV stigma and continues to marginalize
disenfranchised segments of the population because prevention resources are mainly
concentrated to communities of color and lesbian, gay, bisexual and transgender (LGBT)
communities (CDC, 2015). According to the 2010 census, Americans are seen by medical
professionals an average of four times in a year, which provides an ideal opportunity for routine
HIV testing to occur along with the current routine assessments that occur during medical visits
(U.S. Census Bureau, 2012). In 2010, the CDC reported that an estimated 55% of U.S. adults had
never been tested for HIV/AIDS (HIV Testing in the US, 2010). Moreover, only 17% of U.S.
adults say a physician or health care provider has ever suggested an HIV test which demonstrates
the countless opportunities the public health infrastructure has missed in curbing HIV through
routine HIV testing (The Kaiser Family Foundation, 2009).
Routine Testing for All
The purpose of Routine Testing for All (RTFA) is to create a public health policy that
supports routine HIV screenings for all people, particularly people 13 to 99 years of age. The
goals of this policy are to (a) normalize/destigmatize HIV testing, (b) prevent new HIV infection,
and (c) improve the quality of life for PLWHA. RTFA leverages and strengthens existing CDC
HIV/AIDS testing recommendations through revision and collaborates with the pharmaceutical
industry to socialize these testing recommendations to the general public and medical providers.
ROUTINE TESTING FOR ALL 6
Routine Testing for All relies on a provision in the Affordable Care Act (ACA) that
requires all health insurance companies to provide HIV testing to consumers without any out-of-
pocket cost (DHHS, 2018b). ACA’s support of routine HIV testing creates real opportunity for
consumers to benefit from the act’s provision.
Project Methodology
Creating a public health policy that supports and normalizes routine HIV screenings for
all, despite race, age and sexual orientation, will destigmatize, demystify, and provide adequate
HIV/AIDS information to the general population, thereby decreasing the prevalence of HIV.
Thus, people who are unaware of their status can become connected to appropriate care and
treatment. High-risk HIV negative individuals would be made aware of the availability of anti-
HIV medications and low-risk individuals would be made aware of measures they need to
maintain to continue to remain HIV negative. Currently, HIV testing is only compulsory in the
U.S. for organ and blood donors as well as for those seeking entrance into the military and active
duty service members (The Henry J. Kaiser Family Foundation, 2016). Moreover, the CDC
currently recommends routine HIV testing for people ages 13 to 65 but does not define testing
frequency and stigmatizes the LGBT community by deeming them a high-risk population.
To win the fight against HIV/AIDS in the United States, creating an environment where
an HIV test is as standard as a cholesterol check would transform the approach to HIV
prevention, care, and treatment. This capstone project aims to reframe the prevention narrative
by destigmatizing HIV testing and by making it part of routine medical care in all healthcare
settings.
Problem Statements
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In the United States, an estimated 1.2 million people live with HIV/AIDS, and 13% of the
infected are unaware of their status (CDC, 2018a). Approximately 50,000 new HIV infections
occur each year. Among minority communities, men who have sex with men (MSM) are one of
the fastest growing infected demographics. Black men between the ages of 13 and 24
experienced an 87% increase in diagnosis of HIV, causing this sub-group to be the fastest
growing group in terms of new diagnoses (CDC, 2018a). Because HIV/AIDS is a stigmatizing
diagnosis, it can cause people to avoid or delay HIV testing, which can have fatal consequences
(Young & Zhu, 2012). Additionally, risk-based screening has failed to identify a substantial
portion of people at the early onset of HIV (Branson et al., 2006). Patients do not always disclose
or are aware of their risk, complicating current risk-based HIV testing recommendations (Chou,
Huffman, Fu, Smits, & Korthuis, 2005).
Background
In the United States, an estimated 1.2 million people are living with HIV/AIDS, and
approximately 1 in 8 of those are unaware that they are infected with the disease (CDC, 2018a).
Additionally, approximately 50,000 people are infected annually (CDC, 2018a). While the early
HIV/AIDS epidemic in the United States affected mostly gay and White individuals, over time,
this subgroup has experienced a significant decline in infection rates. Today, HIV/AIDS has
become browner and poorer and, thus, less likely to garner public and political support (CDC,
2016b). Among the fastest growing infected demographic are MSM of color. However, despite
the increased incidence of infections within communities of color, little attention has been
focused on understanding the factors that have contributed to this increase (Hutchinson, 1992).
Further, prevention and early intervention approaches for stemming the transmission of the
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disease that proved so successful in previous decades have not been as effective in reducing the
current rise (Hutchinson, 1992).
In this section, we will identify factors that contribute to the current HIV/AIDS epidemic,
explore contemporary programs and policies to end it, and describe a proposal that offers an
innovative approach that recognizes the disproportionate incidence of the disease within
communities of color.
Review of the Literature
In 1981, the term “gay cancer” entered the public consciousness, confounding the
medical community and causing fear among the general public (Wright, 2006). The term “gay
cancer” was introduced through a report published by the CDC that described new illness
affecting five gay males with pneumonia type symptomswho had suppressed immune systems,
similar to a person undergoing chemotherapy (CDC, 1981). By the end of 1981, there were 270
documented cases of severe immune deficiency, all among gay men. By the end of 1981, 121 of
these men would die (Avert, n.d.). In 1982, the CDC renamed “gay cancer” to Acquired Immune
Deficiency Syndrome (AIDS). New York City and San Francisco became the epicenters for
HIV/AIDS in the United States.
During the mid-1980 and 1990s, the entertainment industry grappled with the disclosure
of the HIV status of such entertainment icons as Rock Hudson, Arthur Ash, and Magic Johnson.
Hudson’s disclosure and eventual death due to complications from HIV/AIDS is credited with
moving the public conversation about the disease forward. During this time, stigma and
discrimination experienced by PLWHA was common, and rampant misinformation resulted in
general public fear. PLWHA were prohibited from attending schools, lost housing and
employment opportunities, and faced physical harm (Crowley, Nevins, & Thompson, 2015).
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President Ronald Reagan’s presidency spanned from the first unknown case of AIDS in
1981 through 1989, when there were an estimated 27,408 deaths from the disease (CDC, 1991).
The Reagan administration was slow to respond to the crisis and, retrospectively, the
administration’s response has been described as a ‘fatal inaction in confronting a generation-
defining tragedy’ (Lawson, 2015). Pat Buchanan, President Reagan’s communication director,
argued AIDS was nature’s retribution on gay men (Axelrod, 2011). The government’s inaction
created an atmosphere of erroneous information about the disease. The general public believed
HIV/AIDS could be spread by saliva, handshakes, insect bites and touching objects a person with
HIV/AIDS used (Altman, 1987). Misinformation led to fear of contracting the disease, which,
ultimately, led to discrimination and stigma.
HIV/AIDS can only be transmitted through blood, pre-seminal fluids, semen, breastmilk,
and vaginal and rectal fluids (CDC, 2018b). The vast majority of new infections in the United
States occur among MSM of all races, followed by Black heterosexual women (CDC, 2016b).
The CDC estimates gay and bisexual men represent 4% of the U.S. population, but MSM
account for 78% of the HIV infections among men. Heterosexuals account of 25% of the
infections and about two-thirds of those infected by heterosexual sex are women. Intravenous
drug users account for 8% of infections. Blacks, followed by Latinos, are the most impacted
populations. In other word, Blacks and Latinos are disproportionately affected by HIV/AIDS
when compared to other races. The highest rate of diagnosis is in the South, followed by the
Northeast, then the Western United States and, lastly, the Mid-West (CDC, 2016b).
U.S. HIV Response. There were two seminal events that changed the trajectory for the
