HIVTestingImplementationGuide_Final

Front cover: planning and implementing HIV testing and linkage programs in non-clinical settings: a guide for program managers

Planning and Implementing HIV Testing and Linkage Programs in Non-Clinical Settings
Table of Contents
Table of Contents
Acknowledgements
Chapter 1. About the Implementation Guide
Chapter 2. Getting Started—Preparing to Implement HIV Testing and
Linkage in Non-Clinical Settings
Chapter 3. Targeting and Recruitment
Chapter 4. Risk Reduction
Chapter 5. HIV Tests and Testing Strategies
Chapter 6. Implementing HIV Testing in Non-Clinical Settings
Chapter 7. Referral and Linkage to Health and Prevention Services
Chapter 8. HIV Testing in Outreach Settings
Chapter 9. Quality Assurance and Monitoring and Evaluation
Appendices
A. Glossary
B. Resources
C. Toolkit
D. Templates

Acknowledgments ● Page 1 of 2
Acknowledgements
The Planning and Implementing HIV Testing and Linkage Programs in Non-Clinical Settings: A
Guide for Program Managers (hereinafter referred to as the Implementation Guide) was
created to support planning, implementation, and evaluation of HIV testing and linkage
services in non-clinical settings. The Implementation Guide was developed by ICF Macro Inc.,
which was acquired by ICF International, with funding made available by the Centers for
Disease Control and Prevention (CDC contract #200-2009-30981-0014-0002). The National
Alliance of State and Territorial AIDS Directors (NASTAD) assisted with the development of
this guide under a subcontract with ICF Macro.
To provide direction in the development of the Implementation Guide, an advisory board
composed of 18 representatives of health departments and community-based organizations
was convened. The advisory board met by conference call 13 times between October 2011
and June 2012, with each call addressing a specific content area of either the Implementation
Guide or the Evaluation Guide. A 3-day, face-to-face working session was also held with seven
representatives of the advisory board to work through resource gaps and refine the tools
included in the guides. Advisory board members were asked to share resources and identify
gaps in support necessary for the implementation of HIV testing and linkage, to care as well
as to discuss current practices, challenges, and successes in the field.
CDC would like to acknowledge the advisory board, ICF Macro, and NASTAD team members:
Advisory Board
Jessica Almeida, Brockton-Area Multi Service, Inc.
Jamie Anderson, Kansas Department of Health and Environment
Nicole Brennan, Ohio Department of Health
Heather Bronson, Virginia Department of Health
Jose De La Cruz, Desert AIDS Project
Jacob Dougherty, Diverse and Resilient, Inc.
Eddie Eagle, Making a Daily Effort (M.A.D.E.)
Elaine Esplin, Comprehensive AIDS Program of Palm Beach County

Acknowledgments ● Page 2 of 2
Jenna McCall, Maryland Department of Health and Mental Hygiene
Pete Moore, North Carolina Department of Health and Human Services
Robin Pearce, NO/AIDS Task Force
Sophia Rumanes, Los Angeles County Department of Public Health
Neena Smith-Bankhead, AID Atlanta
Jon Stockton, Washington State Department of Health
Ben Tsoi, New York City Department of Health and Mental Hygiene
Angela Wood, Family and Medical Counseling Services, Inc.
CDC also wishes to thank these individuals who provided additional input and resources:
Barry P. Callis, Massachusetts Department of Public Health
Loretta F. Dutton, New Jersey Department of Health and Senior Services
Ainka Gonzales, AID Atlanta
Jean Haspel, AtlantiCare Regional Medical Center
Jeff Hitt, Texas Department of State Health Services
Mary Beth Levin, Georgetown University School of Medicine
David Ponsart, Arab Community Center for Economic and Social Services
Royale Theus, Michigan AIDS Coalition
ICF Macro
Tamara Lamia, TaNisha Prater, Jessica Wals
NASTAD
Jillian Casey, Natalie Cramer, Lorraine Denis-Cooper, Joy Mbajah, Liisa Randall (consultant),
Lynn Shaull
CDC
Rashad Burgess, Janet Cleveland, Cindy Getty, Kathleen Irwin, Priya Jakhmola, Andrea Kelly,
Amrita Patel

Chapter 1 ● Page 1 of 7
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The Pl
Guide
clinica
Chapter 1. About the
Implementation Guide
CHAPTER 1 AT A GLANCE
This chapter provides an overview of the Implementation Guide. In this chapter we do the
following:
Summarize the process for developing the Implementation Guide
Describe the audience for the Implementation Guide
Explain the organization and use of the Implementation Guide
anning and Implementing HIV Testing and Linkage Programs in Non-Clinical Settings: A
for Program Managers (the Implementation Guide) supports implementation, in non-
l settings, of HIV testing and linkage to care and prevention services. The
Implementation Guide and accompanying toolkit is intended to be used in conjunction with
the Evaluation Guide for HIV Testing and Linkage Programs in Non-Clinical Settings (hereafter
referred to as the Evaluation Guide) for optimal implementation support. The information,
tools, and practice examples included in the Implementation Guide are intended to assist
organizations such as health departments (HDs) and community-based organizations (CBOs)
that operate in non-clinical settings to plan and implement HIV testing and linkage services in
these settings. Agencies already providing HIV testing and linkage services in non-clinical
settings can strengthen these services by using the information and tools contained in this
Implementation Guide.
The Importance of HIV Testing in Non-Clinical
Setting
More than 1.2 million people are living with HIV in the United States and approximately
48,000 new infections occur each year.1
About 70% of sexually transmitted cases of
HIV are attributed to persons who are unaware of their HIV-positive status, and nearly 50%
of people who test positive for HIV are diagnosed with AIDS within 3 years.2,3
1
Prejean, J., Hernandez, A., Ziebell, R., Green, T., et al. (2011). Estimated HIV Incidence in the United States, 2006-
2009. PloSOne 6(8):e17502.doi:10.1371/journal.pone.001
2
Marks, G., Crepaz, N., & Janssen, R. S. (2006). Estimating sexual transmission of HIV from persons aware and
unaware that they are infected with the virus in the USA. AIDS, 20(10), 1447–1450.
3
Centers for Disease Control and Prevention. (2009). Late HIV testing—34 States, 1996–2005. Morbidity and
Mortality Weekly Report, 58(24), 661–665.

This indicates persons most at risk for contracting HIV or who may present with early
infections are not being reached by the clinical and non-clinical HIV testing approaches used
to date. 4
Non-clinical settings are settings in which medical, diagnostic, and/or treatment services are
not routinely provided. However, non-clinical HIV testing programs provide selected
diagnostic services (HIV testing) and selected prevention services (risk-reduction
interventions), and can facilitate access to other medical and social services for clients with
positive or negative test results. Providing HIV testing services in non-clinical venues
facilitates access for individuals who may not access these services through other health care
providers, those who may be testing for the first time, or those at highest risk of acquiring HIV
who would benefit from repeated testing.5
Examples of non-clinical settings in which HIV testing and linkage services could be provided
include mobile testing units, churches, CBOs, bath houses, parks, shelters, syringe services
programs, and other social service organizations. Offering testing in these venues allows
providers to strategically target their services to individuals at highest risk of becoming HIV
infected in their community. By collaborating and building a service network with other local
providers, agencies which provide HIV testing in non-clinical settings can facilitate access to a
more comprehensive set of prevention and care services in the community.5
Provision of HIV
testing in non-clinical settings can also play a key role in linking newly diagnosed and
previously diagnosed HIV-positive persons to medical care and treatment. This link is critical
in increasing access to and utilization of antiretroviral therapy (ART), as well as supporting
retention in medical care and good ART adherence. These factors contribute to HIV-positive
persons living longer and healthier lives.6,7,8
4
Giradi, E., Sabin, C. A., & Monforte, A. D. (2007). Late diagnosis of HIV infection: Epidemiological features,
consequences and strategies to encourage earlier testing. Journal of Acquired Immune Deficiency Syndromes, 46,
S3–S8.
5
Bowles, K., Clark, H. A., Tai, E., Sullivan, P. S., Song, B., Tsang, J., et al. (2008). Implementing rapid HIV testing in
outreach and community settings: Results from an advancing HIV prevention demonstration project conducted
in seven U.S. cities. Public Health Reports, 3, 78–85.
6
May, M. (2011). Impact of late diagnosis and treatment on life expectancy in people with HIV-1: UK
Collaborative HIV Cohort (UK CHIC) Study. BMJ, 343, d6016.
7
Montaner, J. (2006). The case for expanding access to highly active antiretroviral therapy to curb the growth of
the HIV epidemic. The Lancet, 368, 531–536.
8
Centers for Disease Control and Prevention. (2011). CDC trial and another major study find PrEP can reduce risk of
HIV infections among heterosexuals. Retrieved January 12, 2012, from the NCHHSTP News Media Line:
http://www.cdc.gov/nchhstp/newsroom/PrEPHeterosexuals.html

Purpose of the Implementation Guide
Since the release in 2001 of CDC’s Revised Guidelines for HIV Counseling, Testing, and Referral,9
there have been substantial improvements in HIV testing technologies which allow us to
identify infection earlier. Approaches to treatment of HIV have continued to evolve and can
dramatically improve the health of individuals living with the infection. Research has
identified new strategies to locate, engage, and motivate high-risk individuals to accept HIV
testing, and to facilitate access to important prevention, medical and social services to clients
with positive tests and clients with negative tests. More is now known about strategies that
can reduce the risk of infection, and there are many behavioral interventions that are
demonstrably effective in promoting safer behaviors.
This Implementation Guide will help non-clinical testing programs implement strategies that
are new or have greater emphasis in revised and forthcoming CDC recommendations
including:
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Defining and targeting high-risk populations that are likely to have an HIV prevalence of
1% or more.
Identifying effective recruitment strategies to locate members of these target
populations.
Using streamlined methods to identify members of the target population.
Using field-tested recruitment methods to motivate members of the target population
to accept testing.
Offering the most sensitive HIV tests that are feasible in the program.
Assessing the possibility of very recent exposure (≤72 Hours) to make appropriate
referrals for non-occupational post-exposure prophylaxis (nPEP).
Assessing the symptoms of acute antiretroviral infection before testing to determine the
need to offer or refer clients for tests that detect acute infection.
Linking newly identified clients with positive tests to HIV medical care on the basis of
either an initial or supplemental HIV test result.
Providing clients with new positive test results, a basic needs assessment that would
guide decisions on the provision/linkage/referral to appropriate medical, prevention,
and support services. Providing persons previously diagnosed with HIV with the
opportunity to re-test for HIV (e.g., to document HIV status that determines eligibility for
medical or social services) and assistance with linkage to or re-engagement in HIV
medical care.
Classifying clients with negative tests into two categories of risk for acquiring infection
(elevated vs. not elevated) to identify clients that could most benefit from risk reduction
services.
9
Centers for Disease Control and Prevention. (2001, November 9). Revised guidelines for HIV counseling, testing
and referral. Morbidity and Mortality Weekly Report, 50(RR19), 1–58.

• Providing to all clients with negative test results classified as having “elevated” risk a
prevention needs assessment to identify factors that may influence risk of HIV
acquisition.
Providing, linking, or referring all clients with negative tests who are classified as having
“elevated” risk to risk-reduction interventions and other medical and social services
identified in their prevention needs assessment.
This Implementation Guide was developed to assist you in implementing an HIV testing
and linkage program that makes use of these new insights about effective ways to
identify and serve persons at high risk of HIV infection. This Implementation Guide can
also assist you in optimizing the effectiveness and efficiency of your HIV testing and
linkage program. Systematic and data-driven planning, use of monitoring and
evaluation (M&E) data for program improvement, and community engagement and
collaboration are critical elements of a successful program and are addressed in detail in
this Implementation Guide.
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Through adoption of the strategies discussed and tools and samples included in this
Implementation Guide, you can strengthen your HIV testing and linkage program. In doing
so, you can increase the number of individuals who are aware of their serostatus and provide
critical prevention, medical, and social services to clients after they receive their test results.
Audience for the Implementation Guide
The information presented within these pages is targeted to program managers, conducting
HIV testing, providing risk reduction services, and linkage to care and prevention services in
non-clinical settings. Agencies implementing new HIV testing and linkage programs or
refining existing programs can benefit from using the information and tools included in this
guide. Organizations that fund or provide operational direction to non-clinical HIV testing and
linkage services can also use the information and tools to help provide guidance and
technical assistance to the programs they support.
The concepts and activities covered in the Implementation Guide are relevant to all non-
clinical testing programs, regardless of their funding source, data reporting requirements, or
capacity. Each agency has unique needs and priorities when it comes to program planning,
delivery, and improvement. This guide presents a comprehensive look at planning and
implementation and encourages you to use the concepts and information presented to
identify and adopt strategies that are concepts and create a customized approach that is
locally relevant, appropriately scaled, and useful.
Throughout this guide, we use the terms “strategy” and “strategies” in relation to the
component services of an HIV testing program (e.g., “recruitment strategy”). In this guide,
strategy refers to a set of activities (such as risk reduction interventions) and application of
tools (such as HIV tests) that are intended to achieve a program goal or objective.

Organization and Use of the Implementation
Guide
The Implementation Guide is organized by topic area. Where applicable, accompanying tools
and templates are displayed in the text and can be found in Appendices C and D. Readers are
encouraged to reference the Evaluation Guide for further guidance on monitoring and
evaluation of non-clinical HIV testing and linkage programs.
The following chapters are organized in a way that reflects the natural progression from
program planning to evaluation. However, the information in each need not be used in that
order. Program planning and implementation is an iterative and ongoing process that must
respond to changes in target populations, recruitment strategies, HIV test technologies, and
provision of services after clients learn their test results and program goals and capacity.
Programs aiming to refine an established program strategy, for example, may find sections on
quality improvement more useful than sections on basic program planning.
Likewise, the individual chapters of the Implementation Guide can be used independently. A
program that is revising its targeting and recruitment strategy but not its risk reduction
services might only consult the targeting and recruitment chapter. To improve the utility and
completeness of each chapter to “stand alone”, some information is repeated in more than
one chapter, (e.g., quality assurance and M&E). Important references to other chapters or
sections within the Implementation Guide are noted within each chapter.
How New Programs Can Use the Implementation Guide: The Implementation Guide is
designed to assist you in planning your HIV testing and linkage program. The Implementation
Guide will take you through the key steps of program implementation, including formative
evaluation, planning for delivery of services, as well as M&E of the program. Tools included in
the Implementation Guide will help you to plan your program and assess your capacity to
implement services.
How Established Programs Can Use the Implementation Guide: If you have already
implemented an HIV testing and linkage program, you can use this Implementation Guide to
help you to strengthen your program. The information and tools included in the
Implementation Guide can help you assess the extent to which your program is meeting the
needs of your target population, as well as the kinds of strategies or practices that could help
you to better meet community needs and build your capacity to provide these services.
It is good practice to assess your program on a regular basis. Many agencies do this as part of
annual or semiannual program planning and improvement activities. It is always a good idea
to reassess program practices when substantial changes occur in your agency (e.g., staffing
changes) or community (e.g., changes in health and social services in the community). It is
also a good idea to reassess program practices in light of new technologies (e.g., availability
of new HIV tests) or advent of new strategies and tools.

Established programs may choose to use the information and tools included in the
Implementation Guide to assess the status of an HIV testing and linkage program. In this case,
it may be useful to go through the guide chapter by chapter, completing all of the tools. This
approach will also result in a baseline inventory of your program and program practices that
can serve as a reference and can be updated as needed.
Alternately, established programs may choose to focus on assessing and improving one or
two components for the HIV testing and linkage program (e.g., referral and linkage to care). In
this case, you may wish to use the chapters and tools that are relevant to that program
component.
How Health Departments and Other Funders Can Use the Implementation Guide: Health
departments and other funders may wish to use the Implementation Guide in providing
training or technical assistance to grantees or contractors. You could use the entire
Implementation Guide, individual chapters, and/or selected tools to assist agencies that are
just beginning a new program, or for agencies that seem to be struggling with program
implementation. Some HDs or other funders may wish to have grantees or contractors
complete program planning and implementation on the basis of information and tools
included in the Implementation Guide at the beginning of a project (e.g., as a component of a
funding proposal) or on a regular basis (e.g., at the beginning of each contract cycle) as a
means to assess and monitor capacity to provide HIV testing and linkage services. The
Implementation Guide and its tools could also be used as a reference for or foundation of
program standards and practices. Health departments and other funders can adapt the
information and tools included in the Implementation Guide to suit local needs by adding or
adjusting the content to reflect local policies, regulations, or requirements.
Identifying Helpful Hints
As we move through concepts and exercises that relate to HIV testing in non-clinical settings,
we will pause to highlight helpful hints. The call-out boxes below are examples of the types of
information that will be provided.
Tip
Tips include “from the field” advice or helpful hints from your HIV prevention colleagues that will help
you perform HIV testing and linkage activities.
Recommended Activity
Recommended activities are strategies or practices that reflect the optimal way of providing services.
Tools and Templates
Tools and templates will help you construct and document your HIV testing program. They can be
tailored by your agency to reflect local needs and will help you determine agency capacity, prevention
priorities, services for delivery, and so forth.

Accompanying Resources
A guide to evaluating non-clinical testing programs the Evaluation Guide for HIV Testing and
Linkage Programs in Non-Clinical Settings is an essential companion to this Implementation
Guide. The Evaluation Guide is consistent with CDC’s Framework for Program Evaluation and
provides tools and sample forms to assist agencies in implementing the six steps of
comprehensive M&E: engaging stakeholders, describing your program, focusing your
evaluation, gathering credible evidence, justifying conclusions, and ensuring use and lessons
learned.
Other Resources for HIV Testing
Non-clinical testing programs may receive funding or other operational direction or guidance
from one or more sources for your HIV testing and linkage services. These could include
Federal agencies such as CDC, foundations, state agencies like HDs, city HDs, or CBOs. These
entities often allocate funds to target specific populations, investigate new technologies, or
perform special studies that can gauge the effectiveness of interventions. They may require
that specific testing strategies or protocols are followed. This guide does not address the
specific requirements of these entities; rather, it provides examples and best practices of how
one might design and implement a program that may take these requirements into
consideration. For more information program design and planning requirements, please
contact these entities.
This guide addresses HIV testing and linkage in non-clinical settings, only. Additional
information about HIV testing in clinical settings is available from CDC and can be accessed at:
http://www.cdc.gov/hiv/topics/testing/healthcare/index.htm.

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Chapter 2. Getting Started—
Preparing to Implement HIV Testing
and Linkage in Non-Clinical Settings
This chapter addresses planning for program implementation. In this chapter we discuss
the following activities and processes for planning your HIV testing and linkage program:
Steps to plan your HIV testing and linkage program
Strategies to build your capacity to provide HIV testing and linkage
Conducting a community readiness assessment
Strategies for increasing community support for HIV testing and linkage services
Conducting formative evaluation and applying the findings to program planning
The tools and examples provided in this chapter will help you to do the following:
Assess community readiness
Assess program readiness to implement HIV testing
Design your HIV testing and linkage program
Assess the program’s capacity to provide HIV testing and related services
Conduct formative evaluation activities
Overview of HIV Testing in Non-Clinical
Settings
Non-clinical settings provide a key avenue to access HIV testing and linkage services for
individuals at greatest risk for HIV. This is particularly true for individuals who do not routinely
use health-care facilities. By providing clients access to prevention, medical, and social
services on-site or through external agencies, non-clinical testing programs can expand
access to a wide range of medical and social services that can help stem HIV transmission
improve health, enhance the quality of life, and prolong life.
Community Readiness Assessment
As the first point of contact to HIV testing and services for many members of your community,
non-clinical testing programs have the opportunity to provide services tailored to the unique
needs of various target populations. In order to do so successfully, however, they must
evaluate the community’s capacity and willingness to use these services.

