Medical Lab Management: What is the primary mission of the HIV counseling, testing, and referral services at the Oklahoma State Department of Health?

Maria Srouji: The role of the HIV counseling, testing, and referral services of the Oklahoma State Department of Health (OSDH) includes funding five community based organizations (CBOs) in their efforts to identify individuals newly infected with HIV (or those who are unaware of their status) and link them into proper care as quickly as possible.

Of the five CBOs supported by the OSDH, three are located in Oklahoma City and two are in Tulsa; these cities represent the two largest metropolitan statistical areas for HIV in the state. Each of these CBOs employ staffs trained by the health department on proper HIV testing and identification, as well as counseling. While each CBO determines its own areas of outreach and the manner in which it conducts its testing activities, we do require each CBO to identify at least one percent of new infections to the OSDH over the course of a year. This helps us identify areas at greater risk for HIV transmission, as opposed to conducting blanket testing.

MLM: What system do you use to gather information on and report the activities of the CBOs to the CDC?

Srouji: Some practitioners may be aware of the CDC’s program evaluation and monitoring system for reporting HIV statistics, and we use a similar system that allows our contracted CBOs to input their data for us to aggregate. These data include the session date (ie, the number of tests given on a specific date and location), demographic information, and relative risk levels. After the CBOs enter their information, the OSDH is able to analyze the aggregate data and determine where we need to direct our resources.

As part of this analysis, within the testing protocol, there is a question for the client as to whether he or she has had an HIV test before, and if the answer is yes and the test was positive, we know that this is not a newly infected individual. By differentiating between newly infected and previously infected, the OSDH can better allocate its resources.

MLM: How are rapid HIV test kits used in this process?

Srouji: Working with a limited budget, the OSDH collaborates with various state agencies and foundations to provide as many rapid testing kits to the CBOs as possible. Some CBOs that perform large numbers of tests have alternative funding and can purchase their own test kits, but given our status as a state government program, we do not require our CBOs to use a specific vendor of rapid HIV testing kits.

Since March 2014, the OSDH has required a double rapid confirmatory process. If a positive result is obtained from an initial rapid HIV test, we require a second rapid test to be performed using a different vendor’s testing product than the first one. The second test must utilize a blood sample, as opposed to an oral test, which is admissible for an initial test. However, we advise our CBOs to avoid using oral test kits, especially in areas of greatest risk, because if a client tests positive using an oral kit, the CBO must then perform two additional blood-based rapid tests anyway to confirm the result.

Given the stipulation to use a different product for the second, confirmatory test, we train CBO staff on using multiple test kits from the various vendors. The CBOs that contract with the state and receive funding and testing kits from the OSDH tend to be those that do the most testing (ie, higher risk areas) and also rely almost entirely on blood-based rapid test kits. Some of the smaller CBOs around the state (particularly those that do not receive funding or materials from the state) do sometimes use oral test kits, and we are aware that the risk tends to be much lower in these areas with few instances of positive results.

MLM: How does the OSDH work with the CBOs on managing the handling of HIV test kits?

Srouji: For those CBOs under contract with the OSDH, we help train new testing and counseling staff on the basics of blood testing, such as using a lancet and properly taking a sample from a finger stick, as well as the application of universal precautions. After an initial three-day training course on counseling skills for HIV, each new CBO staff member receives further guidance from OSDH on managing the testing and counseling process. On occasion, we invite representatives from rapid HIV test kit vendors to come in and demonstrate their products and train CBO staff on proper use. We have had representatives from all the vendors of rapid HIV test kits come in to present and train.

MLM: What is the process once a client has been identified as HIV positive?

Srouji: The two most important actions subsequent to a positive HIV test result is bringing in a disease intervention specialist (DIS) to help perform partner notifications and guide the HIV positive client into care. Fortunately, the DIS program in Oklahoma is well-established and has an excellent rapport with CBO staffs.

MLM: What is the overall impact of rapid HIV testing kits on HIV management?

Srouji: A great benefit of rapid HIV testing is the ability to perform testing in a variety of settings. Outreach and rapid testing go hand-in-hand in this regard as conventional methods for HIV blood testing are not practical in a nightclub or public park.

It is worth noting that in Oklahoma and across the country, we are seeing a significant increase in syphilis-positive individuals, so we have begun testing all clients who are HIV positive for syphilis as well (currently, there is a single, FDA-approved rapid syphilis test on the market, although others are in various trial stages). The OSDH public health lab provides rapid syphilis tests for our CBOs (who also acquire their own tests) as well as DIS staff for use in the field. Thus, most of our counselors and all of our DISs are trained phlebotomists.

MLM: What do you see as the future of rapid HIV tests?

Srouji: Interestingly, the last several rapid HIV testing company representatives we brought in for product training have indicated they are looking into combining HIV and syphilis testing into a single rapid kit, which is highly anticipated by our operation, as I am sure it is for many others.

Also of note, some companies are looking at testing for antigens as well as antibodies, as most of the current rapid test kits only test for the antibody at this point. The challenge is that there is a period of time between when an individual is exposed to HIV and when the antibody is developed. So, the rapid test companies are looking to close that window by having a test that identifies the antigen or identifies the antibodies in a shorter period of time. In the meantime, we chose to address this issue by performing a second rapid HIV test (using a different vendor product), because each rapid test requires a different time period between exposure and antibody development.

Maria Srouji, MS, recently retired as the manager of HIV counseling, testing, and referral services at the Oklahoma State Department of Health.