care and treatment for PLWHA in the United States. First was the passage of the Ryan White
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legislation in 1990 that mandated the care and treatment of PLWHA. Second was the advent of
antiretroviral medication to prolong the lives and quality of life for PLWHA.
The Ryan White Comprehensive AIDS Resources Emergency Act of 1990 was the
federal government’s response to 10 years of inaction and uncoordinated care for PLWHA
(Health Resources and Services Administration [HRSA], 2017). The legislation was largely
shaped by the gay, White male community and bears the name of a teenage hemophiliac who
contracted HIV/AIDS as a result of a blood transfusion (Markel, 2016). The Ryan White
HIV/AIDS Program (RWHAP) is the federal government’s premier program for providing care
and treatment to PLWHA. Currently, Ryan White funds account for the care and treatment of
52% of all PLWHA in the United States, and rates of retention in care and viral suppression are
higher when compared with other national estimates (Doshi et al., 2014). Beneficiaries of
services supported by the Ryan White legislation fare better than their counterparts who are not
clients of the program. The program boasts of more virally suppressed and retained-in-care
PLWHA than any program in the United States.
The Ryan White legislation is administered under the DHHS, HRSA, and the HIV/AIDS
Bureau. With a budget of $2.3 billion dollars in fiscal year 2016, it serves more than a half a
million PLWHA. The bureau provides grants to every state and territory of the United States for
care and treatment, technical assistance, training for clinicians, and research on innovative HIV
care models (Health Resources & Services Administration, 2017). The legislation has been
amended four times, most recently in 2009, to adjust to the changing healthcare landscape. A
major criticism of the program is that, while RWHAP clients fair better than their counterparts
who are not recipients of the program, the legislation has not changed to reflect the emerging
face of HIV/AIDS in the United States.
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In 2014, 70.6% of clients served by RWHAP funds identified as male. Nearly three-
quarters of RWHAP clients are from racial/ethnic minority populations, and 47.2% self-
identified as Black/African American. Ryan White’s client demographic is reflective of the
United States epidemic. While the program is credited with advancing an 18% decline in
homosexual White male transmission from 2005 to 2014, yet the same decline is not experienced
by people of color. In fact, the diagnosis rates for Black MSM aged 13 to 24 increased 87% in
2015, but that trend has declined by 2% since 2010.
In 2010, under the Obama administration, the National HIV/AIDS Strategy (NHAS) was
crafted to align federal resources under two goals: reducing new infections and increasing access
to care for PLWHA. The strategy was updated in July of 2015, but the strategic goals remain the
same (DHHS, n.d.b). The plan highlights opportunities for improved work in HIV prevention
care, treatment, and research in four critical areas: widespread testing and linkage to HIV care,
support for PLWHA to remain in care, universal viral suppression for PLWHA and full access to
comprehensive PrEP services (DHHS, n.d.b). Aligning the federal HIV response has produced
13 indicators and a mechanism to chart federal action. The NHAS federal action plan presents
167 actions federal agencies can take to move the nation closer to achieving the strategic goals.
To date, the federal government has completed approximately 76% of these actions, and the
remaining 24% are either initiated or have yet to start (DHHS, n.d.a).
Medical advances. Scientific advances in the care and treatment for PLWHA have
provided individuals a better quality of life and life expectancies similar to those who are
disease-free (Cairns, 2014). Palmisano and Vella (2011) characterize this shift as “unprecedented
efforts in the fields of biology, pharmacology and clinical care have contributed to progressively
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turn HIV infection from an inevitably fatal condition into a chronic manageable disease”
(Palmisano & Vella, 2011, p. 44?).
At the onslaught of the epidemic, the medical community did not know how to treat and
care for PLWHA. According to Dr. Osmond of the University of San Francisco, during the early
years of HIV/AIDS, PLWHA lived a year after an AIDS diagnosis (Highleyman, 2005). In the
early days of the disease, medical care focused on managing symptoms and allowing patients to
die with dignity. In 1994, there were over 40,000 AIDS-related deaths in the United States. In
1995, the number rose to 50,000 deaths (CDC, 2018a). After the 1995 peak of AIDS-related
deaths, there has been a steady decline in deaths that has been largely attributed to the
effectiveness of sophisticated medication regiments (HIV InSite, n.d.). The most recent data
show that there were 6,721 deaths attributed directly to HIV/AIDS in 2014 (CDC, 2018a).
The gap. Despite the success of the aforementioned policies/practices, HIV/AIDS is
devastating Black and brown communities across the country (Moreno, 2018). In a recent study,
the CDC concluded that there are no differences in infection and prevalence by race for the urban
poor. People of color are disproportionately affected because they are more likely to be poor and
not because of the color of their skin. According to the Black AIDS Institute, when other racial
groups experience the same social and economic circumstances as Blacks, their rates of HIV are
similar, if not equivalent (Curry, n.d.). In 2016, Hispanics were 18% of the U.S. population yet
accounted for 25% of all new infections while Blacks represented 12% of the population but
accounted for 44% of diagnoses (CDC, 2018a). The CDC has projected that, if current infection
rates continue, 1 in 20 Black men, 1 in 48 Black women, and 1 in 2 Black gay and bisexual men
will be HIV positive in their lifetime (CDC, 2016). These statistics illustrate the widening health
gap people of color experience in terms of this disease.
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The U.S. response to HIV. The CDC serves as America’s lead organization in disease
prevention and health education to improve the health of the nation (CDC, 2015). In fiscal year
2015, the CDC expended over $555 million on HIV prevention, testing, and surveillance
activities (CDC, 2011; The Henry J. Kaiser Family Foundation, 2015). The CDC targets subsets
of the population most affected by HIV in an effort to reduce the current disproportionality.
Based on CDCs epidemiological data across all states and U.S. territories, in 2015, Blacks had
the highest numbers of new HIV infections in the country, followed by Hispanics (CDC, 2018d).
The CDC’s epidemiological data guides the agency on how to deploy its prevention resources.
As a result, the majority of HIV prevention resources are concentrated on communities of color
and the LBGT community (CDC, 2016b).
The CDC describes targeted testing as a strategy that tests people based on characteristics
that increase their likelihood of being infected with HIV. Characteristics can include the presence
of sexually transmitted diseases, behavioral risks, or attendance at venues frequented by high-
risk persons (CDC, 2011). The CDC’s HIV prevention strategies include supporting prevention
programs with a $415 million-dollar investment in health departments to prevent new infections,
tracking the epidemic through a national surveillance system, supporting prevention research,
and raising awareness through communication campaigns (CDC, 2016b). The CDC’s HIV
prevention strategy seeks equity. The organization funds high-impact prevention activities in an
effort to maximize limited resources (CDC, 2015). This translates into testing efforts and
awareness campaigns being aimed at people of color, which contributes to further entrenchment
of stigma and disenfranchisement for people of color.
HIV policy gap. In 2006, the CDC made a historic policy recommendation which
advised medical providers that patients should receive HIV testing, after being informed of it,
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unless the patients declined. The recommendation also states that those who are at high risk for
HIV infection should be tested yearly and that pregnant women should be tested as part of
routine prenatal screenings and then again in the third trimester (CDC, 2018b) Lastly, consent is
implied, but patients can opt-out of testing (Branson et al., 2006). The CDC attempts to
normalize HIV testing through the 2006 recommendations, but it fails to destigmatize HIV
testing for the general population because it requires annual testing only for those deemed at risk,