A community readiness assessment can elucidate how your community currently provides
HIV testing and follow-up services to your target population. It can also reveal the extent of
awareness about HIV, the value placed on HIV testing and follow-up services; the potential
feasibility and acceptability of your program; potential partners and allies that can support
your program; and detractors and other obstacles to program implementation.
A community readiness assessment can also identify external stakeholders who can help you
to locate and engage your target population, provide prevention, medical and social services
to your program’s clients, or assist in evaluating your program. (See Evaluation Guide, Step 1:
Engaging Stakeholders.)
Several strategies can be used to collect information for the community readiness
assessment. These include review of documents of the communities HIV Planning Group (s),
key informant interviews and focus groups or community members who are interested in the
target population and/or providing HIV prevention and care services, or discussions at
established or specially convened community forums. (See Evaluation Guide, Step 4: Gather
Credible Evidence for more data collection strategies.) Examples of the individuals or
organizations that can contribute to your readiness assessment include health care providers,
social service providers, business owners, faith leaders, government officials (e.g., Mayor’s
office, health department), educators, as well as at-large community members.
Interviews, focus groups, and other group discussions with stakeholders and community
members are qualitative methods that cannot be standardized and must be tailored to the
circumstances of the program and the community. Exhibit 2.1 provides examples of various
topics that can be covered in the interviews for the readiness assessment.
Exhibit 2.1. Key Informant Interview Topics
Theme Question Topics
Knowledge and
awareness
• Awareness of the impact of HIV in the community
• Knowledge and awareness of who is affected by HIV
• Knowledge of HIV transmission
• Knowledge of available services
• Community recognition of the value of HIV testing and services
Attitudes • Community attitudes toward health services
• Community attitudes toward discussing health issues
• Community attitudes toward HIV
• Community attitudes toward HIV testing and services
• Leaders’ attitudes toward HIV testing and services
• Community attitudes toward discussing sex and drug use
• Community attitudes toward the target population
Norms • Community norms and values regarding behaviors and practices that increase risk
for HIV
• Community norms regarding use of health services, including HIV services
• Cultural, economic, political, and other issues that impact utilization of HIV services
Access • Where members of the community go for health services
• Who provides health services in the community
• Acceptable and accessible venues for provision of HIV services
• Barriers to access

Leveraging the Assessment to Increase Readiness
After collecting information from stakeholders and community members, you can draft a
Framework for Assessing Community Readiness that illustrates stages of readiness, program
goals suitable for that stage, and strategies to increase a community’s readiness to support
and utilize a non-clinical testing program (Exhibit 2.2.)1
This framework is useful for explaining
program issues to stakeholders and can be revised periodically as you collect ongoing
feedback from community members.
Exhibit 2.2. Framework for Assessing Community Readiness for a Non-Clinical HIV
Testing Program
Readiness
Stage
Stage Description Stage Goal
Ideas for How to Meet the Goal and Move to
the Next Stage of Readiness
No awareness
stage
Issue is not generally
recognized by the
community members
or leaders as a
problem (or it may
truly not be an issue).
Raise
awareness of
issues –
regarding
impact of HIV
and value of
testing
• Conduct one-on-one visits with key
community members
• Meet with existing and established groups
• Connect with stakeholders and potential
supporters
Denial/
resistance
stage
At least some
community members
recognize that it is a
concern, but there is
little recognition that
HIV might be
occurring locally.
Create
awareness of
the issues
regarding the
impact of HIV
and the value
of testing in
this
community
• Discuss descriptive local incidents related to
the issue
• Approach and engage local
educational/outreach programs to assist in
the effort with flyers, posters, or brochures
• Prepare and submit articles for church
bulletins, local newspapers, club newsletters,
and so forth
• Continue strategies from previous stage
Vague
awareness
stage
Most feel that there is
a local concern, but
there is no
immediate
motivation to do
anything about it.
Raise
awareness
that the
community
can make
changes
• Share information at local events
• Make presentations on the issue for existing
groups
• Conduct informal surveys to see how people
feel about the issue
• Publish newspaper editorials and articles
• Continue strategies from previous stages
Preplanning
stage
There is clear
recognition that
something must be
done, and there may
even be a group
addressing the issue.
However, efforts are
not focused or
detailed.
Raise
awareness
about the
impact of HIV
and the value
of testing
with concrete
ideas
• Introduce information about the issue
through presentations and media
• Review existing efforts
• Visit and get investment of community
leaders
• Conduct focus groups and make plans
• Increase media exposure through radio and
television public service announcements
1
Kansas Coalition Against Sexual and Domestic Violence. (n.d.). Community readiness assessment. Retrieved June
14, 2012 from http://www.kcsdv.org/toolkit/commorgtoolkit.html.

Exhibit 2.2. Framework for Assessing Community Readiness for a Non-Clinical HIV
Testing Program (continued)
Readiness
Stage
Stage Description Stage Goal
Preparation
stage
Active leaders begin
planning in earnest.
Community offers
modest support of
efforts.
Gather
existing
information
with which to
plan
strategies
• Conduct school surveys
• Conduct community surveys
• Sponsor a community picnic to kick off the
effort
• Conduct public forums to develop strategies
from the grassroots level
• Have key leaders and influential people speak
to groups and participate in local radio and
television shows
• Plan how to evaluate the success of your
efforts
Initiation stage Enough information
is available to justify
efforts. Activities are
underway.
Provide
community-
specific
information
• Conduct in-service training on community
readiness for professionals and
paraprofessionals
• Plan publicity efforts associated with start-up
of activity or efforts
• Attend meetings to provide updates on
progress of the effort
• Conduct community interviews to identify
service gaps, improve existing services, and
identify key places to post information
• Begin library or Internet search for additional
resources and potential funding
• Begin basic evaluation efforts
Stabilization
stage
Activities are
supported by
administrators or
community decision
makers. Staff are
trained and
experienced.
Stabilize
efforts
• Plan community events to maintain support
for the issue
• Conduct trainings for community
professionals and members
• Introduce program evaluation through
trainings
• Increase media exposure detailing progress
• Hold recognition events for local
supporters/volunteers
Confirmation/
expansion
Efforts are in place.
Community
members feel
comfortable using
services and they
support expansions.
Local data are
regularly obtained.
Expand and
enhance
services
• Formalize the networking with qualified
service agreements
• Prepare a community risk assessment profile
• Publish a localized program services directory
• Maintain a comprehensive database available
to the public
• Develop a local speaker’s bureau
• Initiate policy change through support of
local city officials
• Conduct media outreach on specific data
trends related to the issue
• Use evaluation data to modify efforts

Exhibit 2.2. Framework for Assessing Community Readiness (continued)
Readiness
Stage
High level of
community
ownership
Stage Description
Detailed and
sophisticated
knowledge exists
about prevalence,
causes, and
consequences.
Effective evaluation
guides new
directions. Model is
applied to other
issues.
Stage Goal
Maintain
momentum
and continue
growth
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Maintain local business community support
and solicit financial support from them
Diversify funding resources
Continue more advanced training of
professionals and paraprofessionals
Continue reassessment of issue and progress
made
Use external evaluation and use feedback for
program modification
Track outcome data for use with future
funding applications
Continue progress reports for benefit of
community leaders and local sponsorship; at
this stage community has ownership of the
efforts and will invest themselves in
maintaining the efforts
The Agency Readiness Assessment
Before implementing a new HIV testing and linkage program, or making modifications to an
established program, it is essential for your agency to conduct a systematic planning process.
It is important to understand the basic features of a non-clinical testing program
(see Figure 1) and develop a program-specific operational flowchart that specifies your
agency’s plan. Thoughtful planning will help to ensure that you are well prepared to
implement an HIV testing and linkage program that is both responsive to community needs
and delivers evidence-based, high-quality services. In planning for implementation of an HIV
testing and linkage program, you will need to take the following steps:
• Draft and refine a prototype program using an operational flowchart that reflects CDC
evidence-based recommendations for effective, efficient non-clinical testing programs
and input from internal and external stakeholders.
Select which of the strategies that will be used to implement program activities based
on program goals, objectives, resources, and constraints.
Discuss the operational flowchart with stakeholders and revise accordingly.
Develop draft policies and procedures for implementing the prototype program.
Pilot activities where the most effective and feasible methods to deliver an activity
remains uncertain.
Revise the program operational flowchart and policies and procedures based on pilot
findings and stakeholder input.
Identify and form relationships with partner agencies to ensure that a range of client
needs are addressed.
•
•
•
•
•
•

• Recruit and train staff and/or volunteers2
who will provide services
Secure and/or develop the technologies and materials necessary to deliver services
Conduct formative evaluation to determine feasibility and effectiveness of program plan
Develop plans and procedures for QA of the interventions, procedures, and processes
Develop plans, procedures, and processes for program M&E
•
•
•
•
A large body of research, programmatic experience, and expert opinion collected over the
last decade suggests that non-clinical testing programs can become more effective and
efficient if adopt several new strategies. These new strategies represent the key updates in
CDC’s forthcoming recommendations on HIV testing in non-clinical settings. Below are listed
these strategies and the rationale for this use:
• Defining and targeting high-risk populations that are likely to have an HIV
prevalence of 1% or more.
 Rationale: Many non-clinical testing programs have had limited return on
investment because they recruited populations with much lower prevalence and
identified very few clients with newly diagnosed HIV infection.
• Identifying effective recruitment strategies to locate members of target
populations.
 Rationale: Many non-clinical testing programs recruited clients in fixed or outreach
venues tied to specific geographic locations. However, many high risk populations
are more dispersed and less likely to congregate in specific locales; they may be
easier to locate through “virtual locations” such as Internet sites where people find
sex partners or scattered rural communities where methamphetamine use is
common.
• Using streamlined methods to identify members of the target population using
observation and/or a few simple questions instead of a detailed risk assessment
before offering testing.
 Rationale: Many non-clinical testing programs conduct extensive risk assessments
before offering testing and limited testing to persons who reported risk. Studies
indicate that these detailed assessments deter some persons from accepting
testing and that self-reported risk may not be as predictive of HIV infection status
and population–level characteristics of target populations drawn from
epidemiologic and behavioral data.
2
We recognize that many HIV testing and linkage programs use volunteers to provide HIV testing and linkage
services. Often, volunteers perform the same functions as paid staff. Throughout this guide, for convenience, we
use the word “staff” to refer to both paid staff and volunteers.

• Using evidence-based and field-tested methods of client recruitment and
engagement to motivate members of the target population to accept HIV testing.
 Rationale: Using evidence-based methods such as motivational interviewing
techniques and incentives can often improve acceptance of testing. However, since
not all recruitment methods may work equally well in all populations, they should
be field-tested or piloted in the target population before being implemented.
• Offering the most sensitive HIV tests that are feasible in the program, including
blood-based tests with appropriate quality assurance.
 Rationale: Many non-clinical testing programs use HIV tests based on oral fluid, but
more sensitive blood-based tests that can detect infection earlier after the point of
exposure are now available for use in non-clinical settings.
• Assessing the possibility of very recent exposure before testing to determine
whether it is appropriate to refer clients for non-occupational post-exposure
prophylaxis (nPEP).
 Rationale: Evidence suggests that nPEP, the use of antiretroviral medication within
72 hours of a suspected HIV exposure (e.g., ruptured condom worn by a man with
HIV or sexual assault by a person who may be infected with HIV), is underutilized in
the United States. Non-clinical testing programs are well positioned to facilitate
access to this intervention to populations at high risk for acquiring HIV.
• Assessing the symptoms of acute antiretroviral infection before HIV testing to
determine the need to offer or refer clients for tests that detect acute infection.
 Rationale: New tests for acute infection have been developed that expand
opportunities to identify persons during the highly infectious stage of acute
infection and refer them to risk reduction interventions and early HIV medical care.
• Linking newly identified clients with an HIV-positive test results to HIV medical
care on the basis of an initial or supplemental HIV test result.
 Rationale: Research demonstrates that many clients with an initial positive rapid
test result may not return for supplemental test results, thereby missing the
opportunity to get linked/referred to HIV medical care, risk-reduction intervention
and other services. With the introduction of new, highly sensitive and specific rapid,
point-of-care tests, initial results are more predictive of actual infection status so
HIV medical providers are more likely to accept clients with initial positive test
results while supplemental test results are pending.
• Providing all clients with new HIV-positive test results, a basic needs assessment
that would guide decisions on the provision, linkage, or referral to appropriate
medical, prevention, and support services.
 Rationale: The basic needs assessment is a simple planning tool to assist testing
program staff to determine the type, intensity, and the geographic location of the
services needed by the client and his/her ability to access them easily.

• Providing persons previously diagnosed with HIV infection with the opportunity
to retest for HIV (e.g., to document HIV status that determines eligibility for
medical or social services) and assistance with linkage or re-engagement in HIV
medical care if they are not currently receiving HIV care.
 Rationale: Programmatic evidence indicates that many previously diagnosed HIV
infected persons seek retesting for legitimate reasons ( i.e., to document their HIV
infection when determining eligibility for medical and social services. )
Classifying clients with HIV-negative test results into two categories of risk for
acquiring infection (elevated vs. not elevated) to determine which clients could
benefit from intensive risk-reduction services.
 Rationale: Programmatic experience indicates that many non-clinical testing
programs can have greater impact if they devote less time to prevention services
for clients at low risk of HIV acquisition and greater time to high risk clients who
warrant intensive, risk-reduction interventions.
Providing to all clients with HIV-negative test results identified as having
“elevated” risk a prevention needs assessment to identify factors that may
influence risk of HIV acquisition.
 Rationale: Programmatic experience indicates that many non-clinical testing
programs can have greater impact if they devote more time to and linkage or
referral to medical and social services that may influence risk of HIV acquisition,
such as substance use treatment.
Providing, linking, or referring all clients with HIV-negative tests as classified as
having “elevated” risk to risk-reduction interventions and other medical and social
services identified in their prevention needs assessment.
 Rationale: As noted above.
The flowchart (Figure 1) illustrates the operational flow of activities and outputs for clients
targeted by a “generic” non-clinical HIV testing program that features these new strategies.
•
•
•

Figure 1. Operational Flowchart of HIV Testing in Non-Clinical Settings
Seeking testing at the
testing Program
Implement Recruitment Strategy for the Target Population 1
Inreach
(other programs
within the CBO
Outreach
(Venue-based, internet,
social marketing, incentives)
Determine Target Population
(using population level data)
External Referrals
(other agencies,
partner referrals)
Offer HIV
Test
1) Informed consent
2) Ask if recent exposure or symptoms
of acute HIV infection in the last month
3) Explain testing procedures and the
meaning of test results
4) If more than one testing option
available, provider and client choose
appropriate testing procedure6
Did client accept
testing?
Is the client
previously positive?
1) Link or refer to linkage
services staff to reengage in
HIV care and services
2) Link or refer to other medical
and social services5, if
requested.
Perform HIV
Test7
Is the
client currently in
HIV Care?
No
Offer
condoms
and provide
information
on other
services if
requested
Flow chart notes
actions of the
testing program
1) Discuss and address reasons for not testing
2) Recommend HIV Testing at a future date
3) Provide prevention information/material (e.g.,
condoms, syringe exchange (where available))
4) Refer to appropriate staff in the CBO or
externally for linkage to other medical and social
services4, if requested.
of
the non-clinical
entity, not all
functions of that
entity.
HIV Positive9c (including acute
HIV infection)
Notification of test results (results
may be available same day if
point of care test)8
HIV Negative 9a 9b
No
Yes
Yes
Yes
Document* test results in
client chart
1. A program may use a combination of different strategies including social networks depending on the program capabilities, resources, and characteristics of the target
population. People may become aware of testing by seeing a testing sign/booth or intercepted by an outreach worker who lacks testing equipment.
2. For persons not seeking testing, asking one to two simple questions to determine if they are members of target population (e.g., MSM, IDU) may be needed in addition
to observation. Questions would depend on characteristics of population targeted by testing program and would not be intended to assess risks of HIV infection.
However, asking questions may motivate person to test or help build rapport with client when notifying of test results or risk reduction interventions. In field, determining
eligibility by observed and non-observed characteristics is usually integrated into single encounter. The 1-2 questions selected should NOT be determined by data
collection needs for case reporting or assessment of service needs. ( See Tools for Flow Chart Document for examples)
2(b) If social network strategy is used, 2(c) Persons who volunteer risk factors without being questioned, indicating membership of another population targeted for testing.
3. Persons that do not meet any program criteria (member of target population, social network or those that volunteer risk factors) need not be approached. The number
of people falling into this group may be very small.
4. If recruitment strategy uses incentives and HIV+ person seeks re-testing even without an incentive (e.g., needs documentation of test to access services), re-testing
should be offered. However, if HIV+ person declines re-testing without an incentive, staff should discourage re-testing but offer other services as needed, such as
information, linkage/retention in care, condoms, etc.
5. Examples of services are substance abuse treatment, mental health services, pregnancy health, etc.
6. Pretest information may vary by test type. Explain criteria for choosing a particular method if more than one test is available at the testing facility (consider acute
infection test).
7. Many testing programs will offer only one test. If the program offers more than one test, please see guidance on the choice of test (Recommendations, Section #, etc.)
8. Indeterminate test results will only be applicable to testing programs using Western Blot (that can yield indeterminate results)
9a. Negative results can be provided face to face, on telephone, internet, or mail
9b. If the program does not offer acute HIV testing and acute infection suspected based on exposure or symptoms of antiretroviral syndrome, refer to the appropriate
program for testing for acute infection if not offered by nonclinical testing program.
9c. Positive test notification to be done face to face, whenever possible. Alternatives include phone or a client log-in to a password protected site. Letters and/or email
can be used to invite a person for in-person or telephone notification.
10. Recent exposure: unprotected sex with a partner of unknown or known HIV+ serostatus, shared needles, exposure to blood or other infectious body fluids.
Walk-ins
(Persons not
specifically
recruited)
Offer test to all persons seeking
testing regardless of Target
Document* Population eligibility
Document*
Not seeking testing but a
member of Target Population
based on observation or
information volunteered by
person without being
questioned by recruiter
Recruitment
No
(Testing same day
Pre-testactivities
or later; offsite or
onsite)
ProvidingResultsHIVTesting
If the client reports possible recent
exposure10 (within last 72 hours),
recommend one of three options:
immediate acute test, immediate
referral to acute test, or immediate
regular rapid to determine
eligilibility for nPEP
Not seeking testing, 2 not member of Target
Population based on observation but deemed
to be members of Target Pop. based on (a)
simple questions (b) member of social
network2b, (c) volunteers risk factors 2c
Does not meet
any criteria3 on
the left
Document*
Document*
Document*
Do not offer test
Is the
client seeking
HIV test?4
No
6/29/2012
Yes
Social Networks
(social connections,
relationships)
*Information collected when
documenting provision of this
service/question/encounter
element, and in some cases,
the outcome of that service/
question/encounter element,
can be used to evaluate or
monitor the testing program
Figure 1 depicts the various activities of a non-clinical HIV testing program starting with the targeting and recruitment of the high-risk populations, followed by HIV testing, result notification, services for those
who suspect recent exposure (e.g., acute testing, non-occupational post exposure prophylaxis), and ending with services for HIV positive persons (e.g., linkage to care, basic needs assessment, support services,
and partner services) and services for HIV negative persons stratified by risk (e.g., condoms, prevention information, prevention needs assessment, and referral for other support services). The flowchart notes the
actions of the testing program but does not include all the functions of a non-clinical program.

Figure 1. Operational Flowchart of HIV Testing in Non-Clinical Settings (continued)
Moderate/high/
highest risk 12
1. Prevention needs assessment: an assessment of
factors and behaviors related to HIV acquisition risk. **
2. Make referrals to other services that may influence
HIV acquisition 13
(Can be done off-site or referred to another agency)
Use triage process to define
HIV acquisition risk.* 9
Is the testing program
able to do same day risk reduction
intervention on-site?
Yes No
9. The triage elements depend on characteristics of target population and is used only to determine if clients warrant any additional services at the time of testing beyond
condoms and information. It is not a detailed risk or needs assessment. If client was offered testing in field and was asked questions to determine if member of a specific
target population (e.g, MSM, IDU) , these questions would not need to be repeated if triage done by same person who assessed membership in Target Population.
10. Note, after linkage to care, partner services is urgent for persons diagnosed with HIV acute infection
11. Assuming cannot be provided by agency
12. Terminology is consistent with CDC Funding Announcements for nonclinical HIV testing
13. May include referral for HCV screening if recommended by CDC at time of guideline release
14. Encourage use of CDC compendium of effective interventions
* Elements of the triage process are found in the “Tools for Flow Chart” document
** Elements of the prevention needs assessment are found in the “Tools for Flow Chart” document
HIV Negative
No/low risk 11
• Conduct same day behavioral risk reduction
intervention on-site
• Whenever possible, actively link to intensive risk
reduction interventions as appropriate
• Whenever possible, actively link to evidence-based
behavioral risk reduction intervention tailored to client
needs. It may be on-site (but outside testing program
function) or offsite; and may be appropriate to client
characteristics14
Continued from previous page….
HIV Positive (including acute HIV
infection)
Minimum services10 include:
• Link or refer to linkage services staff (may not
be same day) for HIV care
• Basic assessment of issues that promote
transmission or pose barriers to linkage to care
• Link or refer to support services including risk
reduction interventions11
• Basic risk reduction messages
• Partner services – refer to Health Department
• Offer condoms
Optional if agency resources permit
• More detailed needs assessment
• Linkage or referral to other services defined by
more detailed needs assessment
• Provide risk reduction intervention other than
basic messages (e.g., DEBIs)
(Can be done on same day if feasible)
• Provide condoms and
prevention information.
• Provide advice on HIV
retesting frequency.
If suspect recent HIV exposure,
provide education and link or refer
to nPEP program
Document*
Document*
Document*
Document*
Document*
Document*
*Information collected when documenting provision of this service/question/encounter element, and in some cases, the outcome of that service/question/encounter
element, can be used to evaluate or monitor the testing program
• Provide condoms and
prevention information.
• Advise to retest if
starting to practice risk
behaviors.