and risk is defined based on behavior.
Based on the CDC’s (2018b) demographic categorization of HIV risk, MSM, transgender
individuals and Black and Latino individuals are at high risk of contracting HIV. Additionally,
CDC categorizes HIV risk by behaviors. Behaviors highlighted that are at highest risk for HIV
infection include: anal and vaginal sex without proper use of a condom or HIV preventing
medication and needle sharing (CDC, 2018b). CDC’s 2006 HIV testing recommendations fall
short as it leaves too much to the discretion of the provider, which could perpetuate the existing
HIV/AIDS stigma.
Additionally, medical providers are not aware of the benefits of routine HIV testing or
CDC’s 2006 HIV recommendation. In a study sponsored by the National Institutes of Health
(NIH), nearly half of physicians surveyed were not aware of CDC’s routine HIV
recommendation (Arya et al., 2014). The medical community’s lack of awareness and practice of
routine HIV testing possibly contributes to the 50,000 new HIV/AIDS infections our country
experiences each year.
Proposed solution: Routine HIV Testing For All. Routine annual physical exams have
become a common practice in the U.S. healthcare system since the early 1940s (Bloomfield &
Wilt, 2011). Annual physicals consist of screenings consistent with age, gender, risk factors,
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patient and family medical histories and potential presenting symptoms (Moyer, 2012).
Screenings range from pap smears for women ages 21 to 65 (Moyer, 2012) to cholesterol checks
beginning at age 20 and then every five years if no other diagnoses exist (American Heart
Association, 2018). Each of the described screenings offered during the annual physical exams
do not require written consent. Doctors simply describe the screening process, provide a brief
high-level patient-centered education on potential risk factors associated with the screening, and
then perform the screening. This makes pap smears, as uncomfortable as they maybe, a non-
stigmatizing medical activity as the practice has become normalized in medical settings. In a
similar way, creating a public health policy that ensures normal and standardized HIV screening
for people 13 to 99 years of age during routine physical exams would remove HIV testing
stigma.
The proposed policy innovation, RTFA, is a three-tiered public health policy strategy that
singularly supports and promotes routine universal HIV screenings for people 13 to 99 years of
age with the ultimate goal of destigmatizing HIV testing, preventing new HIV infections, and
providing accurate information on HIV/AIDS to the general population. RTFA will operate
under a customer centered strategic focus, building long term relationships with federal
healthcare partners, the general public, pharmaceutical companies and medical training facilities
to normalize HIV testing.
Tier 1: Demonstration Project. In RTFA’s two years, the launch of a demonstration
project will be the primary focus. The goals of the RTFA demonstration project are to (a)
demonstrate the benefit of universal HIV testing in a health care setting, (b) develop clinical
guidelines for universal testing HIV testing in healthcare settings, (c) create universal HIV
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training materials for medical professionals and (d) create a multimedia campaign supporting
routine HIV testing for all.
Tier 2: Revise the Centers for Disease Control and Prevention (CDC) 2006 Universal
HIV Testing Recommendation. In 2006, the Centers for Disease Control and Prevention,
Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD and TB
Prevention recommended HIV testing for patients that are informed that testing will occur unless
the patients decline the test. The recommendation also states, “persons at high risk for HIV
infection should be screened for HIV at least annually,” pregnant women should be tested as a
part of routine prenatal screenings and then again in the third trimester and lastly, consent is
implied and patients would only opt-out of such testing (Branson et al., 2006, p. 5). While CDC
attempts to normalize HIV testing through the 2006 recommendations, it fails to destigmatize
HIV testing for the general population because it only requires annual testing for those deemed at
risk, and risk is defined based on behavior. Based on a CDC’s demographic categorization of
HIV risk MSM, transgender individuals and Black and Latino individuals are at high risk of
contracting HIV (CDC, 2018b). Additionally, the CDC categorizes HIV risk by behaviors, and
those highlighted as at highest risk for HIV infection are anal and vaginal sex without proper use
of a condom and sharing HIV preventing medication or needles (CDC, 2018b).
Conceptualizing the intervention of universal HIV testing through high-risk behaviors
and not by race or sexual orientation helps to destigmatize HIV testing and removes the burden
marginalized populations consistently experience in the United States. Unfortunately, there is too
much discretion left to the medical provider to determine whether the patient is high-risk or not,
which is not the case with cholesterol and blood pressure screenings. Therefore, RTFA would
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convene a public/private workgroup to revise the CDCs HIV testing recommendations as
follows:
1. Remove the high-risk designation from the 2006 HIV/AIDS screening recommendation
and explicitly recommend that all people be tested for HIV/AIDS routinely.
2. Currently, the CDC HIV/AIDS testing recommendation calls for people ages 13 to 65 to
be tested, but the age limit needs to be increased to age 99 as the U.S. population is living
longer, there are medical advances in sexual dysfunction, and there is research supporting
occurrences of sexually transmitted diseases in the elderly population that is inconsistent
with the current recommendation’s age range.
3. Define the frequency with which HIV/AIDS screenings should occur. The 2006 CDC
universal HIV/AIDS screening only defines the frequency with which high-risk
populations should be tested yearly and erroneously states that everyone else should be
tested in their lifetime. The danger in this section of the recommendation is that risk is
not a fixed position and can change with lifestyle choices. Leaving a medical professional
to determine the complex factors that contribute to risk is daunting and can contribute to
stigma related to HIV testing.
Tier 3: Partner with pharmaceutical companies that manufacture HIV tests and
medication to promote and market universal HIV testing to medical professionals and the
general public. As previously mentioned, an NIH-sponsored study found nearly half of
physician participants were not aware of the CDC’s routine HIV testing recommendations and
that adolescents and adults should be routinely screened. The medical community’s lack of
awareness and practice of routine HIV screening offers a prime opportunity to increase testing
through medical provider education detailing, among other things, the benefits and
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recommendations associated with routine testing. To accomplish this goal, RTFA will, with the
assistance of pharmaceutical companies, aggressively market routine HIV testing to medical
students and schools as a best practice, create public awareness campaigns and general
pharmaceutical marketing for the public, and encourage consumers to get tested through their
medical professional or through direct consumer marketing.
Mission and vision statements. Routine Testing for All (RTFA) is a public health policy
that singularly supports routine HIV screenings for all people 13 to 99 years of age with the
ultimate goal of destigmatizing, eliminating new HIV infections, limiting the spread of the
disease, and providing adequate information to the general population about the disease.
Mission statement: To eliminate the spread of HIV through universal HIV screening for
all people residing inthe U.S.
Vision statement: Zero new U.S. HIV infections.
Routine HIV Testing Conceptual Framework and Theory of Change
Stigma, defined as the shame or disgrace attached to something considered socially
unacceptable is the greatest inhibitor of HIV care and prevention (Herek, Capitanio, & Widaman,
2002). The population targeted by the public health infrastructure to prevent and treat HIV has
also been marginalized and stigmatized (Sayles, Wong, Kinsler, Martins, & Cunningham, 2009).
Current HIV prevention practices stigmatize already stigmatized groups: people of color, the
LBGT community, and substance users (Kempf et al., 2010). Targeted testing geared to
populations considered at high risk for exposure compounds the stigma these groups experience
through the practice of targeted testing (CDC, 2011).

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The Innovation of Equality
The Interaction Institute for Social Change (2016) commissioned artist Angus Maguire to
illustrate the difference between equity and equality. The illustration depicts three males of
varying heights attempting to watch a baseball game over a fence. The split screen shows the
equality model where the males are each given a box of the same height on which to stand on to
view the game, leaving one male unable to view the game obstruction-free. The second half of
the screen depicts the equity model where each male is given just enough boxes to allow him to
view the game free of obstruction. The appendix includes the full illustration (Interaction
Institute for Social Change, 2016).
The Cambridge dictionary defines equality as ‘the right of different groups of people to
receive the same treatment’ (“Equality,” n.d.). Equity is defined as ‘the situation in which
everyone is treated fairly and equally’ (“Equity,” n.d.).
Routine Testing for All revisits the rallying cries of the U.S. civil rights movement for
equality. Furthermore, RTFA reimagines Maguire’s illustration by removing the metaphoric and
physical fences of racism, sexism, homophobia and all other forms of oppression and
degradation and allows each person to enjoy the game at his height. Through RTFA, these fences
are removed by treating everyone the same, as HIV test are administered regardless of race,
sexual orientation, marital status or any other categorization. No boxes are needed to view the
game because the boxes are a continuation of the stigma applied to people of color and other
groups in this country. The current public health infrastructure applies equity to the HIV
prevention strategy, meaning people of color and the LBGT community are experiencing
disproportionate rates of HIV, and, as a result, resources are deployed to quell the disease in
these communities. Thus, RTFA approaches HIV prevention from a conceptual framework of
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equality, meaning prevention strategies are applied evenly regardless of socioeconomics, race or
sexual orientation. In essence, RTFA has reimagined the Interaction Institute for Social Change
illustration of equity and equality (Appendix).
Routine HIV testing leverages equality through environmental change as it removes the
boxes needed to prop up the shorter individuals to allow them to view the game while respecting
their individuality and diversity. RTFA is an environmental change that recognizes that the
public health infrastructure cannot solve or resolve the injustices people of color have
experienced in this country. However, RTFA can create environments that allow people to be
treated equally regardless of race, gender, and sexual orientation.
Logic Model
Purpose. The purpose of RTFA is to create a public health policy that supports routine
HIV screenings for people 13 to 99 years of age with the goal of destigmatizing, demystifying,
and providing adequate information on HIV/AIDS to the general population and, consequently,
reducing the overall incidence of HIV/AIDS in the United States.
Context. The U.S. healthcare system was at the forefront of the 2016 presidential
elections and, while the election was decided over a year ago, attempts to repeal and replace the
ACA have been relentless and have left the current healthcare law unchanged. However, RTFA
relies on ACAs provision to require health insurance companies to allow HIV testing to
consumers without any out-of-pocket cost (DHHS, 2018b). Barring a similar replacement,
ACA’s repeal would make RTFA’s dependence on ACA’s reimbursement for routine HIV
testing untenable. Repeal or replacement of the ACA could have an effect on HIV testing cost
reimbursement.
ROUTINE TESTING FOR ALL 21
Outputs. The expected output is an increase in the number of people who are routinely
tested for HIV.
Outcome. The expected outcome is an increase in the portion of the total population that
is tested. Through a demonstration project and revisions to existing HIV recommendations,
RTFA will increase the number of Americans who are routinely tested for HIV and provide
timely and relevant clinical guidelines to medical professionals.
Impacts. The greatest impact of RTFA is to improve population health through
decreasing the rates of HIV incidences, connecting those who are HIV positive to adequate care,
and providing accurate information about the transmission of the disease to the general
population.
Resources. For the purposes of this paper, the rate of reimbursement for HIV testing will
reflect the New York State’s Designated AIDS Center Hospitals (DACs) of $102.00 in lieu of
the Georgia State Medicaid office’s rate, which were not available at the time of completing this
assignment (Lubinski, n.d).
Comparative Analysis of Current Market for Innovation
Within the U.S. healthcare system, there are universal screenings for other diseases. For
example, mammograms are conducted to detect breast cancer, Mantoux screening serves to
detect the presence of tuberculous exposure, and pap smears detect the presence of precancerous
cells in the cervix (Screening (medicine), 2017). To aid in universal testing, pharmaceutical
companies could prove a strong partner for RTFA. According to some estimates, American
pharmaceutical companies spend $5 billion dollars per year on marketing, which equates to
$8,000 per physician in the United States (Kshirsagar & Vu, 2016). Most pharmaceutical
companies’ marketing budgets are larger than their research and analysis budgets, leaving many
ROUTINE TESTING FOR ALL 22
to question the ethics and entrenchment of pharmaceutical companies’ heavy-handed influence
on patient care and treatment (Kshirsagar & Vu, 2016). By collaborating with an industry that is
politically savvy and well-financed, RTFA stands to prevent the spread of a preventable chronic
disease.
In October of 2003, the southern African country of Botswana implemented nationwide
routine HIV testing to reduce the high rates of the disease in the country (Kenyon, 2005). One
study found that after a little over two years of nationwide routine HIV testing, there was a
significant increase of HIV testing throughout the country and HIV screening had become
widely accepting by the population (Steen, et al, 2007). Additionally, since routine HIV
screening has been implemented there has been an increase in linkage to HIV care and the
prevalence of the disease is experiencing a slow decline (Steen, et al, 2007). While Botswana is a
developing country and healthcare infrastructure, demographics and country size are different
when compared to the U.S., the country’s 2003 implementation of routine HIV testing
demonstrates that the benefits associated with routine HIV testing outweigh any potential harm
and contributes to reducing HIV testing stigma at a population level.
Unique Value Proposition: Normalizing HIV Screening in Primary Care Medicine
Routine physical examinations have become common practice in the U.S. healthcare
system. Routine physicals consist of health screenings consistent with age, gender, risk factors
and patient and family medical histories. The screenings described previously are performed
during the routine physical examination and do not require written consent from the patient.
Healthcare providers simply describe the screening process, provide high-level patient-centered
instructions on potential risk factors associated with the screening, and perform the screening.
Including HIV screening as a part of the menu of the routine screening activities in itself is not
ROUTINE TESTING FOR ALL 23
innovative since the U.S. healthcare system promotes preventative screenings through primary
care visits. Therefore, RTFA’s innovation lies in (a) its partnership with pharmaceutical
companies to support the routine HIV screening agenda to the medical community as a best
practice, (b) the inclusivity and frequency revisions of the CDCs 2006 HIV testing
recommendation, and (c) the elimination of targeted race and sexual orientation-based screening
tactics. By innovating on these three levels, there is an opportunity for an HIV diagnosis to be as
rare as polio within a generation.
Additionally, the cost savings associated with routine HIV screening are significant, as
the federal government spent $34 billion in fiscal year 2017 on domestic HIV prevention, care
and treatment (The Henry J. Kaiser Family Foundation, 2017). With RTFA, these costs are
expected to decline because HIV screening will become part of the screening patients will come
to expect during their routine physical exams. Furthermore, RTFA leverages the Affordable Care
Acts provision for HIV screening for all insurance plans with no out of pocket cost to the
consumer. ACAs provision does not cost or require anything additional of the consumer, creating
an opportunity for a seamless transition. Lastly, the reputable medical organizations in Table 2
support routine HIV screening. These organizations support will help galvanize support from the
medical community which in turn will increase the likelihood of routine HIV testing becoming
part of the standard medical screens in the U.S.
Evidence to Support Routine Testing for All
The causal link between socioeconomic standing and health outcomes is well established
(Adler, 2006; Ickovics et al., 2002; Satz, 1993). Socioeconomic standing determines access and
quality to healthcare, which ultimately affects overall health. Lower income individuals are more
likely to be plagued with chronic diseases and have poorer health outcomes as compared to
ROUTINE TESTING FOR ALL 24
individuals with higher incomes. Poverty has materialized as the most significant influencer in
perpetuating the HIV virus (Demming & DiNenno, 2017). The CDC concludes poverty as the
most critical risk factor of HIV infections (Demming, & DiNenno, 2017) and the Black AIDS
Institute concurs (Curry, n.d.). These findings strongly suggest that HIV infection has less to do