An important first step in designing or refining a non-clinical testing program is designing a
“prototype” program plan that captures program goals, objectives, and strategies that are
likely to maximize program effectiveness, efficiency and impact. One way to do this is to
create a program-specific operational flowchart based on the “generic” operational flowchart
above. Another way that you could do this is to develop a logic model for your HIV testing
and linkage program. A detailed discussion of logic models is included in the Evaluation
Guide. Including input from internal and external stakeholders of the program will strengthen
your program. It is also important to consider several factors unique to your testing program.
These include testing program goals, objectives, and target populations defined by funding
agencies, authorizing authorities, and community needs assessment (see below).
Testing programs can make different choices how to recruit clients and deliver services.
Among the most critical choices are
•
•
•
•
•
which target population to serve,
which recruitment methods to use,
which HIV tests to offer,
how to define clients with HIV-negative tests with elevated risk that warrant more
intensive risk-reduction services,
whether services to clients with HIV-positive tests and clients with HIV-negative tests will
be offered onsite, or through linkage or referral assistance to external agencies.
You can revise the program-specific flowchart to reflect initial choices about how the
program recruits clients and provide services. By seeking repeated review by internal and
external stakeholders, the program can revise the prototype flowchart so it better reflects the
program goals, resources, and constraints. It can then serve as a critical blueprint to define
how each activity will be provided, the expected outputs of each activity, and the policies and
procedures that are needed to operationalize the program.
The tool below is designed as a guide for and a tool to document your program planning
efforts. Using this tool will also help you to identify potential challenges to program
implementation and strategies to address these challenges.
Before implementing an HIV testing and linkage program, or making modifications to an
established program, you will also need to assess the extent to which your agency has the
capacity necessary to deliver these services. Tool 1 will assist you in making that assessment.
Tools and Templates: Tool 1—HIV Testing and Linkage Implementation Planning
Tool 1 can assist in the design of your HIV testing program. It will help identify the “who” and “when” for
necessary activities, as well as the “how” to overcome challenges.

Tool 1. HIV Testing and Linkage Program Planning and
Capacity Assessment
About Tool 1: Tool 1 is divided into two parts. Part I: HIV Testing and Linkage Program
Planning serves as a guide for and tool to document your program planning process. Part II:
HIV Testing and Linkage Capacity Assessment assists you in assessing your capacity for
implementing an HIV testing and linkage program. The “Domains of Readiness” presented in
Part II correspond to the major implementation activities that need to be completed to
prepare you to implement HIV testing and linkage services. The greater the number of
domains of readiness completed, the greater your capacity to fully implement HIV testing and
linkage services.
Part II is designed to be completed after Part I. If you are planning a new program, it is
recommended that you do not begin providing services to clients until you have full capacity
to implement HIV testing and linkage services (i.e., all of the boxes on Part II are checked as
complete). However, established programs may wish to begin with Part II to identify those
domains where program improvement efforts can be concentrated.
This tool should be completed in conjunction with discussion with staff members who
provide HIV testing and linkage services, as well as others, such as consumer advisory board
members or members of your board of directors. Multiple perspectives will result in richer
discussion, a deeper understanding of program planning issues and program operations, as
well as better ideas and strategies to ensure a successful program.
Tool 1 presents HIV testing and linkage program planning activities as though they occur in a
sequential fashion. It is important to note, however, that some activities may occur at the
same time. For example, you may be simultaneously working on developing your recruitment
protocol and developing client educational materials. Some activities may reoccur at multiple
points in time, such building new partnerships, establishing a new memorandum of
agreement (MOA), or hiring new staff members who must be trained.
How New Programs Can Use This Tool: This tool is designed to assist you in planning your
HIV testing and linkage program. This tool will take you through the key steps of program
implementation, including formative evaluation, planning for delivery of HIV testing and
linkage services, as well as monitoring, providing QA, and evaluating your program. This tool
will help you to assess your capacity and readiness to implement your HIV testing and linkage
program. It will help you to identify any gaps in your knowledge or resources that will need to
be addressed to ensure that your program will meet the needs of your target population and
that you have the knowledge, tools, and resources needed to deliver high-quality services.
How Established Programs Can Use This Tool: If you have already implemented an HIV
testing and linkage program, you can use this tool to help you to assess whether your
program is still meeting the needs of your target population, and if you need to make any
changes to strengthen your program. It is good practice to periodically reassess your program

to ensure it is still meeting community needs and that you are using the tools and strategies
that help you deliver effective and high-quality HIV testing and linkage services.
Many agencies reassess their programs on an annual basis, as part of a regular program
planning and improvement process. Some funders require work plans on a regular (e.g.,
annual) basis. It is always a good idea to reassess program practices when substantial changes
occur in your agency (e.g., staffing changes) or community (e.g., changes in health and social
services in the community). It is also a good idea to reassess program practices in light of new
technologies (e.g., availability of new HIV tests) or advent of new strategies and tools.
Established programs may find it helpful to use this tool as to take inventory of a program and
its capacity. In this case, you could complete the entire tool and update it periodically (e.g.,
during your annual planning process) or as changes warrant (e.g., when policies and
procedures are updated). Alternately, established programs may not need to complete the
entire tool, but only sections which are most relevant. For example, if you are considering
adopting a new test technology, you may only need to complete the section on testing
capacity and QA.
How Health Departments and Other Funders Can Use This Tool: Health departments and
other funders may find this tool helpful for use with grantees or contractors. You could use
this tool in providing technical assistance to agencies that are just beginning a new program,
or for agencies that seem to be struggling with program implementation. Some HDs or other
funders may wish to have grantees or contractors complete this tool at the beginning of a
project (e.g., as a component of a funding proposal) or on a regular basis (e.g., at the
beginning of each contract cycle) as a means to assess and monitor capacity to provide HIV
testing and linkage services. HDs and other funders can adapt this tool to suit local needs by
adding or adjusting the activity fields to reflect local policies, regulations, or requirements,
such as specific training or certification requirements for staff providing HIV testing and
linkage services.

Instructions for Completing Tool 1. Part I: HIV Testing and Linkage Program Planning
What is the purpose of this tool? Tool 1, Part I is used to guide and document your program planning efforts.
Who should complete this tool? HIV testing and linkage program managers, in collaboration with staff, consumer advisory
board members, and others involved in planning, implementation, and evaluation of the program.
When should this tool be completed? Before you implement HIV testing and linkage services or as part of periodic program
assessment of established programs.
How should this tool be completed? In the top portion of Tool 1, Part I, record the following information in the designated cells:
• Agency/Program: Record the name of the agency and/or program completing this tool.
Target Population: Record the target population.
Date Completed: Record the date that the tool was completed or updated, as applicable.
Participants: Record the names and/or positions/roles of the individuals participating in completing this tool.
•
•
•
The left column presents the key activities involved in planning for and implementation of an HIV testing and linkage program.
HDs and other funders, in particular, may wish to add, delete, or modify these activities to suit local needs and requirements. For
each activity listed, record the following information in the designated column:
• Last Update: Enter the date that corresponds to when the activity was completed or last updated.
Responsible Individual/Position: Enter the name of the individual (or title of the position) that has taken responsibility for
the activity.
Timeline for Completion: Enter the date by which the activity must be completed.
Challenges: Summarize challenges, if any, which may delay completion of the activity.
Strategies: Summarize strategies that you will use to address the identified challenges in completing the activity.
•
•
•
•
Tool 1, Part I has been partially completed to illustrate how it may look after completion. The example reflects how an agency
developing a new HIV testing and linkage program would use this tool.

Tool 1. Part I: HIV Testing and Linkage Program Planning
Agency/Program: ACME Prevention Services, Center Point Program Participants:
Target Population:
(IDUs) over 30 years
White and African American injection drug
of age living in North Center City
users • ACME executive director
• ACME HIV prevention manager
• ACME board chair
• ACME community advisory board chair
Date Completed: January 15, 2012
Activity
Last
Update*
Responsible
Individual/Position
Timeline for
Completion
Challenges
Strategies to Address
Identified Challenges
Implementation Planning—General
Conduct community readiness
assessment
Conduct agency readiness
assessment
Review applicable State and
local laws, regulations, and
policies governing HIV testing
and linkage
HIV prevention
manager
January 2012 Ensuring identification of
applicable State and local
statutes, regulations, and
policies
Consult with Center City Health
Department (CCHD) to identify
and interpret applicable
statutes, regulations
Identify partner agencies that
may refer clients to the testing
program or provide medical
and social services to tested
clients
HIV testing
coordinator
June 2012 Gaps in knowledge of and
relationships with
potential partners
Community advisory board and
planning coalition members to
assist with identification of and
introduction to potential
partners
Obtain input from
representatives of the target
population in development of
plans for implementing HIV
testing and linkage services
HIV prevention
manager
April 2012 Identifying and engaging
gatekeepers
Community advisory board
chair and members to assist
Develop staffing and
supervision plan
• HIV prevention
manager
• Volunteer
coordinator
April 30, 2012 None identified Not applicable
*Existing programs may note the date that the activity was completed or last updated. New programs should leave this column blank.

Tool 1. Part I: HIV Testing and Linkage Program Planning (continued)
Activity
Last
Update*
Responsible
Individual/Position
Timeline for
Completion
Challenges
Implementation Planning—General (continued)
Hire staff in accordance with
staffing and supervision plan
HIV prevention
manager
June 30, 2012 • Identifying qualified
candidates
• Hiring HIV testing
coordinator prior to
other HIV testing and
linkage staff to assist
with program
implementation
planning
and planning coalition
members to assist with
recruitment
Develop agency policies for
HIV testing and linkage
services
• HIV prevention
manager
• HIV testing
coordinator
May 31, 2012 Identifying sample policies HIV testing coordinator to
consult with CCHD and
planning coalition members for
sample policies
Client Targeting and Recruitment
Conduct formative
evaluation**
HIV prevention
manager
January to March
2012
Expertise and resources to
collect and analyze data
• Collaborate with City
Center University Social
Science Department
• In consultation with the
City Center planning
group, identify and use
existing sources of data
when possible
**Refer to the section titled Formative Evaluation and Implementation Planning (including Tool 2) in Chapter 2 for additional information on formative
evaluation activities.

Activity
Last
Update*
Responsible
Individual/Position
Timeline for
Completion
Challenges
Client Targeting and Recruitment (continued)
• Define the target
population and select a
targeting strategy
• Select a recruitment
strategy
• HIV prevention
manager
• HIV testing
coordinator
April 2012 Identifying evidence-
based strategies
• HIV testing coordinator
will research potential
strategies that match with
needs identified through
formative evaluation
• Obtain assistance from
Center City University
Social Science Department
(graduate intern)
Identify recruitment venues HIV testing
coordinator
July 2012 Gaps in knowledge of
appropriate venues
and planning coalition
members to assist with
identifying venues for
recruitment
Execute MOA with
recruitment partners
Executive director August 2012 Ensuring recruitment
partners will provide data
needed for program M&E
Planning coalition members
and agency board of directors
to assist in negotiating MOA
Obtain incentives HIV testing
coordinator
September 2012 Identifying appropriate
incentives with resource
limitations
Board of directors will seek
donations from local
businesses
Testing
Select HIV tests that will be
offered
HIV testing
coordinator
Ensuring the test is the
most sensitive and cost
efficient
• Research the most
sensitive tests available in
one’s jurisdiction
• Conduct a cost analysis on
the tests to offer

Activity
Last
Update*
Responsible
Individual/Position
Timeline for
Completion
Challenges
Services for HIV-Positive Clients
• Identify providers of risk
reduction and medical
and social services of
value to clients with
positive tests
• Decide if will provide
these onsite or through
external agencies, and if
the later, by linkage,
referral, or both
HIV testing
coordinator
• Lack of linkage to
care specialists
• Use evidence-based
strategies to
coordinate linkage
• Cross train staff to be able
to do linkage to care and
triaging to other
prevention services
• Research evidence-based
strategies to coordinate
linkage
• Approach HIV medical
associations to learn
about providers available
in the community
Execute MOA with health
departments for partner
services
Executive director Ensuring confidentiality
when passing on client
information for partner
services
Adhere to privacy and
confidentiality laws
Services for HIV-Negative Clients
Develop a tool to classify
clients with negative tests as
having elevated risk that can
be used to triage these clients
to more intensive risk-
reduction services
HIV prevention
manager
Identify tools and
resources to adequately
categorize and facilitate
this process
Research potential tools
Decide whether risk-reduction
interventions will be provided
onsite or through linkage or
referral
HIV testing
coordinator
HIV prevention
manager
Adequate and competent
staff capacity to provide
interventions onsite
Develop partnerships with
organizations in the
community that can help
support risk reduction
interventions

Last Responsible Timeline for Strategies to Address
Activity Challenges
Update* Individual/Position Completion Identified Challenges
Training
Develop written targeting,
recruitment, testing, and
services for HIV-positive
clients and services for HIV-
negative clients procedures
HIV testing
coordinator
September 2012 No existing procedures •
•
HIV prevention manager
will provide assistance in
development
HIV testing coordinator
will research existing
procedures that can be
adapted
Develop (or identify and
obtain) marketing materials
•
•
HIV testing
coordinator
Community
advisory board
September 2012 None identified Not applicable
Training (continued)
Train staff on targeting,
recruitment, testing and
services after testing
strategies (e.g., SNS)
HIV testing
coordinator
October 15, 2012 Two HIV testing and
linkage staff members
have been waitlisted for
the Social Network
Strategies (SNS) training
Contact CCHD to identify next
training opportunity or
alternative strategy for
training staff
Orient/train staff on targeting,
recruitment, testing, services
for HIV positives and services
for HIV-negative client
procedures
HIV testing
coordinator and
volunteer
coordinator
October 31, 2012 None identified Not applicable
Train/certify staff as required
by statute, regulation, or
policy
HIV testing
coordinator
July 2012 Staff providing HIV
testing and linkage staff
must complete CCHD’s
HIV Basics course and two
staff have been waitlisted
until December 2012
Contact Center City HD to
explore and negotiate
alternative strategy for
meeting this requirement

Instructions for Completing Tool 1. Part II: HIV Testing and Linkage Capacity Assessment
What is the purpose of this tool? Tool 1, Part II can be used to assess your capacity to implement an HIV testing and linkage
program.
Who should complete this tool? Program managers can complete this tool, in collaboration with HIV testing and linkage staff,
consumer advisory board members, and others involved in planning, implementation, and evaluation of your program.
When should this tool be completed? This tool should be completed before you implement services. It can also be used to assist
and document ongoing program assessment and to plan for program enhancements if you have already implemented services.
How should this tool be completed? The left column presents the domains of readiness associated with implementing HIV
testing and linkage programs. For each of the major program areas included in Part II (e.g., recruitment, testing), there is some
overlap in the kinds of activities that must be completed (e.g., development of implementation procedures). These activities are
grouped together in Part II and are often developed at the same time.
For each domain of readiness listed, record the following information in the designated column:
• Complete: Check the corresponding box if the activities associated with this domain have been completed (or have been
updated, if completed by an established program). Leave this box blank if the activities associated with the domain have not
been completed or updated.
Timeline for Completion: If the activities have not been completed or updated, enter the date by which the activities
associated with the domain must be completed.
Strategies to Address Gaps in Capacity: Summarize the strategies that you will use to address identified gaps. If you are
planning a new HIV testing and linkage program, it is recommended that you do not begin providing services to clients until
you have full capacity to implement HIV testing and linkage services (i.e., all of the boxes on Part II are checked as complete,
and all identified gaps in capacity have been addressed).
•
•
Tool 1, Part II has been partially completed to illustrate how it may look after completion. The example reflects how an agency just
beginning an HIV testing and linkage program would use the tool.

Tool 1. Part II: HIV Testing and Linkage Capacity Assessment
• ACME executive director
• ACME HIV prevention manager
• ACME HIV testing and linkage coordinator
• ACME volunteer coordinator
• ACME board chair
• ACME community advisory board chair
Target Population: White and African American IDUs over 30 years of age
living in North Center City
Date Completed: September 21, 2012
Domains of Readiness Complete
Timeline for
Completion
Strategies to Address Gaps in Capacity
Community readiness assessment
Agency readiness assessment
Formative evaluation
Agency policies
Staffing plans
Recruitment/hiring of staff
Implementation strategies selected:
a. Population targeting
b. Client recruitment
c. Testing (field—initial test)
d. Testing (laboratory for any supplemental testing)
e. Linkage to care for HIV-positive clients
f. Basic needs assessment for HIV-positive clients
g. Partner services for HIV-positive clients
h. Triaging HIV-negative clients into highest risk and
low/medium risk

Tool 1. Part II: HIV Testing and Linkage Capacity Assessment (continued)
Timeline for
Completion
Implementation strategies selected (continued):
i. Condoms and basic prevention information for low-risk
clients
j. Prevention needs assessment for highest-risk clients
k. Risk reduction interventions for highest-risk clients
MOA established with partners for the following:
c. Testing (field – initial test)
d. Testing (laboratory for any supplemental testing) October 31,
2012
Center City HD public health laboratory does not
offer RNA testing. ACME’s executive director and
board chair are negotiating the contract with
Center City Hospital to process specimens for
clients with possible acute infection.
e. Linkage to care for HIV-positive clients November
15, 2012
ACME’s executive director and board chair are
negotiating an MOA with Center City Community
Clinic to accept referrals for care of clients dually
infected with HIV and HCV and for clients co-
infected with HCV.
low/medium risk
clients
k. Risk-reduction interventions for highest-risk clients

Timeline for
Completion
Written policies and procedures developed for the following:
h. Triage process to classify clients with negative clients into
those with and without elevated risk of HIV acquisition
clients
k. Risk-reduction interventions for highest-risk clients
Written quality assurance plan developed
Monitoring and evaluation plans developed
Staff trained/certified to implement:
b. Client recruitment December
15, 2012
Two HIV staff members were waitlisted for the
Social Networks Strategy training. CCHD has
confirmed that staff are registered for the
December training. Until they have completed this
training, they will be unable to conduct recruitment
activities. Staffing plans and recruitment schedules
will be temporarily adjusted.

Domains of Readiness
Timeline for
Complete Strategies to Address Gaps in Capacity
Completion
(continued)
e. Linkage to care for HIV-positive
f. Basic needs assessment for
g. Partner services for HIV-positive
h. Triaging HIV-negative
low/medium risk
clients
HIV-positive clients
clients
clients into highest risk and
i. Condoms and basic
clients
Risk-reduction interventions for highest-risk clients
activities
prevention information for low-risk
k.
l.
m.
n.
Quality assurance plans and
M&E plans and activities
Other training/certifications
statute, regulation, or policy
Risk-reduction materials secured
Client educational materials secured
required by State or local October 11,
2012
Two staff were not able to attend the scheduled
July 2012 HIV Basics training. The Center City HD
will conduct an in-service training for ACME staff
October 11, 2012.
on

Formative Evaluation and Implementation Planning
Before implementing an HIV testing and linkage program, or making modifications to an
established program, consider conducting a systematic planning process (see flowchart and
Chapter 2, Figure 2.1 for additional discussion about implementation planning). A key part of
your planning process is conducting formative evaluation. Through formative evaluation you
will explore the need in your community for testing and linkage services and more
importantly, identify the strategies needed to target and recruit clients into HIV testing.
Continual evaluation of a program’s targeting and recruitment strategy through thorough
formative evaluation is a key to successfully accessing your target population for HIV testing
and related services. Formative evaluation will help you to decide the following:
• Are the program strategies effective and feasible? Specifically:
 Targeting, recruitment, and engagement strategies, (i.e., which messages,
strategies, and tools will be most successful in engaging the target populations in
HIV testing)
Selecting the most appropriate HIV testing strategies and technologies based on
programmatic and client needs
Appropriate linkage and referral strategies for clients with HIV-positive tests
Appropriate services for clients with HIV-negative tests based on their individual
risk factors



In the context of established HIV testing and linkage programs, formative evaluation can
provide information needed to adjust the program to respond to changes in the community,
target population(s), and technology.
Good formative evaluation uses mixed methods to collect data. Methods include focus
groups, individual interviews with gatekeepers and other community members, ethnographic
information, surveys, and review of existing information. You and/or your partner agencies
may collect some data expressly for the purpose of planning your program. Other data could
be collected by other entities for other purposes but useful to you in planning your program.
Information provided by your staff, volunteers, and partners who serve and/or represent the
target population(s), even if not collected systematically (i.e., anecdotal information), can be
useful to you in program planning and refinement and may be included in your formative
evaluation. It is important to note, however, that anecdotal information should not be the
only or the primary source of data that you use to plan implementation of, or adjustments to,
your program. If multiple sources of data support a specific finding (e.g., the target
population will be unlikely to return to the agency for a second visit to receive HIV test
results), you can have greater confidence that the program strategies that you select are the
best ones to meet the needs of the target population.
You can obtain additional information and guidance about data sources, including the
strengths and weaknesses of each, and guidance for selecting data collection methods in

Chapter 3 of the Evaluation Guide, Step 4: Gather Credible Evidence (look particularly at the
subsection titled Solidifying a Data Collection Plan).
Tool 2 is designed as a guide and a tool for documenting your formative evaluation efforts
and findings. Tool 2 is also designed as a guide and a tool for helping you to apply the
findings of your formative evaluation to select the most appropriate strategies, messages, and
tools for your HIV testing and linkage program.
Tools and Templates: Tool 2—Formative Evaluation and Implementation Planning
The tool that follows can assist you in conducting formative evaluation and applying the findings of your
formative evaluation activities to planning your program.
Tool 2. Formative Evaluation and Implementation
Planning
About Tool 2: Complete Tool 2 for each of your target population(s). Tool 2 is divided into
two parts. Part I: Organizing Your Formative Evaluation Data is intended to provide a guide for
the kinds of questions that your formative evaluation efforts should try to answer. It is not
intended as a guide on the types of methods you should use or the specific questions that
you should include in focus group scripts, interview guides, or survey questionnaires. Before
you begin to use this tool, you will need to gather all of the data that you intend to use to
plan your program. Part I is also a tool for you to use in compiling and summarizing your data.
Part II: Interpreting and Applying Findings of Your Formative Evaluation is intended to help
you and your staff to interpret the data you have compiled for your formative evaluation and
apply it to your program plan, including selection of strategies for recruitment, testing, and
linkage. It will also help you to identify gaps in your knowledge about the target population
and community resources to serve this population. Part II is designed to be completed after
Part I. Compile and summarize your data before you begin to process it and decide how to
apply it to program planning.
This tool may be completed in conjunction with discussion with staff members who provide
HIV testing and linkage services, as well as others, such as community advisory board
discussion, a deeper understanding of program planning issues and program operations, as
well as better ideas and strategies to ensure a successful program. For more information on
working with key stakeholders, please refer to Chapter 3, Step 1 in the Evaluation Guide.
How New Programs Can Use This Tool: This tool is designed to assist you in planning your
HIV testing and linkage program by providing you with guidance on the kinds of information
that you may find useful to collect through your formative evaluation. It will also help you to
organize and interpret your data. Working through this tool will help you to plan a program
that uses strategies, messages, and tools that are best suited to meet the needs of your target
population(s) and which will successfully engage members of the target population services.