with race and more to do with economic opportunity and social conditions. Nonetheless, most
HIV prevention targets Black and Latino men and women along with MSM, leaving a large
swath of the population out of the HIV prevention conversation and further stigmatizing
marginalized groups. To address this issue, RTFA normalizes HIV prevention for all regardless
of race or sexual orientation.
The need for RTFA is further supported as targeted or risk based HIV testing has failed to
identify substantial proportion of people with HIV early in disease (Branson, et al, 2006). Risk
based HIV screening is resource intensive and fails to acknowledge that the HIV/AIDS epidemic
affects all populations (Branson, et al, 2006). Patients are not always aware or disclose their risk
to healthcare providers (Chou, et al, 2005). Studies have revealed 39% of men who had sex with
a man within the past year did not disclose to their health care provider (Bernstein, et al, 2008)
and 51% of rapid HIV test positive patients were identified in the emergency department of U.S.
hospitals (Lyss, et al, 2007). RTFA can close these gaps in the U.S. healthcare infrastructure as it
can improve health outcomes by enabling infected people to receive treatment and care and also
by monitoring how the infection may affect other medical conditions.
Grand Challenge and Innovation
By normalizing testing for all, RTFA addresses the current disproportionality in the U.S.
HIV epidemic, thus removing the intractable social norms and barriers to HIV testing and
treatment related to the disease. HIV-related stigma negatively impacts the health of people
ROUTINE TESTING FOR ALL 25
living with HIV and has been cited as a barrier to medical care (Sayles et al., 2008).
Furthermore, research demonstrates perceived and internalized stigmas negatively impact the
retention in care (Mills et al., 2006), HIV testing (Rintamaki et al., 2006), mental health (Kempf
et al., 2010) and treatment adherence (Park et al., 2008).
Innovation Feasibility
While RTFA is reliant on current government practices and policies that support the care,
treatment and prevention of HIV, the recent change in administration and political ideology
places many government public health care policies in jeopardy of being reimagined, and this
uncertainty will require flexibility in how the research is implemented into policies. To ensure
RTFA is cemented into U.S. healthcare policy and practice, the backing of the pharmaceutical
industry is needed in an aggressive and persuasive lobbying effort. A major pharmaceutical
company may need to sponsor the demonstration project and convene a working group to revise
the CDC’s 2006 HIV testing recommendations.
Both of RTFA’s sources of startup funds, the ACA and the Special Projects of National
Significance (SPNS), are in jeopardy of being eliminated or altered under the Trump
administration’s proposed 2018 budget and policy pushes. In the Trump administration’s 2018
proposed budget, the SPNS program is zeroed out, eliminating the program from the Ryan White
Care and Treatment program (National Minority AIDS Council, 2017). A substantial portion of
RTFAs revenue would be lost if the Trump administration’s proposed budget is passed as is,
which would require the program to identify other sources of revenue or rescale the
demonstration project to account for potential lack of government support. Additionally, the
Trump administration campaigned on the promise of a wholesale repeal and replacement of
ACA, and Congress has voted 70 times to repeal or alter ACA (Riotta, 2017). Barring a similar
ROUTINE TESTING FOR ALL 26
replacement, the repeal of ACA would make RTFA dependence on ACA’s reimbursement for
routine HIV testing potentially unreliable for future consideration.
Change –Transformation-Upheaval-Revolution
As proposed, RTFA is a policy revision that would affect the nation’s healthcare delivery
system and is a transformational policy, as it leverages the CDC’s 2006 recommendation on HIV
testing in an effort to provide the medical field guidance and clarity on HIV testing.
Additionally, RTFA highlights existing healthcare laws to support its mission of universal HIV
testing for all people ages 13 to 99. Collaborating with pharmaceutical companies to assist in
lobbying and pushing this agenda to elected officials is revolutionary. The relationship with these
companies and our healthcare system is well documented but never at the behest of a
government agency. Universal HIV testing is possible even in an uncertain political environment
as the current healthcare landscape supports the innovation through the ACA and current CDC
recommendations.
RTFA Implementation Strategy
According to Proctor et al. (2013), “methods of techniques used to enhance the adoption,
implementation, and sustainability of a clinical program, policy or practice” are required to
ensure the innovation fully executed (p. 3). Therefore, RTFA will employ a multifaceted
implementation strategy that consists of multiple discrete actions that will, in essence, be a
branded implementation strategy. The strategy will ensure buy-in from key stakeholders to
include medical professionals, medical training facilities, medical licensing boards, medical
consumers and pharmaceutical companies.
Strategy 1: Use advisory boards and workgroups. A work group of public health
leaders to include the CDC, NIH, HRSA HIV/AIDS Bureau, HIV/AIDS testing manufacturers,
ROUTINE TESTING FOR ALL 27
infectious disease doctors, and PLWHA would be organized to consider the efficacy of the
revising the CDC’s 2006 testing recommendations through a large-scale evidence-based
demonstration project, a thorough review of the literature, and agency-specific HIV screening
policy and practices.
Strategy 2: Fund and contract for the clinical innovation. Currently, the American
South is experiencing the fastest rates of HIV infection when compared to other parts of the
country (CDC, 2016b). For that reason, a federal innovation grant would be created to deliver
RTFA. During routine visits at internal or primary medical care appointments, patients will have
a rapid HIV test administered along with other routine health screenings. Patients will receive
their HIV results during the primary care appointment and, if needed, follow-up testing referrals
for inconclusive or positive results. In the first year of the demonstration project, at least 10,000
people will be screened for HIV/AIDS.
The federal partners within RTFA’s work group would fund demonstration projects
throughout the southern United States to show the efficacy of routine HIV testing in clinical
practice, to generate buy-in, and to motivate other general practice medical professionals to
deliver routine testing to their patient population regardless of race, sexual orientation or gender.
Strategy 3: Work with educational institutions. Conceived out of the demonstration
projects and the recommendations from the RTFA work group, RTFA will partner with
pharmaceutical companies to reach medical training facilities to socialize and market routine
HIV testing with the nation’s future medical providers to ensure they understand the benefits of
universal testing and incorporate it into their practice.
The perceived barriers to implementing RTFA are significant but can be overcome by
leveraging the inherent facilitators to implementation through strategic thinking and realistic
ROUTINE TESTING FOR ALL 28
timelines. The goal is that RTFA will be implemented over 4 years and will occur over four
distinct phases derived from the Exploration, Preparation, Implementation and Sustainment
(EPIS) Model, which is an implementation framework that offers four tiers of considerations for
evidence-based interventions, policies, and programs.
RTFA’s exploration phase will involve the first 2 years of gathering the necessary
information to convene a public/private work group to review and revise the CDCs 2006 HIV
testing recommendations, conduct a comprehensive literature review of the benefits of universal
testing, secure funding from federal partners to conduct the demonstration project, and partner
with pharmaceutical companies to socialize the benefits of universal HIV testing to current and
future medical professionals. RTFA’s exploration phase is crucial to the success of the overall
policy innovation because it is the bedrock of the plan, and the materials and processes
developed during this time will be useful in shaping policy positions and attracting stakeholders
and funders for the project. During the exploration phase, the current administration’s desire to
repeal the ACA is a potential barrier that must be considered through each phase of
implementation (Riotta, 2017). To mitigate this potential barrier, RTFA will leverage the ACA’s
HIV testing benefits and simultaneously work with pharmaceutical companies to lobby elected
officials to have this provision remain within ACA’s potential replacement and buy into the idea
of socializing routine HIV testing among the medical community.
During the preparation phase, RTFA will outline the parameters of the HIV testing work
group, the demonstration project, and the partnership with pharmaceutical companies. Staff will
be hired to begin this work at this phase because of the many aspects that require a diverse set of
skills and expertise. Additionally, we will socialize the demonstration project through existing
ROUTINE TESTING FOR ALL 29
stakeholder networks to generate organizations interest in applying for the grant that would
support the demonstration.
HIV testing work group and demonstration project. A task force of leaders in public
health, medicine, medical training facilities, and pharmaceutical companies will be convened to
consider the efficacy of the CDC’s testing recommendations through a large-scale evidence-
based demonstration project, a review of literature, and agency-specific HIV screening policy