How Established Programs Can Use This Tool: If you have already implemented an HIV
testing and linkage program, you can use this tool to help you plan for modifications or
enhancements to existing services. Conduct formative evaluation if program M&E efforts (see
Chapter 2, Tool 1 for additional information about program M&E) suggest that the strategies,
messages, or tools you are currently using may not be as successful or well-suited to the
target population as they were previously. In addition, before implementing specific changes,
such as introducing a new HIV testing technology or adopting a new linkage strategy, you
need to understand the extent to which the proposed modification or enhancement is
responsive to the needs of your target population(s). Established programs may wish to
complete only those sections of the tool relevant to the part of the program for which
adjustment or enhancement is being considered, such as where services should be provided.
How Health Departments and Other Funders Can Use This Tool: HDs and other funders
may find this tool helpful for use with local grantees or contractors. You could use this tool in
providing technical assistance to agencies that are just beginning a new program, or agencies
that seem to be struggling with program implementation. Some HDs or other funders may
wish to have grantees or contractors complete this tool at the beginning of a project (e.g., as a
component of a funding proposal) or when they are proposing expanding services to a new
target population or adopting new strategies or technologies. HDs or other funders may also
wish to adapt this tool for use with other interventions or services.

Instructions for Completing Tool 2. Part I: Organizing Your Formative Evaluation
Data
What is the purpose of this tool? Tool 2, Part I is a tool for you to use in framing your
formative evaluation and in compiling and summarizing data.
Who should complete this tool? HIV testing and linkage program managers can complete
this tool, in collaboration with staff and/or volunteers, consumer advisory board members,
and others involved in planning, implementation, and evaluation of your testing and linkage
program.
When should this tool be completed? Before you implement services. It can also be used
prior to implementing adjustments or enhancements to established programs.
How should this tool be completed? Conduct formative evaluation for each target
population you intend to or are serving. You may also want or need to complete formative
evaluation for individual programs or funding sources. In the top portion of Tool 2, Part I,
record the following information in the designated cells:
Target Population: Record the target population for which this tool is to be completed.
Date Completed: Record the date that the tool was completed or updated, as
applicable.
Participants: Record the names and/or positions/roles of the individuals participating in
completing this tool.
•
•
•
The left column presents evaluation questions related to the kinds of information that you
will need to gather in order to plan your HIV testing and linkage program and to help you
identify the best strategies for recruitment, testing, and linkage. It is best to use multiple
sources of data, including anecdotal sources, to fully answer these questions.
For each evaluation question listed, record the following information in the designated
column:
• Answer to Evaluation Question: Record a brief summary of available data
corresponding to the evaluation question.
Information Source and Date of Collection/Publication: Record the source of the
data. This will help you to refer back to the source if more information is needed. Record
the date of collection/publication associated with each data source. This will help you to
know whether the data is current.
•
Tool 2, Part I has been completed for you to illustrate how it may look after completion.

Tool 2. Part I: Organizing Your Formative Evaluation Data
• ACME Prevention Services program director
• Center Point program coordinator
• Center Point outreach coordinator
• Center Point consumer advisory board chair
• ACME Prevention community coalition chair
• Center City planning group co-chairs
• Center City University ethnographers
Target Population: White and African American IDUs over 30 years of age
living in North Center City
Date Completed: May 15, 2012
Formative Evaluation Questions Answer to Evaluation Question Information Source and Date of Collection/Report
Where does the target population
live?
• Abandoned homes in Riverside
neighborhood
• Center City Shelter
• Ethnographic mapping (Center City University Report,
August 2011)
• PS data (Center City HD, October 2011 to March 2012)
• Outreach staff (Staff meeting minutes, October 2011)
• Planning coalition members (Coalition meetings minutes,
July and September 2011)
socialize?
Center City Shelter • Ethnographic mapping (Center City University Report,
August 2011)
meet sex partners?
• Abandoned homes in Riverside
neighborhood
• Riverside Park—especially the old band
shell
use/share drugs?
Abandoned homes in Riverside
neighborhood
• Ethnographic mapping (Center City University Report,
August 2011)

Tool 2. Part I: Organizing Your Formative Evaluation Data (continued)
Where does the target population get
health and dental care?
Center City Hospital emergency room
Visiting Nurse mobile outreach
ACME syringe services program (SSP)
• Interviews with IDUs in Center City conducted by the HIV
planning group (HPG) and Center City University (Report
produced by the HPG April 2011)
• Behavioral Surveillance conducted by State HD (Report,
December 2010)
• Planning coalition members (Coalition meeting minutes,
January 2011)
health and dental information?
• ACME SSP
• Friends
• Interviews with IDUs in Center City conducted by the CPG
and Center City University (Report produced by the HPPG,
April 2011)
• Planning coalition members (Coalition meeting minutes,
January 2011)
Who/what does the target population
trust for its health information? Why?
• Visiting Nurse—nurses are “non-
judgmental” and “really care”; provide
hygiene kits, socks, blankets, bottled
water
• SSP outreach workers—“they’ve been
where we’re at”
• Interviews with IDUs in Center City conducted by the CPG
and Center City University (Report produced by the CPG,
April 2011)
December 2010)
• Brief interviews with exchangers at ACME SSP (Report,
November 2011)
What issues or factors are barriers to
HIV testing for the target population?
Why?
• HIV is not a health priority; HCV and
dental care are priorities
• Experience with providers “pushing”
drug treatment is a deterrent
• “Judgmental” providers
• Difficult to get to testing site
• Too hard to return for results, and the
wait is too long
• Active users do not believe they are
eligible for care services
• Target population believes treatment is
too expensive
• Focus group of IDUs (Center City Recovery Alliance, Report,
June 2011)
December 2010)
• Brief interviews with exchangers at ACME SSP (Report,
November 2011)

What other kinds of health or
preventive services interest the target
population?
•
•
HCV screening and
Dental care
treatment •
•
•
•
Brief interviews with exchangers at ACME SSP (Report,
November 2011)
Focus group of IDUs (Center City Recovery Alliance Report,
June 2011)
Interviews with IDUs in Center City conducted by the CPG
April 2011)
Referral assessments conducted with ACME clients (Chart
reviews: April to June 2011)
For HIV-positive individuals in the
target population, what issues or
factors are barriers to linkage to care?
•
•
•
•
•
•
“Judgmental providers”
HIV care not a priority
Believe not eligible for care services
(active users)
Do not want to have to enter drug
treatment
Believe treatment too expensive
Difficult to make/keep appointments
(scheduling, transportation)
•
•
Interviews with HIV-positive IDU patients at Center City
Clinic (Presentation to ACME Board, January 2011)
Focus group of IDUs (Center City Recovery Alliance Report,
June 2011)
factors are barriers to linkage to PS?
•
•
Believe HD “doesn’t want to help
Believe HD working is with law
enforcement
me” •
•
Interviews with HIV-positive IDU patients at Center City
Clinic (Presentation to ACME Board, January 2011)
Interviews with IDUs in Center City conducted by the CPG
April 2011)
For the target population, what issues
or factors are barriers to linkage to
risk-reduction services?
Lack of behavioral risk-reduction services
(other than substance use disorder
treatment) for active IDUs
ACME community resource inventory (Updated April 2012)

Instructions for Completing Tool 2. Part II: Interpreting and Applying Findings of
Your Formative Evaluation
What is the purpose of this tool? Tool 2, Part II is designed as a guide and tool to help you to
apply the findings of your formative evaluation in order to select the most appropriate
strategies, messages, and tools for your HIV testing and linkage program.
Who should complete this tool? Program managers can complete this tool, in collaboration
with testing and linkage staff and/or volunteers, consumer advisory board members, and
others involved in planning, implementation, and evaluation of your program.
When should this tool be completed? This tool may be completed before you implement
HIV testing and linkage services and/or prior to implementing adjustments or enhancements
to established programs.
How should this tool be completed? In the top portion of Tool 2, Part II, record the following
information in the designated cells:
Date Completed: Record the date that the tool was completed or updated, as
applicable.
Participants: Record the names and/or positions/roles of the individuals participating in
completing this tool.
•
•
•
Discussion questions are presented in the left column and are segmented by program
component: recruitment, testing, and linkage. For each of the discussion questions, record
the following information in the designated column:
• Summary of Formative Evaluation Questions: Record a summary of the findings of
your formative evaluation (as recorded in the Answer column in Part 1. This will help you
to draw conclusions about which strategies are appropriate for the target population.
Strategies, Gaps, and Next Steps: Brainstorm about the strategies and practices that
could best address your findings and record them in this column. Include gaps in
knowledge or resources for which you will need additional information, along with next
steps to address these gaps.
•
Tool 2, Part II has been completed for you to illustrate how it may look when completed.

Tool 2. Part II: Interpreting and Applying Findings of Your Formative Evaluation
Agency/Program: ACME Prevention Services, Center Point
Program
Participants:
• ACME prevention services program director
• Center Point program coordinator
• Center Point outreach coordinator
• Center Point outreach workers
• ACME SSP program coordinator
• Visiting Nurse HIV prevention coordinator
• Center City Hospital HIV clinic manager
Target Population: White and African American IDUs over 30 years
of age living in North Center City
Date Completed: June 5, 2012
Discussion Questions for Program
Implementation
Summary of Formative Evaluation
Findings
Strategies, Gaps, and Next Steps
Targeting
• What data sources might be useful to
identify areas of high prevalence?
• Which risk groups should be targeted
for testing?
• Within jurisdictions, where do high-risk
groups congregate?
• How can you determine membership in
a target population with a few
questions?
• What additional information is needed?
• Surveillance data can be limited to
ZIP code level
• Nontraditional data sources might
be helpful in addition to
surveillance data
• Risk group defined by funding
stream
• Characteristics and behaviors of
the target population define
questions
• Collaborate with health departments to obtain prevalence
and incidence data
• Conduct formative research to identify areas where high risk
people congregate
• Nontraditional data sources are helpful in identifying areas
where high-risk groups congregate
• Define characteristics of the target population and develop
questions to accompany them

Tool 2. Part II: Interpreting and Applying Findings of Your Formative Evaluation (continued)
Implementation
Findings
Recruitment
• Where should we recruit and offer
testing and linkage?
• How should we recruit for HIV testing?
• What recruitment messages will be
persuasive?
• Who should do the recruiting?
• How many previously diagnosed
positives are recruited for retesting?
positives that may be encountered
during testing efforts have fallen out of
care?
• Depending on the recruitment
strategy, lots of staff time needed
to locate members of target
population, motivate, and engage
into testing
• There are practical barriers to HIV
testing (appropriateness of
location, hours offered, need for
second visit for results)
• HIV not a high priority for target
population; HCV testing and
dental services are priorities
• HIV retesting can occur at higher
rates when incentives are provided
• Venue-based recruitment at Center City Shelter and ACME
SSP
• Outreach recruitment in Riverside neighborhood
• Bundle HIV testing with valued health services—partner with
visiting nurse to provide outreach testing so HIV and HCV
testing can be provided together
• Recruitment messages should address misconceptions about
treatment
• Engage peers as recruiters
• Providing access to dental services in conjunction with HIV
testing may encourage testing
• We need to find out if it possible/feasible to partner with
CCHD on mobile van health service to arrange to provide
dental care along with HIV and HCV testing
• Evaluate recruitment strategy if many previously diagnosed
HIV persons are retesting
• Reengage previously diagnosed patients to care

Implementation
Findings
Testing
• Which HIV testing strategy should
we use?
• Where should HIV testing be
provided?
• What kinds of things might motivate
or interest our target population in
HIV testing?
• Who will provide supplemental
testing, if the program only offers
rapid testing?
• Will the testing program provide
blood-based or oral tests?
• Does the testing program able to
train staff to ask about recent HIV
exposure?
• Does the staff have capacity to
evaluate recent infection?
• What additional information is
needed?
• There are practical barriers to HIV
testing (location/hours offered)
• Other health and daily life issues are
higher priority than HIV
• There are practical barriers to learning
result
• Clinical providers in the community
can provide supplemental testing
• Testing technologies can depend on
resource availabilities
• Use rapid HIV test
• Venue-based HIV testing at Center City Shelter and ACME SSP
• Conduct outreach HIV testing in Riverside neighborhood
• Use incentives valued by the target population (e.g., blankets,
hygiene kits)
• Bundle HIV and HCV testing
• Explore feasibility of providing HIV testing in conjunction with
dental services
• We need to find out whether the target population will
accept a finger stick rapid test or must oral fluid be used?
• Partnerships need to be developed with clinical providers
• Staff training on asking about recent exposure can be helpful
to provide referrals to non-occupational post-exposure
prophylaxis
• Screening for acute infection is useful in helping triage these
patients to needed care and alerting health departments for
partner services

Implementation
Findings
Services for HIV-Positive Clients
• What strategies and resources are
required to link HIV-positive
individuals in our target population
to care?
• What potential barriers are faced by
HIV-positive individuals for linkage
to care?
• What kinds of practices or things
might help HIV-positive individuals
in our target population link partner
services (PS)?
• Can basic needs assessment be
provided onsite following testing?
might help HIV-positive clients link
to risk-reduction services?
needed?
• Target population has
misconceptions about HIV treatment
(cost, eligibility)
• Practical barriers to HIV care
(scheduling, transportation)
• Trust peers for health information and
services
• Other health and daily life issues are
higher priority than HIV
• Mistrust of HD PS
• Basic needs assessment can inform
potential barriers that may prevent
linkage to care efforts
• No identified behavioral risk-
reduction services for active IDUs
available in the community
• Referral assessment and planning should address
misconceptions about HIV treatment eligibility and cost
• Use peer navigator to facilitate linkage to HIV medical care
• Collaborate with Center City Community Hospital case
management program to ensure clients have support to
access a range of enabling services
• Collaborate with Center City Community Hospital HIV clinic to
identify resources and strategies to provide treatment for
HIV-HCV co-infected clients
• What community resources can effectively address the needs
of clients with HCV infection, including co-infection?
• Referral assessment and planning should address
misconceptions about and value of PS
• Partners will be elicited by peer navigator and referred to
the HD
• We need to explore whether it is feasible to provide
community-based PS through collaboration with Center
City HD
• Basic assessment of needs should address potential barriers
to linkage to care or adherence to care
• We must evaluate whether CRCS staff currently have the
knowledge and skills necessary to be effective in delivering
risk-reduction interventions
• Logan Community Services (LCS) in a neighboring city offers
holistic Health Recovery Program; we must determine
whether it is feasible to collaborate with LCS to have them
provide services to our clients

Implementation
Findings
• What strategies can be used to
triage the highest-risk persons to
prevention services?
• What kinds of practices or tools are
available to conduct a prevention
needs assessment for the highest-
risk clients?
• Are there prevention messages or
tools available for low-risk clients?
needed?
• Characteristics of the target
population can define whether client
is high risk or low/medium risk, if not
determined during the targeting
phase
• No identified behavioral risk-
reduction services for active IDUs
available in the community
• Prevention needs assessment tool
can be dependent on the client
characteristics and services available
in the community
• Provide risk-reduction counseling to IDU clients at elevated
risk for HIV
• Assess resources in the program and community that are
available, if the client needs to be referred for prevention
services
• Factors and behaviors related to HIV acquisition risk should
be evaluated during the prevention needs assessment

Practice Example 2.1.
Applying Findings of Formative Evaluation to Program Implementation Planning
The example in Tool 2, Part II, ACME Prevention Services (APS) used formative evaluation to determine which
strategies would help them to implement an effective HIV testing and linkage program for their target
population, IDUs over the age of 30 years. Tool 2 helped APS organize and apply the findings of their
formative evaluation to program planning.
Recruitment and testing will be conducted in the following locations: Center City Shelter, the ACME syringe
services program, and through outreach in the Riverside neighborhood. Peers will perform recruitment and
recruitment messages will highlight the availability of free HIV care.
APS will partner with the Visiting Nurse Program to provide services in the Riverside neighborhood. APS will
use rapid HIV testing. Through targeted interviews with SSP clients, they learned that blood samples obtained
through a fingerstick were not a deterrent to testing, and so they will use this method. To encourage testing,
they will distribute blankets, hygiene kits, and bottled water. Through partnership with the Visiting Nurse
Program, they will be able to offer both HIV and HCV testing through outreach activities.
APS has received training from the CCHD on conducting partner elicitation. They have entered into an MOA
with CCHD that ensures that the HD will allow APS 5 business days to elicit and forward to CCHD partner
information. After 5 days, if CCHD has not received partner information, PS staff will contact the client.
Referral assessment procedures have been revised to ensure that clients receive information about the
availability of HIV medical care, which is free of charge. Peer navigators provide information and support to
HIV-positive clients to ensure that clients successfully link with HIV medical care. APS has entered into an MOA
with the Center City Community Hospital. This agreement gives APS clients priority for HIV medical care
(including same-day appointments), as well as priority for enrollment case management services.
APS CRCS staff has received training to increase their knowledge and skills for working with the target
population and will provide risk-reduction counseling to high-risk HIV-negative clients onsite. LCS is
interested and willing to provide Holistic Health Recovery Program for APS clients. The two agencies are
collaborating in seeking resources to enable this programming.

Chapter 3. Targeting and
Recruitment
This chapter addresses targeting HIV testing and linkage services to high-risk populations
and recruiting members of these populations into your program. In this chapter we will
discuss the following:
• The value of conducting highly targeted HIV testing and linkage services
The kinds of data that can be used to improve targeting, and where to obtain these
data
Recruitment strategies, including how to select the best strategy for your program
Incentives for recruitment, including the advantages and disadvantages
Quality assurance of recruitment activities, including training and assessing staff
proficiency
Monitoring and evaluation of recruitment activities
•
•
•
•
•
• Apply data to decisions about targeting
Select and implement recruitment strategies
Monitor the success of your recruitment efforts
•
•
What Is Targeting?
Targeting is the practice of directing HIV testing and linkage services to high-risk populations
and settings in which high-risk persons can be accessed, with the purpose of ensuring that
services are offered to persons who need them (at the place of recruitment or an affiliated
nonclinical venue). As an HIV testing and linkage provider, you may find it useful to employ
local information and data to identify individuals at highest risk for HIV infection and tailor
services to ensure that they are acceptable and accessible to them.
In providing HIV testing in non-clinical settings, it is important to target high-risk individuals
who do not access health care services or who otherwise may not have access to HIV testing
in clinical settings. This is done by narrowing the focus around specific subsets of a
population and tailor programs to provide services that have been proven effective with
high-risk populations.

It is important to continually refine your targeting practices and recruit individuals at highest
risk for HIV infection. Formative evaluations can provide valuable information refining
targeting and recruitment strategies (See Chapter 2 for more details). Continual assessments
of these strategies will ensure that your programming has the greatest impact possible and
does so with maximum efficiency.
This chapter discusses and provides examples of different data sources useful for targeting,
and strategies to help you determine which source(s) will work best for you and for your
target populations. It also includes examples of successful targeting practices and
suggestions for fine-tuning targeting to better inform recruitment.
Use of Data in Targeting
When defining and determining how to most effectively access a target population, it is
important to use a variety of data sources. Your agency may find it useful to consider data
such as the percentage of individuals infected, the rate of new infections, as well as the profile
of risk behaviors present within the community. Typically agencies will rely on State-, city-,
and/or county-level disease surveillance data to narrow the scope of their targeting. To gain a
more nuanced understanding of where infections are occurring and the behaviors implicated
in driving infection, you may want to obtain other sources of data, such as substance abuse
treatment admissions or law enforcement data to help identify neighborhood- and street-
level profiles of high-risk behaviors, such as sex work or injection drug use. Examples of
sources you may use for targeting and recruitment planning are presented in Exhibit 3.1.
Exhibit 3.1. Sources of Data for Targeting and Recruitment
Characteristics/
Factors
Examples Where to Get Information/Data
Epidemiological • HIV prevalence
• Sexually transmitted
disease (STD) prevalence
• HIV incidence
• Disease surveillance data (e.g., HIV, STD, tuberculosis
[TB] case registries) (e.g., CDC’s State and local
surveillance reports:
http://www.cdc.gov/hiv/surveillance/resources/repor
ts/2010report/pdf/2010_HIV_Surveillance_Report_vo
l_22.pdf#Page=79)
• Serologic Testing Algorithm for Recent HIV
Seroconversion HIV incidence reporting
• State/local epidemiologic profiles
• HIV prevention service data
• Medical modeling project
• Substance abuse admissions and treatment
Geographic • Particular counties in a
state
• Particular ZIP codes in a
county
• Particular
neighborhoods of a city
• Particular venues in a city
• Geographical information systems (GISs) (e.g., CDC’s
ATLAS (http://www.cdc.gov/nchhstp/atlas) and
AIDSVu (http://AIDSVu.org))
• Police data
• Disease surveillance data
• State and local health department surveillance data

Exhibit 3.1. Sources of Data for Targeting and Recruitment (continued)
Characteristics/
Factors
Examples Where to Get Information/Data
Behavioral • Sexual behaviors
• Use of risk-reduction
strategies
• Injection drug use
• Youth Risk Behavior Surveillance System
• National HIV Behavioral Surveillance
• Behavioral Risk Factor Surveillance System
• Community assessments
• Law enforcement data
• Substance abuse treatment data
• Emergency room admissions data
• Members of target population, other stakeholders
Social • Social networks
• Sexual mixing across
social groups
• Focus groups
• Key informant interviews
• Surveys
• Cluster analysis of STD data
Contextual • Poverty
• Access to care systems
• Educational attainment
• Housing stability
• Model-based Small Area Income and Poverty
Estimates for school districts, counties, and States
• Census
• County and city data
• National Center for Education Statistics
• Data from local service providers (homeless shelters,
drug treatment sites, etc.)
Demographic • Gender
• Age
• Race
• Ethnicity
• Sexual orientation
• HIV prevention service data
• Census
• State/local correctional system data
For more information on how to define, locate, and engage high-risk populations, please see
the Public Health Workbook to Define, Locate and Reach Special, Vulnerable, and At-Risk
Populations in an Emergency: http://emergency.cdc.gov/workbook/
Evaluate each source of data for relevance to your program, as well as the strengths and
limitations of each data source. Please reference Chapter 3, Step 4 of the Evaluation Guide
(Gather Credible Evidence) for more information about selecting and evaluating data. Some
data sources, such as data collected by disease intervention specialists (DIS), may help you to
identify networks of partners around individual cases of infection. This method of
recruitment, also known as social networking strategy, is effective when HIV transmission is
fueled by transmission between friends, acquaintances and colleagues, but may be less
effective when transmission is fueled by contact between anonymous, transient, or hard-to-
locate persons such as some commercial sex worker, transient MSM, migrants, and
immigrants.

Your target population, staff, and other service providers are also an important source of
information for you. Members of the target population can help you segment your target
population, thereby increasing the effectiveness of your targeting and informing the
selection of recruitment strategies. For example, if you are planning to target men who have
sex with men (MSM), try to gain an understanding of subpopulations (e.g., ball or bear
communities), as this will help you to select the best recruitment strategies to reach your
target population(s). Staff as well as other service providers typically have deep knowledge of
a community and may also be able to provide you with needed data.
Other sources, such as data from local service providers, can help to uncover the most
appropriate venues and locations for outreach testing. It is important to seek data sources
that can also assist you in identifying acute infections, as this is the stage at which individuals
are most infectious. If disease surveillance data are not available quickly enough to effectively
target local cases of acute infection, your agency may also work with other HIV service
providers and clinics to share data to help identify populations where acute infection is likely.
The delay in availability of consolidated, published surveillance data is a common challenge
faced by many HIV testing and linkage providers that are trying to use such data for planning
and evaluating their programs. Agencies rely on State and local data to the extent that it is
available; however, the lag time often hinders their ability to capture the most at-risk groups.
For this reason, many organizations build partnerships with other service organizations and
gather information from individuals who are familiar with “hot spots” of higher-risk behaviors.
For example, some agencies work with local taxi drivers to learn not only where to find sex
workers, but also where to provide services to them without interrupting their work.
Working with other service agencies and stakeholders should begin during the community
assessment process. Essentially, by assessing the community you can start to identify the
target population, as well as uncover challenges that your target population faces in
accessing HIV testing and linkage services and strategies on how to recruit high-risk
individuals for testing. Community partners can also be involved in identifying locations and
venues for testing. By working with local faith leaders or club owners, for example, program
staff can gain access to their communities and provide testing at their facilities. For further
support on how to identify and engage stakeholders in program planning (i.e., formative
evaluation) activities, please refer to Chapter 3 of the Evaluation Guide, Step 1: Engaging
Stakeholders.
It is helpful to coordinate or collaborate with the State and/or local HDs to obtain needed
data. HDs typically conduct community health assessment activities as part of their ongoing
program development and planning activities. Community assessment reports often contain
information about specific population groups, community resources, service utilization data,
and gaps in services. Contact your State or local HD for additional information.
Work in partnership with State and local HIV/AIDS planning groups to obtain (and plan for)
data needed to guide your targeting efforts. HIV/AIDS planning groups and State HDs
collaborate in the development of jurisdiction-level epidemiologic profiles (i.e., “epi profiles”).

Epi profiles contain a wealth of disease surveillance, behavioral, and other health indicator
data and can be an excellent source of information for HIV testing and linkage providers.
Geo-mapping is increasingly being used for epidemiological surveillance and is growing in
importance as a tool for health program planning. Geo-mapping simply means that various
data are displayed according to geographic coordinates. Complex data can be presented and
integrated in a visual way, which enables users to easily patterns and identify gaps. Geo-
mapping can be a useful tool in planning HIV testing and linkage services. Geo-mapping HIV
prevalence data can help you quickly discover where the burden of disease occurs and
suggest where you might want to focus your program efforts. You can overlay HIV data with
other health (e.g., STD prevalence) or demographic data (e.g., race/ethnicity) to get a more
precise idea of where program efforts are best focused. Current services can also be geo-
mapped so that you can see where there are gaps in services. Geo-mapping typically requires
GIS software. Some HDs routinely geo-map HIV and STD data and may be able to easily
provide this information. Some HDs work with their HIV/AIDS planning groups or other health
assessment processes to prepare health and service data in geo-mapped formats. Contact
your State or local HD for additional information. For an example of local-level geomapping,
visit the Northwestern University’s Web site at http://chicagohealth77.org/hiv-and-aids/map/.
Tip
Check with your county health department to see if they have conducted geomapping to identify
clusters of HIV infection. The AIDSVu Web site (http://AIDSVu.org) provides county and State profiles
of infection, and also includes data regarding poverty and STDs.
In the textbox below, Jamie Anderson discusses how to conduct targeting in low-incidence
areas where 1% positivity rates are difficult to obtain.
In an effort to meet the 1.0% positivity rate for HIV incidence, Kansas Department of Health and
Environment (KDHE) will support five CBOs in 2012, with funding directed toward implementing
targeted testing with high-risk individuals using Clearview Complete rapid HIV 1/2 test kits.
These supported sites will be required by contract to collaborate and recruit for testing efforts
with organizations in their communities in order to access populations at highest risk for HIV.
Collaborative events include HIV awareness days; community and agency health fairs; bar
outreach recruitment activities; pow-wows; church events; and lesbian, gay, bisexual, and
transgender (LGBT) community pride events. The five CBOs funded to implement targeted rapid
testing will be required to partner with at least one other non-HIV testing organization to
provide outreach recruitment or testing on a quarterly basis. These relationships will be
established in an effort to target organizations, offer testing, or conduct recruitment efforts
where priority populations are. These sites are required to conduct a minimum of three
community outreach testing events in venues or settings which reach one or more priority
populations.
- Jamie Anderson
HIV Counseling, Testing, and Linkage Director
Kansas Department of Health and Environment

What Is Recruitment?
Once your target population has been clearly defined, you must determine how best to
locate, engage, and motivate the population to access HIV testing services. There are many
different strategies to use when recruiting individuals to HIV testing; typically a combination
of approaches works best. No matter what strategies are selected, however, it is critical to
engage key informants in the process to ensure that the approach is culturally appropriate
and that it will be effective with the target population. (Notice a pattern that engaging the
community throughout each step of your program planning and implementation is a
priority!)
From working with stakeholders to defining the target population, program staff may already
have some insight into what types of recruitment strategies might be successful. With your
target population identified, program staff can continue collaboration with informants to
tailor recruitment strategies. Formative evaluations can provide valuable information on the
best ways to locate, engage, and motivate members of the target population given the
dynamics of different communities and strategies that work best with particular high-risk
populations.
When planning one’s program strategies, it is important to consider several categories of
people that may be naturally encountered during recruitment (see “generic” operational
flow-chart in Chapter 2 for details). As a minimum, testing programs are encouraged to recruit
and offer testing to persons who fall into the first three core categories. They may also choose
to recruit and offer testing persons who fall into the 4th and 5th optional categories:
Core Categories:
1. Persons who are members of the target population based on observation or
information volunteered by the person without being questioned by the recruiter.
For example, recruiters seeking Latino MSM in a specific neighborhood would attempt to
recruit Spanish speaking men who congregate at a gay bookstore.
2. Persons who are not a member of the target population based on observation, but
recruiters classify them as members of the target population after asking a few
questions. For example, recruiters seeking members of a young MSM target population
would ask young men if they are gay, bisexual, queer, or have sex with other men.
3. Persons spontaneously seeking testing without having been specifically recruited or
offered testing by a recruiter

Optional Categories:
4. Persons who are in a social network (sex or drug) of members of the target population
noted in 1 and 2 above if the program opts to use a social network recruitment
method.
5. Persons who volunteer individual risk factors for HIV, without being questioned by
recruiters.
Thus, persons who do not meet either the core or optional categories would not be offered
testing. If an appropriate recruitment strategy is selected, the number of people in this
category should be very small. Recruiting a lot of people whom meet neither the core nor
optional categories suggests that the recruitment methods need to be refined to better
locate or engage members of the target population. Formative evaluation may be conducted
to elucidate more precise strategies.
Depending on the type of people encountered, the program will need to develop appropriate
messages and procedures to recruit clients, including the characteristics that define
membership in the population that can be determined strictly by observation, a limited
number of questions that would need to be asked to determine membership in the target
population if observation alone does not suffice, and whether the program will offer testing
to persons in categories 4 and 5.
Definition
Recruitment is the process by which individuals are located, engaged, and invited to test.1
The key steps involved in recruitment include the following:
•
•
•
•
•
•
•
Precisely identify and describe the target population and actual or “virtual” places (e.g.,
Internet) to locate the population.
Develop appropriate messages, tailored to the target population.
Develop and plan a recruitment strategy (i.e., when, where, how should recruitment be
done).
Pilot the recruitment strategy and refine based on results.
Use the piloted recruitment strategy for a specific service (i.e., testing).
Monitor success of recruitment strategies in engaging individuals in the service.
Refine recruitment strategies, messages, and venues/settings on the basis of M&E data
and feedback from the target population.
Each of these steps will be explained in further detail throughout the remainder of the
chapter.
1
Centers for Disease Control and Prevention. (2011). Vital signs: HIV prevention through care and treatment—
United States. Morbidity and Mortality Weekly Report, 60(47), 1618–1623.

Recruitment Strategies
This section will describe the uses of various recruitment strategies and provide support for
selecting those that are appropriate for your target population. Once you define your target
population, focus on developing messages for and planning your recruitment strategy.
When selecting a recruitment strategy, first and foremost, the strategy must be appropriate to
the target community and must facilitate accessing and engaging the target community. If,
for example, you are working with homeless IDUs, you will likely need to meet them on the
street or in another venue (e.g., a shelter) rather than use the Internet for recruitment, as this
population may have limited or no access to the Internet.
Practice Example 3.1: Matching Recruitment Strategies to the Target Population
Acme Prevention Services (APS) provides HIV testing and linkage services in Center City. Their target
population is homeless IDUs. APS decides to partner with a homeless shelter and three warming centers to
provide HIV testing and linkage. APS also collaborates with CCHD to conduct health screenings using CCHD’s
mobile vans (street-based outreach) in the Riverside neighborhood. Formative research identified the
Riverside neighborhood as a location where this population congregates, because of the large number of
abandoned homes available to use to inject drugs.
In the textbox below, Robin Pearce discusses how the NO/AIDS Task Force uses the Internet
to recruit clients.
About 30% of our testing clients visit one of our fixed sites because they did a Google search for
free HIV testing in New Orleans, found our Web site, and read our testing hours. We have
separate Facebook pages for our satellite prevention offices and we use them to promote
events, though clients rarely cite this as the way they find our testing hours.
- Robin Pearce
NO/AIDS Task Force
New Orleans, LA
Below, Jacob Dougherty describes how Diverse and Resilient adopted the use of motivational
interviewing to improve recruitment efforts.
We use motivational interviewing as a strategy with our volunteer health promoters that do
recruitment out in the field. We chose motivational interviewing because as a strategy it’s
relatively easy to train to our health promoters, and it has proven effective at translating issues
we hear directly from members of our target population into action. During pride festivals, we
deploy many volunteer health promoters throughout the festival to have one-on-one
conversations with attendees that fit the target population for our programs. The volunteer
health promoters are trained before the festival on motivational interviewing skills, and the
training includes practices, teach-backs, and several field examples from previous years. This

way, the volunteer health promoters are able to adapt to different situations they may
encounter in the field, and motivate a large number of people to consider getting tested or
enrolling in an HIV prevention program.
- Jacob Dougherty
Data Specialist
Diverse and Resilient
Milwaukee, Wisconsin
Review the following recruitment strategies and select those that are within your agency’s capacity to
implement and are appropriate for use with your target population.
Exhibit 3.2 describes the different recruitment strategies employed by HIV testing and linkage
providers. If your agency is already using some of the strategies shown here, it is
recommended that you evaluate their effectiveness to ensure that you are using appropriate
methods. Evaluation of recruitment strategies will be described later in this chapter.

Exhibit 3.2. Recruitment Strategies
Recruitment
Strategy
Definition Uses/Populations Limitations
Outreach:
• Street-based
• Venue-based
• Social
Marketing
• Internet
Street-based and venue-
based:
Meeting clients in their own
environment to engage
persons at high risk, often
conducted by peers or
paraprofessionals
Social marketing:
The use of media to recruit
clients into HIV testing
programs, through modes
such as the Internet, radio,
television, posters, and flyers
Internet:
Outreach to clients through
online venues such as chat
rooms and social networking
sites. The Internet can also be
used to promote and market
program services
Street-based:
• Mobile testing units
• IDUs
• Sex workers
• High-risk hot spots
Venue-based:
• MSM
• IDU
• Homeless populations
• Recently incarcerated individuals
• Useful in places where high-risk groups
spend time
• Testing may or may not be provided at the
venue
Social marketing:
• Useful for raising awareness of HIV and HIV
testing
• Tailor messages to recruit youth, MSM, IDU,
and so forth
Internet:
• MSM
• IDUs
• Youth
• Other high-risk groups
Street-based:
• Clients may not want to receive services at
the same place where they engage in high-
risk behaviors
• Street-based services require additional
resources (e.g., mobile testing units,
additional staff, demonstration materials)
• Additional safety and security protocols
• Limits test selection if blood draws are not
done onsite
Venue-based:
• Can over-test the same people
• Must pay attention to shifts in popular
meeting places and meeting days or times
so that you are not testing at a venue that is
no longer frequented by high-risk
individuals
• Limits test selection if blood draws are not
done onsite
Social marketing:
• Difficult to evaluate who you are reaching
and missing
• Must test messages and seek feedback from
clients to make sure marketing is
appropriate and effective
• Can be expensive
Internet:
• Difficult to evaluate effectiveness other
than self-report
• Does not reach those without Internet
access such as homeless/transient people

Exhibit 3.2. Recruitment Strategies (continued)
Recruitment
Strategy
Internal Referrals
Definition
Accessing clients through
other services that are
•
Uses/Populations
Useful for working with groups receiving
other services and in correctional facilities
•
Limitations
Many high-risk individuals do not access
services such as the ones listed here
provided within the agency
where the testing program
resides (e.g., syringe exchange
programs, substance abuse
programs, mental health
services, crisis care)
• Testing can be provided onsite or referrals
can be made
•
•
Important to also provide outreach and
other services to supplement internal
referrals
Requires coordination with other agencies
External Referrals Clients are referred by external
agencies to the testing
program
•
•
No-cost recruitment
Useful for high-risk groups accessing other
sites (e.g., syringe exchange, homeless
shelters, STD programs, substance abuse
programs)
•
•
•
Must develop relationships with other
agencies
Provide training/ information on how to
make appropriate referrals
Must make sure referrals truly are high-risk
so as not to overwhelm your agency’s
testing capacity
Social
Networking
A peer-driven approach of
identifying HIV-positive or
HIV-negative high-risk persons
from the community who are
able to recruit individuals at
high risk from their social,
sexual, or drug-using
networks; partner referral is a
type of social networking
which involves members
•
•
•
•
MSM
IDUs
Sex workers
Other high-risk groups
•
•
Recruiters much be provided with coaching
and supporting from the implementing
agency
Staff providing coaching and support must
receive training to ensure that they are
knowledgeable about the model and have
the skills to support recruiters.
referring their sexual partners
to a testing program

Selecting a Recruitment Strategy
After reviewing the available strategies for recruitment, your agency must decide which
methods are appropriate and feasible for working with your target population. It is important
to pilot the recruitment strategy to see how well it works and refining as needed. One of the
first factors you might consider in piloting/selecting a recruitment strategy is location:
•
•
•
•
•
Where are you planning to access the population?
Will you reach them in bars?
Will they come into a social service agency?
Are they already engaged in other services?
What time of day do you have the best ability to access them?
By conducting your readiness assessment and formative evaluation, you may have a better
idea of where to reach high-risk individuals. For example, if you also offer a syringe services
program and your target population is IDU, you can recruit testing clients who are receiving
syringe services. Alternately, you may decide that it is better to access the target population
in a setting where they congregate, such as a shelter, or where HIV risk behavior occurs, such
as a bar. (See Chapter 2: Getting Started—Preparing to Implement HIV Testing and Linkage
Services in Nonclinical Settings for more information on formative evaluations. In particular,
review the section titled Formative Evaluation and Implementation Planning. Tools that will
help you to identify appropriate recruitment strategies are also included in that section.)
Safety: Another factor that must be considered in conjunction with testing venues is safety. If
you are trying to reach commercial sex workers, for example, you probably need to conduct
outreach. Still, if you try to provide services to commercial sex workers when they are
working, you could be costing them clients and disrupting the environment. You could be
putting both clients and staff members in danger, so it is important to know the clientele and
the location before sending staff out to provide services. Here are a few questions to think
through before selecting a recruitment strategy:
•
•
•
•
What are the characteristics of the testing environment? Is it closed (e.g., a building) or
open (e.g., a street corner)?
What kind of traffic will be present at the time of testing? Are you testing late at night?
Will other people be around?
How many staff members will you need to have present? Is it safe to have only two or
three people onsite? Will you need to have more staff available?
What type of exit route is available? Are you recruiting in an alley? Can your staff quickly
and safely leave the site if necessary?
When testing in an unfamiliar area, it is a good idea to consult with local law enforcement to
inform them of your plans. Having a police presence at a testing event would certainly deter
many high-risk individuals from testing, so it is important to have police available—should
you need them—but not visible to the population.