and practice. RTFA would use the demonstration project mechanism to further explore universal
HIV testing efficacy, power of universal testing in early disease detection, and universal
normalization of HIV testing in health care settings. In the first year of the demonstration project,
at least 10,000 people, regardless of sexual orientation, race or gender will be screened for
HIV/AIDS.
Partnership with the pharmaceutical industry. Through the work group and
demonstration project, program staff will forge a relationship with major HIV/AIDS drug
manufacturers to propel the work of RTFA through pharmaceutical industries’ established
networks. A potential barrier to overcome during the preparation phase for RTFA is the isolated
nature with which federal agencies operate. The federal agencies that would need to partner to
ensure RTFA success include the CDC, HRSA, and NIH. While these agencies are under the
auspices of DHHS, the agencies are often working in silos and rarely collaborating due to
bureaucratic hang-ups and identifying agency champions to motivate federal staff buy-in.
Additionally, the entrenched relationship that pharmaceutical companies have with U.S.
lawmakers could potentially be the extra nudge NIH, HRSA and CDC need to fully cooperate
and create an environment for successful implementation of RTFA.
ROUTINE TESTING FOR ALL 30
During the implementation phase, we will execute the HIV testing work group, the
demonstration project, and the beginning phases of the partnership with pharmaceutical
companies. Implementation would occur in Year 2 of the project and will take two full years to
complete a full cycle. The greatest barrier to RTFAs implementation is the disease controversy
associated with HIV. RTFA main objective is to normalize HIV testing and eliminate the stigma
associated with the disease. This will be done with the aggressive marketing campaign that the
pharmaceutical companies will embark upon with the general public as well as medical
professional implementing routine HIV testing in their general practice. Coupled with CDCs
revised guidelines for a more defined frequency with which HIV testing should occur among the
general public and the removal of all destigmatizing language, there are many facilitators in the
implementation phase that can be leveraged to ensure RTFA is implemented to achieve full
potential.
At each phase of RTFA, there will be follow-up and evaluation to ensure lessons learned
and best practices to inform each new phase of the project. At the end of a phase, stakeholders
and agencies involved will convene for debriefings to discuss lessons learned and how
information learned from the previous phase will inform the next phases.
Lastly, during the sustainment phase of implementing RTFA a wholesale review of the
EPIS, implementation strategy will occur to identify new barriers and facilitators to RTFAs
sustainment. During the sustainment phase, data collected would be used to message the success
of RTFA through mass media markets. One of the challenges in research is that publishing that
occurs for research projects do not influence the general public as the research becomes buried in
journals and books that are not consumable to those who have the power to sustain the
innovation. RTFA will use local and national newspapers, TED Talks, magazine articles,
ROUTINE TESTING FOR ALL 31
podcast, social media and interviews to share the favorable outcomes achieved through this
innovation as a continued way to socialize HIV testing and destigmatize HIV. The project Gantt
Chart is located in Appendix A.
Implementation Barriers and Facilitators
Startup funds are generated by ACA and the SPNS, both of which are in jeopardy of
being eliminated or altered (National Minority AIDS Council, 2017). In effect, $750,000 in
RTFAs revenue would be lost if the budget is passed as is. Thus, RTFA’s proposed partnership
with the pharmaceutical industry is an example of outer context implementation facilitator of
funding ripening the environment to ensure buy in from key stakeholders, the medical
community and our elected officials. The pharmaceutical industry’s influence in the American
healthcare landscape is well documented and appreciated for its ability to push an agenda
forward, and here lies the strength of RTFA’s partnership with this industry. By collaborating
with the pharmaceutical industry during the preparation phase, RTFA stands to prevent the
spread of a preventable chronic disease.
Measuring RTFAs Impact: Experimental/Evaluation Design
Key research question: Will offering an HIV test as part of the routine medical
appointment increase HIV testing?
To evaluate RTFA, we will recruit 2000 participants to evaluate the demonstration
projects program effectiveness. The randomized control group will consist of 1,000 individuals
who are not enrolled in the demonstration project as a comparison group and 1,000 individuals
enrolled in the RTFA demonstration project. The 1,000 non-enrolled individuals will be recruited
from a community clinic similar to the demonstration project site, offering similar services.
Threats to internal validity with the treatment and comparison groups include history, selection,
ROUTINE TESTING FOR ALL 32
instrumentation and testing. Participants in the treatment group will include those who have had
HIV testing offered to them as part of the standard medical assessment routine primary care
appointments. To understand how RTFA (testing patients ages 13 to 99 for HIV without written
consent,) affects HIV testing, participants will be asked if they have ever been tested for HIV
prior to this medical appointment at the end of the visit. The comparisons group’s data will be
collected at the same intervals as those of the treatment group.
The goal is to measure RTFA success against CDCs HIV testing, treatment and viral
suppression data. Currently, CDC is reporting 45% of the U.S. adult population has been tested
for HIV in their lifetime. Of the people who are HIV positive, 30% are virally suppressed and
39% are in appropriate HIV care and treatment. At the end of Year 1, we expect that the
demonstration project data will yield better results than what the CDC is currently reporting,
meaning the control group will exceed the CDC’s HIV testing, viral suppression and HIV
treatment data. The table in the appendix illustrates our anticipated outcomes.
Summary Statement
Creating a public health policy that supports routine HIV screenings for all people 13 to
99 years of age will accomplish the goal of destigmatizing, demystifying and providing adequate
information on HIV/AIDS to the general population. Currently, HIV testing is only compulsory
in the United States for organ and blood donors and for those seeking entrance into the military
as well as active duty service members (The Henry J. Kaiser Family Foundation, 2016).
Direct and Indirect Links to Grand Challenge
The current U.S. HIV prevention strategy is in need of change, and RTFA will eradicate
HIV as our country has come to know it. Through a direct link to the Social Work Grand
Challenge of closing the health gap, RTFA would directly impact and improve the health of all
Americans by providing no-cost HIV testing. For those identified as HIV positive through RTFA
ROUTINE TESTING FOR ALL 33
efforts, the direct link to healthcare providers should halt the effects of untreated and
undiagnosed HIV. Additionally, RTFA would help prevent the infectious rates among HIV
negative persons.
Next Steps and Other Considerations
Routine HIV testing as a practice during standard health encounters dissipates HIV
testing stigma and offers everyone equal opportunity for testing regardless of race or sexual
orientation. Incorporating routine HIV testing into the U.S. healthcare system will offer those out
of HIV care an opportunity to reengage in care and treatment, make those who are unaware of
their status aware, provide patients with accurate and timely prevention information, connect
those in need to medication, and, ultimately, normalize this testing.
General Insights and Overarching Conclusions
With the recent change of administration and political ideology, many of the government
public health care policies that support the care, treatment and prevention of HIV are in jeopardy
of being reimagined, and this uncertainty will require flexibility in how RTFA is implemented. It
is possible that RTFA may need the backing of the pharmaceutical industry before it receives
government support due to the pharmaceutical industry’s aggressive and persuasive lobbying
arm and relationship with elected officials. A major pharmaceutical company may need to
sponsor the demonstration project and convene a working group to revise the CDC’s testing
recommendations. While, this alliance with the pharmaceutical industry may not be palatable to
those in the public health arena, as the pharmaceutical industry has been demonized for its
entrenched and at times questionable influence on the U.S. healthcare system, public health
advocates must keep the goal of RTFA in focus. If an alliance with the pharmaceutical industry
ROUTINE TESTING FOR ALL 34
will meet that goal, then it should be formed to eliminate the possibility of HIV in one
generation.
Lastly, and maybe most importantly, the health disparities people of color experience in
the U.S. healthcare system is sewn into the foundational fabric of this nation. The systematic
state sanctioned oppression of people of color was and is still profitable. Equity, while good
intentioned, attempts to right the wrong of America’s present and past consequentially,
stigmatizing marginalized people. The public health infrastructure is no David to the Goliath of
institutional and generational racism. And knowing, that this system cannot remedy four hundred
years of oppression, practitioners must look for new ways to improve health outcomes of people
of color without adding additional stigma. Routine HIV testing offers equality for all and
normalizes HIV testing.