Another way to increase safety is to enlist a gatekeeper to help you build trust with the
community. When clients know your agency and trust that you will not give their names to
the police if they are engaging in illegal behavior, they will be more receptive to your services.
If you are trying to reach non-gay-identifying MSM, for example, your clients need to trust
that you will not out them to the community. A gatekeeper can help establish the necessary
rapport and also keep you informed as to where to provide services, as hot spots and popular
meeting venues may frequently change. More information on safety is available in Chapter 9:
Quality Assurance and Monitoring and Evaluation. For HIV testing conducted in outreach
settings, safety considerations for outreach testing are addressed in Chapter 8: HIV Testing in
Outreach Settings.
Agency Capacity: Consider your agency’s capacity for implementing and sustaining
recruitment efforts. Some strategies can be resource intensive and may require hiring
additional staff or purchasing new materials. Your agency may wish to use a multipronged
approach in which resource intensive recruitment activities are used sparingly. It can also be
beneficial to work with partner organizations to combine resources and extend your reach in
the community. For example, if your agency does not possess a mobile testing unit, you could
partner with other agencies to make use of their mobile units. You might also host an event at
which HIV testing is provided alongside non-communicable disease or other health screening
to attract more clients and to share the organizational burden with a non-HIV missioned
agency. Building such partnerships and collaborating in this way will also help to brand your
services and increase name recognition. This can increase the number external referrals made
by other organizations for services. Please refer to Chapter 7: Referral and Linkage to Health
and Prevention Services for additional information about and discussion of collaboration.
Practice Example 3.2: Collaboration to Enhance Organizational Capacity for HIV Testing
and Linkage
APS provides HIV testing and linkage services in Center City. Their HIV testing and linkage program offers
targeted services for MSM. APS also operates a very successful YouthWorks! program that provides
community education and leadership development for low-income minority youth. While APS has been
successful in providing services in gay-identified venues, they have been less successful in providing services
to MSM who do not self-identify as gay or who do not access gay-identified venues.
CCHD has two large mobile vans that they use to conduct health screenings at various events and as part of
their community health outreach program. Nursing staff can perform STD screenings, other health
screenings, as well as vaccinations. CCHD has had difficulty in reaching youth, who find it difficult to get to the
CCHD clinic during operating hours and fear that their parents will learn about their receiving services.
APS and CCHD decide to collaborate in providing services for their mutual benefit. On two Saturdays each
month, APS staff joined CCHD staff on the mobile vans that travel to areas of Center City where the
prevalence of HIV and other STDs is relatively high and there are clear gaps in services. APS staff provide HIV
testing with a rapid test, offer risk-reduction counseling, and help to refer clients to other risk-reduction
services. For clients who are HIV-positive, they provide “concierge” service to link these clients with the HIV
client at Center City Hospital. CCHD nursing staff members conduct screening for gonorrhea, chlamydia, and
hepatitis C. They also provide vaccination for hepatitis B.

Implementing Recruitment
Implementing new recruitment strategies can be time and resource intensive. A few of the
inputs recruitment may require the following:
•
•
•
•
•
Staff training
Contracting with consultants
Purchasing new materials
Cultivating new partnerships
Developing and testing recruitment messages
Conducting recruitment for testing requires multifaceted training for HIV testing and linkage
staff and/or volunteers. If testing is to be conducted at the recruitment site, staff/volunteers
need to be trained in HIV testing, and also in how to perform linkage from outreach, external
and internal referral venues. Depending on how active your agency’s recruitment efforts are,
your program manager may decide to hire staff accepted by the target community to
specialize in outreach or internal referrals. If staff members/volunteers can interact with
clients in their environments as peers, your program may have better recruitment outcomes.
Regardless of their specialization, all recruitment personnel must also be trained in cultural
competence, as they prepare to enter communities with the objective of recruiting
individuals into testing. More information on cultural competency can be found in the section
titled Cultural Competence, located in Chapter 9: Quality Assurance and Monitoring and
Evaluation.
Obtaining outside expertise, such as a consultant, may be necessary to inform a recruitment
strategy and messaging. This is particularly true for efforts in social marketing and Internet
recruitment when media advertising is involved, which requires expertise beyond the
capacity of many community-based providers. Identifying the most effective Internet
recruitment strategy for your organization necessitates pilot testing messages with
representatives of the target population. It is important to test messages for reading level to
ensure that your target audience comprehends them, for appropriateness to discover how
the population perceives them, and for effectiveness to see how the population responds to
them.
Practice Example 3.3: Testing Recruitment Messages
APS provides HIV testing and linkage services in Center City. Their HIV testing and linkage program targets
MSM, some of whom are gay-identifying and some of whom are not. APS has an advisory board with gay-
identifying MSM members who provide feedback on the messages developed to target MSM. Still, in order to
effectively reach MSM who do not self-identify as gay, APS had to delve deeper into the psychosocial
constructs of machismo and internalized homophobia within Center City’s Latino community. APS partnered
with local men’s faith and recreation groups to construct messages that equate testing with masculinity and
assert male sexuality. These messages were pilot tested at community testing events to ensure that they were
effective in recruiting men into testing without threatening their sexual identities.

Recruitment efforts may also require additional materials and resources. For example, if your
program’s scope of service includes street outreach, your agency may need to acquire a
mobile testing unit. You also might need printed materials to distribute information and
provide referrals. When selecting a recruitment strategy, it is important to consider the costs
of implementation and weigh them against the projected yield. Surveying members of your
target population and interviewing community partners is one way to develop yield
expectations, though it is also useful to compare effectiveness of this strategy among other
service agencies working with similar populations.
Finally, in order to conduct effective internal referrals, external referrals, and/or social
networking, your agency must build partnerships with other service organizations in the
community. By building partnerships, your agency can often make inroads in all three of
these areas, as the program can provide testing at another agency, receive referrals from
other providers, and establish relationships with members of the target population who can
recruit others into testing. Make sure to have an updated inventory of local service providers
and explore opportunities for new collaborations. Partnerships and collaboration, including
strategies for developing and operationalizing them, are discussed in detail in the section
titled Community Partnerships and Referral Resources, presented in Chapter 7: Referral and
Linkage to Health and Prevention Services.
Once you have trained staff, tested your messages, and gathered all other necessary inputs,
you can begin recruiting individuals into testing and other services. You will need to exercise
the following steps in order to successfully implement your selected strategies:
• Develop targets for each recruitment site: What are your goals? (Do you hope to provide
testing and identify positives? Do you plan to provide referrals? Are you aiming to make
your services known to high-risk individuals and to decrease stigma?)
Based on your targets, select the dates and times for your recruitment activities and
coordinate these with all necessary parties (partner organizations, host sites, law
enforcement officials, etc.).
Schedule sufficient staff, volunteers, and supervisors to implement the recruitment
effort.
Prepare and package necessary supplies (pamphlets, appointment cards, referral slips,
etc.).
Pilot test your recruitment efforts at the selected sites to ensure that you are reaching
the intended population.
If referrals are made to your agency or other agencies, follow up with each agency to
track referral success.
Evaluate your efforts: If recruitment efforts do not meet your targets, try to figure out
why. (More detail will be provided on evaluation later in this chapter.)
Refine your messages and alter your efforts as necessary to reach your targets.
If targets still cannot be met, discontinue recruitment at ineffective sites.
•
•
•
•
•
•
•
•

Tip
Develop sample scripts to engage both community partners and clients.
Site Set-Up and Preparation
In getting ready to conduct recruitment efforts, prepare the following:
•
•
•
•
•
Site-specific protocols, including safety procedures
Messaging guides for engaging clients
Standards of conduct for specific venues
Handouts, resources, and/or incentives
Quality assurance procedures
For more detail about recruitment in outreach venues, along with additional information on
site set-up and safety, refer to Chapter 8: HIV Testing in Outreach Settings.
Incentives
Client Incentives
While scientific evidence is inconclusive, program experience suggests incentives can be used
in two primary ways to support HIV testing activities. The first and most prevalent usage is to
directly incentivize clients. Agencies might offer gift cards, food items, clothing, other goods,
and sometimes even cash to motivate clients to accept HIV testing. Typically, incentives are
used to reach high-risk individuals who might not otherwise test. If you provide incentives
they must be offered equitably, and this effort can pose a substantial resource strain on
agencies.
When deciding whether to offer incentives to clients, consider the following factors:
•
•
•
•
•
Are you currently recruiting your target population effectively without incentives? Are
you meeting your positivity targets?
Are other agencies providing similar services in your jurisdiction? Do they offer
incentives?
What is your budget for incentives? How could you ensure sustainability of the
program?
What types of incentives would be appropriate? What would be effective with your
target population?
What policies or regulations (if any) are in place regarding the use of incentives (e.g., is
their use allowed by the funder)? Who must approve them? What is allowable? What
would be coercive?

Challenges to Using Incentives
Repeat Testers: The use of incentives, while often effective in recruiting people into HIV
testing services, can also pose several concerns. By using incentives, your agency may by
overwhelmed by repeat testers who are testing primarily to obtain the incentive. You may
need to have a tracking system in place to prevent people from receiving the incentive more
frequently than at a predetermined interval. (You might decide that it is beneficial for
members of your target population to retest every 3 months and offer incentives at that
interval.) Sample procedures for using client incentives are available in as Template 1
Appendix D.
Interagency Competition: The use of incentives can also create competition among groups.
For example, if your agency provides $25 gift cards to a local grocery store, and another
agency provides $25 in cash, clients may be less inclined to test at your agency, as they can
shop for services with the best incentives. Similarly, clients may collect on incentives at
multiple agencies, thus further draining resources. Your agency may be pressured to use
incentives in order to compete with nonservice-delivery organizations. If, for example, you
want to provide testing at a health fair, but clients are drawn to an incentive for completing a
behavioral risk survey, you may not be able to “buy” their time without offering them
something in return. For an example of how this competition can impact testing programs,
read the following textbox by Mary Beth Levin.
Some programs compensated clients $15 to $20 for getting an HIV test. What resulted is that
clients visited all of the programs that offered money, making the rounds every 3 to 6 months. In
addition, they were less inclined to access services of any kind that did not offer compensation. I
also noticed that staff themselves promoted the compensation rather than the service and its
benefits. Some programs will financially compensate clients who consent to an HIV test. A guy
on the street approached me, asking “How much are you going to pay me to get tested?” I
informed him that we weren't one of those programs. His response: “Well then, why should I get
tested with you?” I answered that the important thing wasn't that he tested with us, but that he
test with someone. I reviewed who should get tested and how often, finishing with “If you do
decide to test with us, we will be with you every step of the way for as long as you want us.” He
took a moment, looked me up and down, shrugged his shoulders, and said “OK, let’s do it.”
- Mary Beth Levin
Associate Professor
Department of Family Medicine and Community Health
Georgetown University School of Medicine
Washington, DC

Testing Program Capacity: Another challenge with the use of incentives relates to
organizational capacity. Not only does your agency need to have the resources to provide the
incentives, you must also have the capacity to test and link the flow of clients who access your
services because of the incentives. If offering incentives at outreach locations, you may run
out of incentives and have a crowd of upset clients to address. Such a situation could put your
staff in danger if they are unable to provide incentives for everyone. The decision to offer
incentives can also have long-term implications for the success of your program if you are
unable to sustain them. If you offer incentives because you have a grant to do so this year, but
then you will not have the money to offer them next year, you may have more difficulty
recruiting clients once the grant ends.
As you can see, incentives can pose unique challenges for your program, and you must
carefully think through your process for selecting and distributing them in order to be
successful. Some popular alternatives to monetary incentives include giving away small items
such as water bottles, t-shirts, or other materials that may be left over from large testing
events. You could also enter clients into a raffle or provide compensation for transportation
costs in the form of bus tickets or subway fare. Social marketing can also be used to market
your services and increase social value of HIV testing. These methods can all help facilitate
testing and linkage without draining the resources.
Most importantly, if your agency is reaching its targets without incentives, there is little
reason to consider offering them. If, however, you are unable to test and link clients to care
because other agencies offer incentives or because HIV testing is not a valued priority of your
target population, then you might explore and pilot test their use. Due to their complex
challenges, you may consider looking for ways to incentivize clients using limited resources
and in sustainable ways.
There may be policies or regulations which prohibit the use of incentives or specific kinds of
incentives, such as cash. Check with your State or local HD or your funder to learn about
applicable policies or requirements.
Performance-Based Payment
The second kind of use of incentives occurs between funders, such as HDs, and their
contractors. Some funders encourage refinement of targeting and recruitment by their
contractors through performance-based payment. In this way, contractors may be
incentivized to provide services to the highest risk individuals and direct greater effort on
recruiting and linking such individuals to services. For community-based and other non-
clinical providers, funders typically provide a base amount of funding. Contractors are then
eligible to receive additional payment on the basis of the services they provide (e.g., number
of tests performed). Sometimes performance-based payment is structured to provide
incrementally higher levels of payment for more targeted or more intensive services. For
example, a contractor may receive one payment amount for each low-risk individual recruited
to testing, and a different, higher amount of payment for recruiting high-risk individuals.
Similarly, contractors may be reimbursed one payment amount for making referrals to HIV

medical care and may receive additional payment for confirming that the individual was
successfully linked to HIV medical care.
A variation on performance-based payment provides contractors with a payment amount for
meeting performance targets. In this scenario, a funder may set aside a maximum amount of
funding available to a contractor, provided that performance targets are met. In the case of
HIV testing and linkage services, a certain percentage of payment is tied to meeting a specific
performance target. If all of the performance targets are met, then the contractor would
receive 100% of the payment for which it is eligible. If one or more targets are not met, than
the contractor’s payment would be reduced proportionately.
Practice Example 3.4. Performance-Based Payments
Los Angeles County Health Department has implemented performance-based payment for HIV
testing and linkage providers. Providers have two budgets—one is a “base budget” and the
second is a “pay for performance budget.” The combination of the two budgets comprises the
maximum financial obligation to an individual contractor. Payments from the base budget are
made on a cost reimbursement basis. Payments from the performance budget are made based
on achievement of specified performance measures: 20% of payment is based on achieving the
target for the number of tests conducted; 50% is based on reaching the target HIV seropositivity
rate; 15% is based on reaching the target for successful linkage to care, and 15% is based on
reaching the target for successful referral to partner services. If providers do not meet a
performance target, they are not eligible for receiving payment associated with that measure.
- Sophia F. Rumanes, MPH
Chief, Prevention Services Division
Los Angeles County Department of Public Health
Los Angeles, CA
In this resource-limited climate, performance-based payment may motivate staff to prioritize
follow up with clients who need to be linked or to identify new testing sites to increase their
yield of new positives. One of the greatest challenges of HIV testing and linkage work is that
the target populations are dynamic. Just as the population shifts, so too does the favorite hot
spot or the preferred access point for services. Agencies must constantly revisit and refine
their practices, though with limited time and resources this can be a difficult task.
Performance-based pay is a type of incentive that may help stimulate providers to meeting.
Additional information about use of incentives in conjunction with delivery of test results and
linkage to care is available in Chapters 6 and 7.

Quality Assurance of Targeting and
Recruitment
Review your practices to ensure that targeting and recruitment is being conducted according
to your established procedures and that you are meeting the standards developed for your
programs. This means there needs to be written policies and procedures for targeting and
recruitment and that you conduct QA activities on a regular basis.
In this section discussion will be limited to QA as it pertains to targeting and recruitment
strategies. Additional detailed information on QA, including tools and practice examples, is
presented in Chapter 9: Quality Assurance and Monitoring and Evaluation. A few of the major
topics for quality assurance in relation to targeting and recruitment are as follows:
•
•
•
•
Maintaining effective supervisors and recruiters
Conducting data-driven targeting
Ensuring recruitment is conducted according to protocol
Reaching targets for recruitment
Training1
As mentioned earlier in this chapter, additional staff2
training may be needed in order to
conduct effective recruitment. Training alone, however, may not be enough to ensure
successful practices. Some agencies choose to use staff or volunteers who are members of the
target population for recruitment. This can be helpful in establishing rapport, but it does not
negate the need for training and reviewing performance.
Ensure that staff conducting targeting and recruitment have received training appropriate to
their responsibilities. It is important for staff performing targeting and recruitment to receive
training and education on the following:
•
•
•
•
•
Use of data to inform targeting.
Recruitment planning and management, including the specific steps in the recruitment
process, as defined in agency policies and procedures.
The recruitment model, if applicable (e.g., social networking).
Population-specific issues which impact reduction of risk for HIV transmission or
acquisition.
Properly and accurately documenting all aspects of the recruitment process and
maintaining confidentiality.
2
We recognize that many HIV testing and linkage programs enlist volunteers to provide HIV testing and linkage

• Factors that influence a client’s willingness or ability to use referral services.


Community resources necessary to meet client needs.
Agency policies and procedures regarding recruitment.
It is important that supervisors receive training in the recruitment model to ensure that they
possess the knowledge necessary to support staff in implementation and to enable them to
effectively assess staff proficiency. Supervisors may find it useful to obtain education and
support to work with partner agencies and are encouraged to adjust recruitment practices to
the population as necessary.
Proficiency
It is important to evaluate staff conducting recruitment to assess their proficiency. Direct
observation of sessions with clients is an effective strategy to assess proficiency. It may be
useful to observe staff at regular intervals (e.g., quarterly) and more frequently after initial
training (e.g., monthly for the first 3 months) or when conducting recruitment in new
venues/settings. Additional information on assessment of proficiency is presented in Chapter
9: Quality Assurance and Monitoring and Evaluation.
Documentation and Record Keeping
Keep documentation of the following:
•
•
•
Staff training and proficiency assessments, including orientation to risk-reduction
policies and procedures.
Recruitment activities, including information that helps to explain the productivity of
various locations and strategies used for recruitment (e.g., the size of the venue, other
activities occurring in the venue).
Client satisfaction with services.
Additional information on documentation and record keeping is presented in Chapter 9:
Quality Assurance and Monitoring and Evaluation.
Monitoring and Evaluation
Evaluation of recruitment on an ongoing basis is essential, regardless of whether your agency
is already using effective strategies or you are just beginning a testing program. Sometimes
efforts that have been effective in the past stop reaching high-risk individuals; through
evaluation, you can begin to understand why. Investigate the following:
•
•
•
•
Is your program reaching members of the target population?
Are members of the target population agreeing to HIV testing?
Is the program reaching your positivity target?
Have the positivity rates at this site changed significantly in the past several months or
years?

If you are just getting started or are trying a new recruitment strategy, evaluate the strategy
during the first few months after you implement it.
One way to understand whether your program is doing everything it can to reach the target
population is to evaluate how the program recruits for testing and linkage services. This starts
with asking clients how they heard about your testing program at the point-of-service. HIV
testing staff can ask about this during the testing session and record it into a recruitment
logbook or clients can answer questions on an intake and information form. By asking the
client directly, you may be able to discover more specific information about the recruitment
method rather than simply receiving a form with checked boxes. For example, in conversation
staff can uncover what Web site the client visited, what advertisement was seen, as well as the
lag time between the client’s receipt of the message and his or her testing visit. The client can
also provide feedback and suggestions for where else services should be advertised or where
your recruitment efforts are not working.
Exhibit 3.3 provides an example set of questions to ask clients about how they were recruited
into testing. This form can be adapted to include each of your program’s current targeting
strategies, and questions can be added to gauge the appropriateness of new strategies being
considered.
Exhibit 3.3. Tracking Recruitment Efforts
Where did you hear about our services? (Please check all that apply)
________________________________________________________
? ______________________________________________
_______________________________________________
? ____________________________________________
_____________________________________________
A friend
Online
Craigslist
Facebook
Twitter
Adam4Adam
Referral from another agency
What agency referred you?
Advertisement
Where did you see the advertisement
When did you see the advertisement?
Saw us providing services elsewhere
Where did you see us providing services
When did you see us providing services?
Been here before

If you are recruiting using outreach or social networking strategies, it may not be necessary to
collect this kind of information from clients, but you might still find it useful to have a way of
keeping track of how individual clients were recruited to your program. Often this is as simple
as assigning a specific code associated with each recruitment strategy to client records.
Practice Example 3.5. Coding Data by Recruitment Source
APS provides HIV testing and linkage services in Center City. They use venue-based outreach and social
networking strategies to recruit clients to their program. Clients can also walk into the APS offices and request
a test. APS has a field on their client data collection form (collected by testing and linkage staff) to help them
track source of recruitment. Recruitment sources listed on the form include the following:
•
•
•
•
•
Self-referral
Outreach by APS
Referred by a partner
Referred by other
Social network
Review data regularly (e.g., quarterly) to assess which recruitment strategies are most
successful, determine which strategies are most effective in recruiting your target
population(s), and suggest areas where program refinement might be needed. Also look
closely at the venues in which you are conducting recruitment to assess the extent to which
those venues are providing access to your target population(s) and helping you to identify
individuals with HIV infection. By evaluating recruitment efforts on an ongoing basis, you will
be able to refine practices to keep pace with shifts in your target population. In this way,
evaluation becomes an integral part of the recruitment planning process.
The section titled Implementing Monitoring and Evaluation, presented in Chapter 9: Quality
Assurance and Monitoring and Evaluation, has additional information and tools to help you to
evaluate your targeting and recruitment efforts. Tools to help you conduct a yield analysis to
better understand how well your program is working and to guide you in discussions about
program improvement are also included in that section.

•
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•
•
•
•
•
Chapter 4. Risk Reduction
This chapter addresses risk-reduction services provided in the context of HIV testing and
linkage services. In this chapter we discuss the following:
Various kinds of risk-reduction services for high-risk HIV-negative and HIV-positive
persons
How to assess client need for risk-reduction services
Providing brief risk-reduction services to the highest-risk individuals
Quality assurance of risk-reduction activities, including training and assessing staff
proficiency
Monitoring and evaluation of risk-reduction activities
Assess clients’ risk level and need for risk-reduction services
Monitor your success in providing risk-reduction services
What Is Risk Reduction?
Clients receiving HIV testing have a range of prevention, medical, and support needs. Risk-
reduction services can help to reduce the likelihood of future infections. Some clients may be
at very high risk for becoming infected (if HIV negative) or for transmitting their infection to
others (if HIV positive). Other clients may be at relatively low risk for acquiring or transmitting
HIV. Clients should be provided with risk-reduction services that address their prevention
needs and level of risk for HIV acquisition or transmission. Clients with low or no risk will likely
have minimal risk-reduction needs. Develop strategies to provide, onsite or through referral,
risk-reduction services that will assist clients in staying negative or from transmitting their
infections to others.
Definition
Risk reduction refers to a range of interventions designed to reduce or eliminate the risk for
transmission or acquisition of HIV infection. Risk-reduction interventions are listed in
Exhibit 4.1.

Exhibit 4.1. Risk-Reduction Interventions
• Screening and treatment for STDs • Pre-exposure prophylaxis (PrEP)
• Screening for viral hepatitis • Individual- and group-level behavioral
• Vaccination for hepatitis B interventions
• Reproductive health services • Syringe access
• Substance abuse treatment • Distribution of risk-reduction supplies (e.g.,
• Non-occupational post-exposure prophylaxis condoms)
(n-PEP)
Determining the Need for Risk Reduction
It is essential for all clients tested for HIV to, at minimum, receive information about HIV
transmission and prevention, along with condoms and/or other risk-reduction supplies
appropriate to the clients’ risk. However, you might find it useful to learn about factors that
may be contributing to increasing the client’s risk for acquiring or transmitting HIV. This will
help you understand which clients could most benefit from risk-reduction services and which
risk-reduction services would help these clients most. Clients who report any of the following
may be at high risk for HIV transmission or acquisition and may benefit from risk-reduction
services:
•
•
•
•
Recent or ongoing unprotected anal and/or vaginal sex with an HIV-positive partner or
partner of unknown HIV status
Recent or ongoing sharing of drug injection equipment with an HIV-positive partner or
partner of unknown HIV status
Current or recent past diagnosis of and/or treatment of an STD in self or partner
Symptoms of viral illness
Learning when the client was last tested for HIV, and the results of their most recent test, will
also help you to gauge clients’ risk for HIV transmission or acquisition. For example, if a client
reports a negative HIV test within the past 6 months but also reports using a condom every
time he has anal sex, that client is probably not at high risk for HIV. On the other hand, a client
who reports a previous negative HIV test result also reports having anal sex with an HIV-
positive partner without a condom is at high risk for HIV.
Learning about your clients’ level of risk for HIV does not require a lengthy, in-depth
assessment of behaviors and other factors that influence risk (e.g., mental health status). A
few brief questions should be able to provide you with this information. Sample questions are
included in Exhibit 4.2. Adjust or adapt these questions to suit your target population.

Exhibit 4.2. Sample Questions to Identify High-Risk Clients Who Could Benefit From
Risk-Reduction Services
Sample Questions to Identify High-Risk Clients
• When was the last time that you had anal or vaginal sex with an HIV-positive partner or with a partner
whose HIV status you did not know?
• When was the last time you shared drug injection equipment with an HIV-positive partner or with a
partner whose HIV status you did not know?
• Have you recently been diagnosed with an STD? If yes, are you being (or have you been) treated?
• Has your sex partner been recently diagnosed with an STD? If yes, is he or she being (or has been)
treated?
• Have you been feeling sick lately? Do you have a fever, sore throat, swollen glands, muscle or joint aches,
or any other flu-like symptoms?
There are several ways that you can gather information to gauge clients’ level of risk for HIV
transmission or acquisition. Exhibit 4.3 presents various methods, along with the benefits and
drawbacks of each.
Exhibit 4.3. Methods to Assess Risk for HIV Transmission or Acquisition
Method Benefits Drawbacks
Written self-
administered
questionnaire (paper
and computer based)
• Low cost (if done with paper
and pencil)
• Requires little staff time to
administer
• Difficult for clients with low literacy
levels to complete
• Translation of questions for non-
English-speaking clients
• Up-front cost for computer
programming, purchase of equipment
• Clients may be reluctant to provide
accurate responses and may instead
provide socially desirable responses
Face-to-face interview • May help clients with low
literacy levels complete risk
screening
• Low cost
• Requires greater staff time to
administer
• Clients may be reluctant to provide
accurate responses and may instead
provide socially desirable responses if
they do not yet know/trust the staff
person conducting the interview
Audio computer
assisted self-
interviewing
• Appropriate for clients with low
literacy levels
• Appropriate and reliable with
adolescent populations
• May result in gathering more
accurate information than self-
or interviewer-administered
questionnaires
• Up-front cost for programming and
purchase of equipment
• Programming costs when changes to
interview tool needed

In deciding how you will gather information on client risk, consider the following:
•
•
•
•
•
•
The literacy level of the target population.
The developmental level of the target population.
The venues or settings where testing is to be performed. For example, it may not be
desirable or feasible to use computer-assisted methods in some outreach settings.
Staff time and skills to collect information via interview with clients.
Staff capacity to provide translation services, if needed.
Resources to purchase equipment for computer-aided methods for risk screening.
Seek feedback from representatives of the target population and line staff to ensure that you
selected a method most appropriate to the target population and within the capacity of your
program.
Below, Ben Tsoi describes New York City’s use of personal computers to assist in collecting
information and educating clients.
A large hospital in New York City uses tablet personal computers (PCs) to collect information
and to provide pre- and post-HIV testing education. These tablet PCs collect patients’
demographic and behavioral information using a computer-assisted self-interview. They also
display videos to provide pre- and post-test HIV education. The use of tablet PCs allows a public
health advocate (PHA) to educate and test more patients. As one patient is receiving education
from a tablet PC, the PHA can be providing an HIV test to another patient.
- Ben Tsoi
Director of HIV Testing
Bureau of HIV/AIDS Prevention and Control
New York City Department of Health and Mental Hygiene
Queens, NY
Providing Risk-Reduction Services
In the context of HIV testing, focus on addressing clients’ most immediate risk-reduction
needs. If clients have multiple and complex needs (e.g., substance use and mental health
issues, along with being unstably housed), it is better to refer them to programs (e.g.,
Comprehensive Risk Counseling and Services (CRCS) or medical case management that are
better positioned to identify and facilitate referral and linkage to a variety of risk-reduction
and/or support services, and can work with clients over a longer period of time.
Risk Reduction for HIV-Infected Clients
Clients diagnosed with HIV or clients who have a reactive rapid test result will benefit from
basic risk-reduction messages and condoms and/or other appropriate risk-reduction supplies.

Many agencies that provide HIV testing and linkage services have staff members that have
been trained in risk-reduction counseling or other prevention interventions (e.g., CRCS).
These may be the same staff conducting HIV testing. Therefore, it may be feasible for you to
provide clients with a positive HIV test result with brief risk-reduction counseling onsite,
either in conjunction with results delivery or at a future time. Another option is to refer clients
with a positive HIV test result to risk-reduction services suited to clients’ needs.
Additional information on behavioral interventions for HIV-positive individuals is available in
Appendix B.
As resources permit, conduct a more in-depth assessment of risk with clients with positive
test results to identify factors implicated in transmission risk and to help guide referrals to the
services (including behavioral interventions) most appropriate to address these factors. It is
essential that referrals be responsive to the findings of this assessment as your agency
capacity and local resources allow. For additional information on performing referral
assessments, please refer to the section titled Implementing Referral and Linkage presented
in Chapter 7: Referral and Linkage to Health and Prevention Services.
Risk Reduction for HIV-Negative Clients
Provide condoms to all clients with negative HIV test results. It is essential to provide HIV-
negative clients that have been identified as being at high risk for acquiring HIV infection with
a brief behavioral risk-reduction intervention during the testing visit, if feasible, or linked to a
program that can provide these services.
As resources permit, conduct a more in-depth assessment of risk with HIV-negative clients at
high risk for acquiring HIV to identify factors implicated in transmission risk and to help guide
referrals to the services (including behavioral interventions) most appropriate to address
these factors. Referrals should be responsive to the findings of this assessment, and linkage
assistance can be provided as your agency capacity and local resources allow. For additional
information on performing referral assessments, please refer to the section titled
Implementing Referral and Linkage presented in Chapter 7: Referral and Linkage to Health
and Prevention Services.
Brief Behavioral Risk-Reduction Interventions
There are a variety of brief low- to moderate-intensity behavioral risk-reduction interventions
that have been demonstrated to be effective with various target populations relative to
reducing HIV risk. Some of these interventions are delivered at an individual level, and some
at a group level. Other interventions (e.g., Safe in the City) do not require trained staff to
deliver the intervention, and instead rely on passive delivery via video. These interventions
can be provided in a variety of settings where HIV testing services are offered. CDC has
developed resources to assist providers in implementing these interventions. Additional
information about these interventions is available in the Resources section of the Toolkit.

If you make referrals for risk-reduction interventions, it is important that those are relevant to
the client’s situation and which address their immediate risk-reduction needs. You should not
provide or refer clients to risk-reduction interventions simply because the intervention is
available onsite or through referral. A poor match between a risk-reduction intervention and a
client’s needs is unlikely to result in the client adopting risk-reduction behaviors and is not an
efficient use of agency resources.
Data obtained from formative evaluation, along with HIV testing and linkage service data, can
be used to gain an understanding of the types of issues that influence the HIV risk of the
target population. This will help you to select the most appropriate brief risk-reduction
intervention(s) to offer to clients. For additional information on applying data from formative
evaluation activities to program planning, please refer to the section titled Formative
Evaluation and Implementation Planning in Chapter 2: Getting Started—Preparing to
Implement HIV Testing and Linkage in Non-Clinical Settings. Additional information on
training and resources to assist HIV testing and linkage providers in selecting the most
appropriate interventions is available in the Resources section of the Toolkit.
Other Risk-Reduction Interventions
If the client indicates experiencing signs or symptoms of STDs, provide them with STD
screening and/or treatment services. If these are not available at your HIV testing site, make
referrals to and provide clients with assistance in accessing STD screening and treatment
services.
If your program is unable to offer STD screening, consider partnering with a community
health center or HD to offer such services, if feasible. At minimum, develop a strong referral
relationship with such agencies to ensure that clients have access to STD screening and
treatment.
If a client reports unprotected vaginal/anal sex with an HIV-positive partner or partner of
unknown HIV status within 72 hours before being tested, and that client has a negative test
result, the client may benefit from n-PEP. You will need to identify providers who can provide
n-PEP services and forge partnerships with them to ensure that clients in need of such
services are able to access them. The Resources section of the Toolkit includes links to
information about n-PEP.
Partnerships and collaboration, including strategies for developing and operationalizing
them, are discussed in detail in the section titled Community Partnerships and Referral
Resources, presented in Chapter 7: Referral and Linkage to Health and Prevention Services.
For HIV-negative clients identified as high risk, more in-depth discussion and exploration of
client needs relative to risk reduction can occur in the context of referral assessment and
planning. Please refer to the section titled Implementing Referral and Linkage presented in
Chapter 7: Referral and Linkage to Health and Prevention Services for additional information
about referral assessment and planning.

Quality Assurance for Risk-Reduction Services
Develop written policies and procedures for provision of and/or referral to brief risk-reduction
services. Ensure that staff members have the training necessary to provide and/or facilitate
access to brief risk-reduction interventions. Some State and local HDs provide training on
prevention counseling or other brief risk-reduction interventions. Additional information on
training and education for brief risk-reduction interventions is available in the Resources
section of the Toolkit.
Training
Ensure that staff1
providing or facilitating access to brief risk-reduction interventions have
received training appropriate to their responsibilities:
•
•
•
•
•
•
•
It is important that staff providing risk-reduction interventions receive training and
education on the following:
Signs and symptoms of viral illness.
Behavioral and other (local) factors associated with increased risk for HIV transmission or
acquisition (e.g., syphilis co-infection, local trends in new infections).
Evidence-based risk-reduction interventions (e.g., Personal Cognitive Counseling), as
applicable.
Population-specific issues which impact reduction of risk for HIV transmission or
acquisition.
Properly and accurately documenting all aspects of provision of risk reduction.
Agency policies and procedures regarding referral assessment and planning (please
refer to the section titled Quality Assurance presented in Chapter 7: Referral and Linkage
to Health and Prevention Services for additional information regarding recommended
training for referral assessment and management).
Proficiency
Evaluate staff providing risk-reduction services to assess their proficiency. Direct observation
of sessions with clients is an effective strategy to assess proficiency in both areas. If direct
observation is not possible, role plays are an alternative strategy for assessing proficiency.
It is useful to observe staff at regular intervals (e.g., annually), and more frequently after initial
training (e.g., monthly for the first 3 months). Additional information on assessment of
proficiency is presented in Chapter 9: Quality Assurance and Monitoring and Evaluation in the
section titled Quality Assurance.
1

Documentation and Record Keeping
As an HIV testing and linkage provider, you will need to keep documentation of the following:
•
•
•
•
•
Staff training and proficiency assessments, including orientation to risk-reduction
policies and procedures.
Provision of risk-reduction services.
Referrals made for risk-reduction services, as applicable.
Authorizations for release of information.
Client satisfaction with services.
Conduct reviews of client charts (e.g., annually) to evaluate their completeness and accuracy
relative to risk reduction. Review of client charts may be conducted more frequently after
initial training (e.g., monthly for the first 3 months). Sampling (e.g., a random sample of five
charts for each testing staff member) is appropriate if it is not feasible for your agency to
review all client charts. Additional information on documentation and record keeping is
presented in Chapter 9: Quality Assurance and Monitoring and Evaluation (refer to the section
titled Quality Assurance).
It is good practice to review data regularly (e.g., quarterly) to assess the extent to which you
are identifying individuals at highest risk for HIV transmission or acquisition and your success
in providing and/or linking such individuals with needed risk-reduction services. By
evaluating efforts to identify and link high-risk clients to services on a regular basis, you will
be able to refine practices to ensure that the needs of your clients are met.
The section titled Implementing Monitoring and Evaluation presented in Chapter 9: Quality
Assurance and Monitoring and Evaluation has additional information and tools to help you to
evaluate your efforts to identify high-risk individuals. Also included in that section are tools to
help you conduct a yield analysis to better understand how well your program is working and
to guide you in discussions about program improvement.

This chapter addresses HIV testing strategies. In this chapter we discuss the following:
•
•
•
•
•
•
The different kinds of tests used to diagnose HIV infection, including test performance
The window period associated with different kinds of tests
The benefits and drawbacks of various tests
Testing for acute HIV infection
The benefits and drawbacks of different testing strategies
Testing strategies, including how to select the best testing strategy for your program
• Select the best testing strategy for your program and clients
HIV Testing Technology
Overview
The overarching goals associated with HIV testing are to identify HIV-infected individuals as
early in the course of their infection as possible and to link them to HIV medical care as soon
as possible. Early treatment for HIV results in better health outcomes. Most people with HIV
receiving care receive antiretroviral therapy (ART) that decreases the amount of the virus (i.e.,
viral load) in their body. Low viral load is associated with better health outcomes for
individuals living with HIV.
Viral load is highest shortly after an individual is infected with HIV. People living with HIV are
more likely to transmit HIV to others during this acute phase of infection. Diagnosing
individuals during this phase and linking them to medical care is an important prevention
strategy, because it reduces the likelihood of transmission of HIV to their partners.
Definitions:
•
•
Acute HIV Infection: The highly infectious initial phase of HIV disease, which can last approximately 2
months. It is characterized by a variety of flu-like symptoms such as fever, fatigue, rash, headache, sore
throat, swollen tonsils, nausea, vomiting, diarrhea, and joint and muscle aches.
Window Period: The time period between when a person becomes infected with HIV and when a test can
detect HIV infection. The window period varies by test.
Chapter 5. HIV Tests and Testing
Strategies

Chapter 5● Page 2 of 18
There are a variety of tests approved by the Food and Drug Administration (FDA) that are
used to identify and diagnose HIV infection. HIV tests vary in how soon after infection they
can detect HIV infection (i.e., window period). The shorter the window period, the sooner a
test can detect HIV after infection. Additional information on HIV tests, including their
characteristics, is available on CDC’s Web site.
Available HIV tests are very accurate and give correct results most of the time, given their
specified window periods. In other words, some tests are better than others in detecting
acute infection. This will be discussed in more detail in the Acute Infection Testing section.
Definitions:
•
•
Sensitivity is the ability of a test to correctly identify clients with HIV infection (i.e., “true positives”).
A highly sensitive test is unlikely to give a false negative result.
Specificity is the ability of a test to correctly identify clients without HIV infection (i.e., “true negatives”).
A highly specific test is unlikely to give a false positive result.
The accuracy of HIV tests is described in terms of sensitivity and specificity. HIV tests vary in
their sensitivity and specificity. Tests with higher sensitivity and specificity will give a correct
result more times than not, after the window period specified for that test, compared with
tests with relatively lower sensitivity and specificity. It is important to note that sensitivity and
specificity vary by test type and also by sample type. This will be discussed in more detail later
in this chapter.
Antibody Tests
HIV screening tests (e.g., enzyme immunoassay [EIA]) and supplemental tests such as the
Western blot detect the presence of HIV antibodies. Antibodies are produced by the body in
response to infection with HIV.
Antibody tests are often described in terms of “generation.” First- and second- generation
tests, including the Western blot, detect only Immunoglobulin G (IgG) antibodies. These
antibodies appear later in the course of HIV infection. The window period for first generation
antibody tests (including the Western blot) is 6 weeks or more. Second-generation laboratory-
based antibody tests have a window period of 4 to 6 weeks. Rapid tests currently used by
non-clinical HIV testing programs have window periods that are equivalent to second
generation laboratory tests.
More recent third-generation antibody tests detect both IgG and Immunoglobulin M (IgM)
antibodies. IgM antibodies appear earlier in the course of infection than IgG. These tests
reduce the window period to 3 to 4 weeks.
HIV-2 is uncommon in the United States, but is reported. Most second-generation HIV tests,
almost all third generation HIV tests, and all fourth generation tests can detect both HIV-1 and
HIV-2. First generation tests, including the Western blot, detect only HIV-1.

Fourth-generation antibody tests detect antibodies (both IgG and IgM), as well as p24
antigens. The p24 antigen is a viral protein of the HIV virus itself that appears before the
production of antibodies. Antigens provoke the body’s immune response to produce
antibodies. Tests that detect the p24 antigen further reduce the window period to 2 to 3
weeks. Currently, the only fourth-generation antibody tests available require serum or plasma
samples and must be performed in a laboratory. There are currently no FDA-approved fourth-
generation rapid HIV tests which are waived under Clinical Laboratory Improvement
Amendments (CLIA) and available for use in non-clinical settings.
Nucleic Acid Tests
Nucleic acid tests detect the presence of the HIV-1 virus itself by testing for its genetic
material, ribonucleic acid (RNA). The window period for RNA tests is 7 to 14 days. RNA tests
must be performed in a laboratory, as they are highly complex and currently require serum or
plasma samples.
Additional information about HIV test technologies is available in Appendix B.
Overview: Laboratory-Based and Point-of-Care Rapid HIV
Testing
You can conduct HIV testing using laboratory-based technologies (i.e., conventional testing)
or at point-of-care, using rapid or conventional HIV tests. In this section we will discuss each of
these, including benefits and drawbacks.
Laboratory Testing
Laboratory HIV testing involves obtaining a blood sample and sending it to a laboratory (e.g.,
a public health or commercial laboratory) for testing. Results are typically available a few days
after the sample is received. Laboratories conduct HIV testing on serum or plasma samples.
Screening tests are typically either third-generation antibody tests or fourth-generation
antibody/antigen combination tests. HIV tests used by laboratories also detect HIV-2. Some
laboratories conduct HIV testing on oral fluid specimens. Current oral fluid laboratory tests are
first- and second-generation HIV-1 antibody tests.
Laboratories typically use combinations of different tests conducted in sequence (called
algorithms), to diagnose HIV infection. If the first test used in the algorithm is reactive,
subsequent tests are conducted to confirm a diagnosis of HIV. Some algorithms include tests
that distinguish between HIV-1 and HIV-2. Some algorithms include RNA tests, which allow
the confirmation of diagnosis of acute HIV infection. The results of laboratory testing can be
considered final unless the client’s most recent exposure occurred during the test’s window
period. The algorithms that include RNA tests and tests that differentiate between HIV-1 and
HIV-2 infection require blood samples. The abilities of some test algorithms to identify acute

HIV infection and to differentiate HIV-1 from HIV-2 infection are key advantages of laboratory
testing.
If you choose laboratory testing, you will need some specific equipment and supplies. Most
HIV testing done in laboratories is performed on blood samples, collected by venipuncture.
Venipuncture simply means drawing blood from a vein in your client’s arm. Depending on
State and/or local regulations, your staff may need special training to do venipuncture. You
will also need equipment and supplies that will enable you to obtain and process blood
samples before sending them to the laboratory, including the following:
• Needle and syringes or other system designed for blood collection
• Tourniquets
• Blood specimen collection tubes
• Personal protective equipment (e.g., lab coat, latex gloves)
• Hazardous waste disposal containers
The red blood cells in the sample you have collected from a client will need to be separated
from the serum or plasma to allow testing. For some tests, this must be done before the
specimen is transported to the laboratory. Separation requires the use of a centrifuge.
Samples may also require refrigeration. Oral fluid testing requires use of a special sample
collection device and sample transport vial, but the sample does not require preparation prior
to submitting it to a laboratory.
Laboratory testing can be used as the method for initial testing or for supplemental testing, in
order to confirm a diagnosis of HIV subsequent to a reactive rapid test result.
Benefits and Drawbacks of Laboratory HIV Testing: The benefits and drawbacks of HIV
testing conducted in the laboratory are presented in Exhibit 5.1.