ROUTINE TESTING FOR ALL 35
Appendix A
Routine Testing for All Logic Model
INPUT PROCESS /
ACTIVITIES
OUTPUT OUTCOME IMPACT

Convene a
working group
of public, private
and citizenry
experts of HIV
care, treatment
and prevention.

To review the
Centers for
Disease Control
and Prevention
2006 HIV testing
recommendations.

Partnerships are
formed with
federal, local, for
profit and private
HIV care,
treatment, and
prevention
stakeholders.

Revised HIV
testing guidelines
that include
frequency of
testing, extends
the age of testing
from 64 years old
to 99 years old,
and eliminates
the high-risk
designation to
make the
guidelines P.

Raise attention and
awareness and
sharpen clinical
recommendations.

Engage
pharmaceutical
companies in
promoting
routine HIV
testing to current
and future
medical
professionals
through existing
marketing
channels.

Increase
awareness of
benefits of routine
HIV testing and
CDCs testing
recommendation
among medical
professionals.

Increased
community access
and participation in
health promotion,
disease prevention,
and spread of
HIV/AIDS.

Relevant and
timely HIV testing
recommendations
to develop clinical
guidelines for HIV
testing and made
available to
medical
professionals.

Improved
medical
community
knowledge that
should translate
into practice of
the benefits of
routine HIV
testing.

Identify, treat,
and link to care
individuals that
are HIV+

Providers should
provide better HIV
care and
prevention.

ROUTINE TESTING FOR ALL 36

Competent and
sufficient staff to
implement
routine HIV
demonstration
project.

Indiscriminately
offer HIV testing
to all at two
internal/primary
care medicine
practices for one
year.

Develop clinical
guidelines and
promotional
materials for
routine HIV
testing for
medical
professionals and
public.

Routine testing
public service
campaign and
pharmaceutical
advertisements
developed.
Increased number
of medical
professionals
practicing routine
HIV testing in
their practices.

Increased public
awareness of
benefits of
routine HIV
testing.
Improved health
outcomes.

ROUTINE TESTING FOR ALL 37
Appendix B

Financial Plan
Budget Format and Cycle:
RTFA will utilize a one-year line item budget that coincides with the federal fiscal year; October
1, 2019 through September 30, 2020.
Revenue Projections
For the purposes of this paper, the rate of reimbursement for HIV testing will reflect the NY
DACs ($102.00 USD) in lieu of the Georgia State Medicaid office’s rate which was not available
at the time of completing this assignment (Lubinski, n.d ).
Projected Revenue Calculations
$102.00 (HIV testing reimbursement) x 10,000 (# of people to be screened in Year 1) =
$1,020,000.00 (projected revenue)
Phases of Intervention
Universal HIV testing is a prevention and treatment strategy based on the sound research which
shows routinely testing for the HIV virus is cost effective, prevents new HIV infections (), and
outweighs any potential harm that testing poses to the patient (Sifferlin, 2013; Walensky et al.,
2007). RTFA has two tracks: Track 1 for individuals confirmed HIV negative through testing
and Track 2 for individuals confirmed positive through testing.
Track 1 (HIV negative)
Test: HIV testing to occur during routine medical appointments with medical professionals.
Results: Results and HIV prevention strategies shared with patient.
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Repeat: HIV testing to occur no earlier than one year from last HIV negative test or new sexual
partner, whichever occurs first.
Track 2 (HIV positive or inconclusive HIV test)
Test: HIV testing to occur during routine medical appointment with medical professional
Results: Results shared with patient.
Counsel: Immediate counseling provided to patient by a licensed mental health professional.
Provide patient with 24-hour crisis hotline information.
Confirm: Blood sample sent to the laboratory to confirm rapid test results.
Treat: Patient prescribed preliminary antiretroviral medication through medical appointment with
HIV doctor.
Refer: Patient is warmly handed off to HIV doctor and services.
Termination: No need for continued HIV testing.
Units of Service
Definition: Number of rapid HIV test administered during a routine medical visit under the
proposed revisions to the 2006 CDC universal HIV screening recommendation.
Measuring units of service in this way will allow for the comparison of the two site locations
HIV prevalence rates against the national and regional averages. This will allow for a cost
benefit analysis to be conducted to measure the efficacy of the program.
Staffing Plans & Costs
RTFA demonstration project will be funded by a grant mechanism through DHHS and will be
subject to the salary limitations on grant funds which states grant funds may not be used to pay
the salary of an individual at a rate in excess of $183,300, or ($88.12 per hour); this amount
reflects an individual’s base salary, exclusive of fringe benefits, and any income that an
individual may be permitted to earn outside of the duties to the applicant organization. This
ROUTINE TESTING FOR ALL 39
salary limitation also applies to sub-awards/sub-contracts for substantive work under a DHHS
grant or cooperative agreement (45 CFR 75, at § 75.404).
Demonstration Project Annual Staff Salaries
Nurse, BA (2) $63,992.00 Licensed Practical Nurse (2)
$41,219.00

Licensed Mental Health
Provider (2) $64,868.00

Nurse Practitioner (2)
$96,916.00
Physician Assistant (2)
$91,054.00
Social Science Evaluator (1)
$61,289.00
Social Science Evaluator
Assistant (2) $45,000.00
Medical Doctor (2)
$183,300.00
Project Director (1)
$85,000.00
*Salaries based on federal grant salary limitations and Georgia state average salary for each
profession.

Other Spending Plans and Costs
In a study conducted by Pinkerton et al. (2010), the mean cost for rapid HIV test was
$14.94 per test. This cost will be used to derive the cost of the rapid test used for RTFAs
demonstration project. While the first-year projections are for 10,000 patients tested, 5,000 more
test will be ordered to account for staff training, test malfunctions and potential user error.
$14.94 x 15,000 = $224,100
Additionally, in Year 2 of the RTFA demonstration project, a training program will be
developed for medical practitioners along with a strategic plan on how to socialize the CDC’s
2006 HIV testing recommendation through public/private partnership to include pharmaceutical
companies. This work will require a consultant agency to assist in Year 1 with pulling data from
the demonstration project and other sources to begin this work in Year 2. Utilizing the federal
cooperative agreement funding structure will allow for DHHS to have substantial involvement in
the activities outlined in the agreement (DHHS, 2016). Awarding a grant or contract to carry out
this work would place DHHS in a monitoring or oversight position and this is undesirable as
DHHS, NIH, CDC and HRSA inform the standards for care, treatment and research surrounding
ROUTINE TESTING FOR ALL 40
HIV in the United States. A cooperative agreement will allow for DHHS to influence and guide
the work in a way a grant or cooperative agreement would not. The consultant agency would
begin in the middle of Year 1, allowing for a substantial amount of data to be collected through
the demonstration project.
Consultant Agency Cost Estimates: $500,000 year 1.
Consultant agency cost will be funded through a multi-year cooperative agreement in
which DHHS will sponsor and write the terms of each year of the agreement.
Routine Testing for All Itemized Budget
Revenues
HIV Testing Reimbursement $1,020,000.00
DHHS Grant $750,000
Total Revenue $1,770,000
Expenses
Staff Salaries $606,080.20

Fringe $240,006.00
Total Personnel $846,086.20
Non Personnel Cost (Cooperative
Agreement)
$500,000
Travel $6,000.00
Supplies $230,375.00
Printing $500.00
Total Non-Personnel Cost $736,875.00
Total Expenses $1,582,961.20
Projected Surplus $187,038.80

Revenue vs. Costs
Based on the estimates for year one of RTFA there is a projected surplus of $187,038.80
which will be reinvested into the program for future activities. Additionally, the surplus could be
used for unforeseen expenses.

ROUTINE TESTING FOR ALL 41
Table 1
People tested for HIV
CDC Baseline: 45%
PLWHA in treatment
CDC Baseline: 30%
Viral Suppression Rate
CDC Baseline: 39%
Control: 45%
Vs
Treatment: +45%
Control: 39%
Vs
Treatment: +39%
Control: 30%
Vs
Treatment: +30%

Table 2
Supporters of Routine HIV Testing
American Academy of
Family Physicians
American Academy of
HIV Medicine
American Academy of
Pediatrics
American College of
Physicians
American College of
Obstetricians and
Gynecologists
American Medical
Association
Society of General
Internal Medicine
U.S. Preventive Services
Task Force
National Medical
Association
HIV Medicine
Association
National Hispanic
Medical Association

Brown, M. (2013). AAFP, USPSTF recommend routine HIV screening but differ on age to begin.
Retrieved from http://www.aafp.org/online/en/home/publications/news/news-now/health-
of-the-public/20130429hivscreenrecs.html
Branson, B.-M., Fenton, K., Hauschild, B.-C., Miller, V., & Mayer, K.-H. (2008). Opt-out
testing for Human Immunodeficiency Virus in the United States. JAMA, 300(8), 945–
951.
U.S. Preventive Services Task Force Recommendation. (2013). Human Immunodeficiency Virus
(HIV) infection: Screening. Retrieved from https://www.uspreventiveservicestaskforce.
org/Page/Document/UpdateSummaryFinal/human-immunodeficiency-virus-hiv-
infection-screening

ROUTINE TESTING FOR ALL 42
Appendix C

Equity and Equality Reimagined

Interaction Institute for Social Change. (2016). Illustrating equality vs equity. Retrieved from
http://interactioninstitute.org/illustrating-equality-vs-equity/

Stigma
Stigma
Stigma
Routine HIV Testing as an environmental change
ROUTINE TESTING FOR ALL 43

ROUTINE TESTING FOR ALL 44

ROUTINE TESTING FOR ALL 45
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Abstract (if available)

Abstract The foundation of the United States of America has been structured and shaped by inequality and disproportionality. The roots of the nation manifest in every facet of American life, including the healthcare system. The Social Work Grand Challenge of closing health gaps in the United States seeks to highlight the disproportionately poorer health outcomes people of color consistently experience (Walters et al., 2016). The American Academy of Social Work and Social Welfare Close the Health Gap work group urges policy makers to make explicit commitments to eliminating health disparities at individual and population levels by eliminating negative social determinants that have become foundations to health conditions and outcomes (Walters et al., 2016). People of color experience disease at much higher rates and at deadlier rates than their White counterparts, which requires the public health community to view U.S. prevention and care strategies through an innovative and transformative lens.

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Asset Metadata

Creator Worrell, Monique M.C. (author)

Core Title Routine testing for all (RTFA): U.S. HIV prevention innovation proposal

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 10/24/2019

Defense Date 12/19/2018

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag AIDS,equality,equity,HIV,Justice,OAI-PMH Harvest,racial disparities,routine testing

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Singh, Melissa (committee chair), Manderscheid, Ron (committee member)

Creator Email monique_worrell@yahoo.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-228789

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Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

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