Exhibit 5.1. Benefits and Drawbacks of Laboratory HIV Testing
Benefits Drawbacks
Population level
• Highly accurate
• Able to detect acute infection
• Can distinguish between HIV-1 and
HIV-2
Client level
• Result is final
• Can be conducted on blood or oral fluid
• Supplemental testing to confirm
diagnosis of HIV infection can be
conducted on single sample
Program level
• No storage of reagents
• Minimal quality assurance
• Ongoing cost to program relatively low
• Minimal staff training for conducting a
test
Population level
Test performance varies by product
Client level
• Wait time for result
• May require invasive collection technique for blood
sample
• Requires second encounter with client to provide test
results
• May delay linkage with HIV medical care
• May delay linkage with PS
Program level
• Requires skilled technician for collecting (e.g.,
phlebotomist) and processing specimen
• Requires strategy to ensure clients receive test results
• May not be appropriate or feasible for some settings
• May require special equipment/supplies (e.g., needles,
collection tubes)
Consider these benefits and drawbacks when deciding on laboratory HIV testing. Selection of
HIV tests is discussed later in this chapter.
Point-of-Care Rapid HIV Tests
There are several FDA-approved rapid HIV tests that can be used by HIV testing and linkage
providers in non-clinical settings. These tests are categorized as waived under CLIA. CLIA sets
Federal regulatory standards that apply to all clinical laboratory testing performed in the
United States. Tests categorized as CLIA-waived can be performed outside of a laboratory
setting, but testing programs must register and obtain a CLIA certificate of waiver. Waived
tests can be performed by anyone who has been trained in their use, but typically no special
credentialing is required. More information about obtaining CLIA waivers is available in
Appendix B: Resources. Many States have policies or regulations that address rapid HIV
testing. Contact your State or city HD to learn more about requirements associated with rapid
HIV testing in your jurisdiction.
CLIA-waived rapid tests typically used in non-clinical settings require oral fluid or whole blood
samples acquired by a finger stick or venipuncture. Blood samples do not need to be
processed further before they are tested. One test can be used with either blood or oral fluid
samples, but the sensitivity and specificity of the test is lower when performed with oral fluid
compared with whole blood. Most rapid tests detect both HIV-1 and HIV-2. The time to
perform the test and obtain results varies by test and ranges from 1 to 60 minutes. This allows
you to provide a client with a result immediately after the test is performed. Reactive test
results require supplemental testing to confirm a diagnosis of HIV. Supplemental testing can
be facilitated by the HIV testing provider or through referral to another, clinical provider.

Using two different rapid HIV tests in sequence can improve the positive predictive value of
an initial reactive rapid test result if the results of both tests are reactive.
Definition:
Positive predictive value (PPV): The percentage of true positive results among all positive results, (i.e., the
number of true positives divided by the number of true positive results added to the number of false positive
results). A low PPV (e.g., 50%) indicates that many of the positive test results are false positives. A high PPV
(e.g., 98%) indicates that most of the positive test results are true positives.
The use of two rapid HIV tests in sequence is discussed below.
If you choose rapid HIV testing, you will need some specific equipment and supplies. If you
are testing using whole blood samples, you will need supplies to conduct sampling either via
venipuncture or finger stick, such as lancets, personal protective equipment (e.g., lab coat,
latex gloves), and biohazardous waste disposal containers. You will also need equipment,
such as refrigerators to store reagents, thermometers to monitor storage and operating
temperature, and timers. Additional detail on supplies and material for rapid HIV testing is
available in Chapter 6: Implementing HIV Testing.
Benefits and Drawbacks of Point-of-Care Rapid HIV Testing: The benefits and drawbacks
of rapid HIV testing in non-clinical settings are presented in Exhibit 5.2. Consider these
benefits and drawbacks when deciding on implementing point-of-care rapid testing.
Exhibit 5.2. Benefits and Drawbacks of Point-of-Care Rapid HIV Testing
Benefits Drawbacks
Population level
Highly accurate
relative to the window
period
Client level
• More clients
receive their test
results without the
need for a second
encounter
• Can be conducted
on finger stick or
oral fluid
Program level
• Can be feasibly
used in a variety of
settings
• Can be conducted
by trained users
Population level
• Decreased sensitivity to detect acute infection
• Cannot distinguish between HIV-1 and HIV-2
• Sensitivity and specificity varies with different products and sample types
• Some reactive test results will be false positive
Client level
• Supplemental testing must be performed to confirm diagnosis of HIV after a
reactive test result
• Longer window period compared with most laboratory tests
Program level
• Requires strategy to ensure clients receive test results (if supplemental testing
is arranged by testing provider)
• Quality assurance at multiple sites
• Quality assurance for multiple tests (if different rapid tests in sequence are
used)
• Requires dedicated and temperature-controlled space to store test kits and
controls and strategies to store and transport test supplies and to conduct tests
• May require additional licensing or certification
• Reader variability in interpreting test results
• Higher costs for testing program, compared with laboratory testing

You may consider several different strategies1
for using rapid HIV tests in non-clinical settings.
Different strategies include the following.
Strategy 1—Single Rapid Test Followed by Laboratory-Based Supplemental Testing for
Reactive Rapid Test Result: You can perform a single rapid HIV test on a blood or oral fluid
specimen. If the result of this rapid test is reactive (i.e., antibodies have been detected), a
sample is obtained for supplemental testing in a laboratory to confirm an HIV diagnosis. It is
helpful to notify the laboratory conducting supplemental testing of the previous reactive
rapid test result.
You will need to contact the client or have the client return to your agency after several days
for the laboratory test results to confirm an HIV diagnosis. Some clients may find it
challenging to return to an HIV testing and linkage provider to receive their results, and you
will need to have a strategy in place to ensure that clients receive their supplemental test
results. Additional discussion of the strategies that you can use to ensure that clients receive
test results is included in Chapter 6: Implementing HIV Testing. One alternative is to initiate
linkage to HIV medical care, on the basis of the reactive rapid test result, and arrange to have
the supplemental test results transmitted to the HIV medical care provider. Obtain an
authorization for release of health information from the client if you pursue this option.
The benefits and drawbacks associated with Strategy 1 are summarized in Exhibit 5.3.
A blood specimen is recommended for supplemental testing after a reactive rapid HIV test.
Strategy 2—Single Rapid Test, Immediate Linkage to HIV Care for Reactive Rapid Test
Result: HIV testing and linkage providers also have the option of linking clients to HIV
medical care on the basis of a single reactive rapid HIV test result. This strategy facilitates
linkage to care and does not require a second visit by the client to the HIV testing provider. In
settings that serve high-risk clients, rapid HIV tests have a high positive predictive value for
detecting antibodies indicative of established HIV infection. In most cases, a reactive HIV rapid
test represents HIV infection. However, supplemental laboratory testing must still be
conducted to confirm an HIV diagnosis. Supplemental testing may be conducted by the HIV
medical provider rather than the HIV testing and linkage provider.
If you choose this testing strategy, it is important to ensure that HIV care providers are willing
and able to accept clients on the basis of a single reactive test result. This may be an
important component to address in MOA with HIV care providers. Consult with your State or
local HD to determine whether there are any local regulations or policies that prohibit you
from making a linkage to care on the basis of a single reactive rapid test result. Submit a
1
In the context of HIV testing, “strategy”, as used in this guide, refers to activities and processes associated with
employing specific testing technologies to conduct HIV testing with clients.

completed HIV/AIDS case report to the State/local HD, pursuant to State statute or regulation.
Contact your State or city HD to obtain additional information about HIV disease reporting.
Strategy 3—Two Rapid Tests, Immediate Linkage to HIV Care if Both Rapid Tests
Reactive; Supplemental Testing if Second Rapid Test Is Nonreactive: You may consider
performing two sequential rapid HIV tests. In this case, a second rapid HIV test is performed if
the first rapid HIV test is reactive. If both tests are reactive, this increases the likelihood that
the results represent a true positive result (i.e., it increases the positive predictive value of the
reactive initial test). If the second rapid HIV test is nonreactive, arrange supplemental testing
either by obtaining a specimen for laboratory testing or by linking clients to HIV medical care
for supplemental testing. In general, most clients with two reactive rapid HIV test results are
infected with HIV, and therefore can benefit from medical evaluation and treatment for HIV
infection. Medical providers can perform supplemental testing necessary to confirm an HIV
diagnosis. If the first rapid test result is reactive, but the second is negative, the client may
have HIV infection. Therefore, it is important to provide or arrange for supplemental testing
and/or medical evaluation.
The first test in the sequence must have sensitivity that is equal to or better than the second
test used in the sequence. The second HIV rapid test must be conducted with a different test
that incorporates different antigens. Usually this is a test from a different manufacturer.
Reactive results on both tests improve the positive predictive value of the first test. However,
supplemental laboratory testing must still be conducted to confirm an HIV diagnosis.
Supplemental testing need not be performed by the HIV testing and linkage provider.
If you choose this testing strategy, ensure that HIV medical providers are willing and able to
accept clients on the basis of one or two reactive results. This may be an important
component to address in MOAs with HIV medical providers. Consult with your State or local
HD to determine whether there are any local regulations or policies that prohibit you from
making a linkage to HIV medical care on the basis of reactive rapid test result. Submit a
completed HIV/AIDS case report to the State/local HD, pursuant to State statute or regulation.
Contact your State or city HD to obtain additional information about HIV disease reporting.

Exhibit 5.3. Benefits and Drawbacks of Point-of-Care Rapid HIV Test Strategies*
Strategy Benefits Drawbacks
Strategy 1: Single
Rapid Test; Laboratory-
Based Supplemental
Testing for Reactive
Result
• Clients can be provided with
negative test results immediately
• Identifies clients most likely to be
HIV-positive and in need of
supplemental testing
• Suitable for use if there is a high
likelihood that clients will receive
results of supplemental tests
• Suitable for use in settings where
QA of multiple products not feasible
• Clients with acute infection may
receive false-negative results
• Supplemental testing delays linkage
with HIV medical care (relative to
rapid test strategies 2 and 3)
• Supplemental testing delays linkage
with PS (relative to rapid test
strategies 2 and 3)
• Clients may not receive results of
supplemental tests
Strategy 2: Single
Rapid Test, Immediate
Linkage to HIV Care for
Reactive Result
• Clients can be provided with
negative test results immediately
• Suitable for use in settings where
QA of multiple products is not
feasible
• Suitable for use if obtaining
specimens for supplemental tests is
not feasible
• Suitable for use if there is a high
likelihood that clients will not
receive results of supplemental tests
• Facilitates linkage with HIV medical
care
• Facilitates linkage with PS
• Clients with acute infection may
receive false-negative results
• Some clients with false-positive
results will be linked to HIV medical
care
• Clients with reactive rapid test
results will still require
supplemental testing to confirm
diagnosis
• Some HIV medical providers may
not be willing to accept clients on
the basis of a single reactive rapid
test result
Strategy 3: Two Rapid
Tests in Sequence,
Immediate Linkage to
HIV Care if both test
results are reactive
• Improves positive predictive value
when two tests are reactive
• Facilitates linkage with HIV medical
care
• Facilitates linkage with PS
• Maintaining inventory and
conducting QA of multiple rapid
tests may be challenging
• Clients will still require
supplemental testing to confirm
diagnosis
• Clients with a nonreactive second
test result will require supplemental
testing
• Some HIV medical providers may
not be willing to accept clients on
the basis of reactive rapid test
results alone
*Adapted from: Association of Public Health Laboratories and the Centers for Disease Control and Prevention.
(2009, April). HIV testing algorithms: A status report. Silver Spring, MD: Association of Public Health Laboratories.
In the following example, Sophia Rumanes of the Los Angeles County Department of Public
Health describes the dual rapid algorithm used to facilitate diagnosis and linkage to care.

The County of Los Angeles, Department of Public Health, Division of HIV and STD Programs
(DHSP) has adopted and implemented a two-test HIV rapid testing algorithm (RTA) at publically
supported HIV testing sites with demonstrated capacity to offer HIV RTA as the standard of
care. HIV RTA uses a sequence of up to two different types of HIV rapid tests to provide clients
with more definitive information about their HIV status within 1 hour, eliminating the need for
laboratory-based supplemental testing, which would require a return visit for results and
allowing for immediate referral and linkage to care and treatment services. According to DHSP’s
HIV RTA study (funded by CDC 2007 to 2009), 100% of HIV-positive clients at the RTA sites
received their results and were referred to care on the same day, compared to 65.4% of clients at
regular HIV rapid testing sites who received their confirmed results (with a median of 8 days)
and were referred to care and prevention services. DHSP plans to expand RTA to be the standard
of care at all funded HIV testing sites to improve disclosure and linkage to prevention and care
services.
- Sophia Rumanes, MPH
Los Angeles, CA
Oral Fluid Testing
Oral fluid HIV testing remains an important tool for HIV prevention programs. However, there
are limitations associated with oral fluid testing about which HIV testing and linkage
providers must be aware.
The Avioq HIV-1 EIA and OraSure® Western blot are the only two FDA-approved laboratory
tests available for oral fluid laboratory testing. Samples for laboratory testing of oral fluid
must be collected with the OraSure oral fluid collection device. The sensitivity and specificity
of these tests are lower with oral fluid samples when compared with blood specimens, and
these tests do not contain antigens that detect HIV-2 antibodies. Laboratory-based oral fluid
tests and the Western blot are less sensitive during acute infection than laboratory-based
screening tests designed for use with blood and have a longer window period than other
blood-based laboratory tests.
The OraQuick ADVANCE® Rapid HIV-1/2 Antibody test is the only FDA-approved rapid test
approved for use on either blood or oral fluid samples. The sensitivity and specificity of this
test is lower when used with oral fluid when compared with blood specimens.
Blood (whole blood, serum, or plasma) is the preferred specimen for HIV testing because the sensitivity
and specificity of tests conducted on blood are higher than those conducted on oral fluid.

In light of advances in technologies for HIV testing, carefully consider the expected benefits of
oral fluid testing relative to the drawbacks (summarized in Exhibit 5.4), the needs and
preferences of clients, and agency capacity.
Exhibit 5.4. Benefits and Drawbacks of Oral Fluid Testing
Benefits Drawbacks
• Permits HIV testing in outreach settings or for client
populations where collection and processing of
blood samples is difficult
• May facilitate testing if clients would not be tested if
venipuncture or finger stick sample collection were
required
• Does not require trained technician (e.g.,
phlebotomist) for specimen collection and
processing
• Decreased risk of occupational exposure to staff
performing HIV testing
• Screening and supplemental assay (Western blot)
performance is acceptable for established infections
• Decreased sensitivity to detect acute
infection
• Decreased sensitivity and specificity
compared with serum or whole blood
specimens
• Increased indeterminate Western blot results
compared with serum or whole blood
• Cannot distinguish between HIV-1 and HIV-2
• Western blot is only supplemental test
available for use with oral fluid to confirm an
HIV diagnosis
• Higher collection and processing costs for
laboratory testing compared with serum or
whole blood
There are many circumstances in which oral fluid testing is appropriate to achieve your
program objectives. However, contemporary HIV tests improve our ability to diagnose HIV
infections earlier, and facilitate earlier entry to care and treatment. In most circumstances,
testing blood specimens is preferred because it enables the use of more accurate testing
algorithms.
Consult with your State/local HD to identify the technologies and approaches that will most
efficiently and effectively address program priorities, respond to the needs of communities,
and be feasible within the capacity of your agency.
Acute Infection Testing
Because viral load is highest shortly after an individual is infected with HIV, people living with
HIV are more likely to transmit HIV to others during this acute phase of infection. Therefore,
diagnosing individuals with acute infection and linking them to medical care, PS, and other
prevention services are important prevention strategies.
If feasible, use a testing strategy that can identify acute infection. Most HIV tests miss much of
acute stage of infection. Algorithms which employ fourth-generation antibody/antigen
combination tests and which include RNA tests can identify acute infection. If you are using
laboratory-based HIV testing, either for initial or for supplemental testing associated with
reactive rapid tests, it is essential that you understand the tests and algorithm used by the
laboratory.
If the laboratory that performs HIV testing for you does not offer tests that detect acute
infection, or if you are not able to conduct laboratory-based HIV testing for all of your clients,

identify and form a partnership with a laboratory or other partner agency that can perform
acute HIV testing. It is important to refer clients who are suspected of acute infection for
testing for acute HIV infection. Exhibit 5.5 presents the criteria for identifying which clients
should receive testing for acute HIV infection. As part of your interaction with clients, you will
be gathering information about risk that can help you determine the need for acute infection
testing. Please refer to Chapter 4, Exhibit 4.2 for questions that can help in this regard.
Exhibit 5.5. Criteria for Identifying Clients for Whom Acute HIV Testing Is Recommended
Criteria for Acute HIV Testing
• Exposure, through unprotected sex or injection drug use, within the previous 2 weeks, to an individual
known to be HIV-positive or whose HIV status is unknown
• Clinical symptoms of viral illness such as fever, fatigue, rash, headache, sore throat, swollen glands,
nausea, vomiting, diarrhea, and joint and muscle aches
If you will be referring clients for acute HIV testing, your process for doing so can be
addressed in your policies and procedures.
Selecting an HIV Testing Strategy
In deciding which testing strategy to use, you will want to consider first, and foremost,
performance. Use a strategy which provides accurate results and which can identify HIV as
soon as possible after infection. However, you will need to balance performance against other
client- and program-level factors, such as client preferences, program capacity, cost, and the
settings in which HIV testing will be performed. You may decide to use multiple strategies,
because different strategies may be appropriate for different venues or settings, or for
individual clients.
You may elect, for example, to use rapid testing in conjunction with outreach testing activities
and laboratory-based testing, using blood specimens, for testing performed within your
agency. You may decide to provide HIV testing using point-of-care rapid tests for the vast
majority of your clients, but for some clients you may recommend and/or provide laboratory
testing that can identify acute infection.
Performance
Laboratory-based tests, using blood specimens, provide more accurate results than rapid
tests or tests that use oral fluid specimens. Laboratory-based testing, using blood specimens,
also enables the use of more advanced testing algorithms (i.e., those that use third- or fourth-
generation tests and may include RNA tests), which allow for earlier detection of HIV
infection. Laboratory-based testing also requires only one sample for both screening and
supplemental testing and, if blood specimens are used, is typically less costly than other
testing strategies.

Client-Level Factors
Client-level factors must also be considered in selecting a testing strategy. The likelihood that
the client will receive a test result is of highest importance. If you plan to use laboratory-based
testing but clients are unlikely to receive their final test results, you must identify strategies
that will ensure that clients receive test results, such as verifying contact and location
information to permit follow-up, or making results available by phone.
In highly transient populations, such as homeless individuals, it may be extremely challenging
and resource intensive to follow up with clients to ensure that they receive test results. In this
case, use of rapid tests may be most appropriate, because it will facilitate receipt of results for
the majority of clients, who will be HIV negative. It will also allow you to either concentrate
resources on following up on clients with HIV-positive test results (if you have used laboratory
testing) or on linking to HIV medical care clients with reactive rapid test results.
Client acceptance of the testing method is also a consideration. Clients may express a
preference for immediate test results (i.e., rapid HIV testing, point of care). This expressed
need may be outweighed, however, by clients’ perception of the accuracy of the test strategy.
For example, clients may tell you that they would prefer to have their test results right away.
This may suggest that it is appropriate to use rapid HIV testing. However, it may be important
to the client that they get a result that is definitive. In this case, it may be better to conduct
laboratory testing.
Explore with the target population, through survey or focus group, different testing methods. This will
help them to understand the relative benefits and drawbacks of the various methods and will help you
understand which factors are likely to be a barrier or facilitator to using particular testing methods.
The results of your formative evaluation activities should factor into your decisions regarding
selection of testing methods, as related to client needs, priorities, and preferences. Additional
discussion of formative evaluation is presented in Chapter 2: Getting Started—Preparing to
Implement HIV Testing and Linkage in Nonclinical Settings. In particular, review the section
titled Formative Evaluation and Implementation Planning.
Program-Level Factors
In selecting a testing method, you must also consider program-level factors. For example, do
you have access to a laboratory that can perform third or fourth generation testing? Does the
algorithm used by that laboratory include RNA testing? Contact your State or local public
health laboratory. Even if they do not perform such testing, they may be able to refer you to a
laboratory that does.
The venues or settings in which testing is to be performed will also weigh into your selection
of testing methods, particularly as related to the type of sample that must be collected. If you
are testing at your agency, i.e., a “fixed site” it may be very feasible to employ a laboratory-

based testing method, using blood samples. If you are testing at an outreach site, such as a
park or bar, it may not be possible to employ laboratory-based testing that uses blood
because it may not be feasible to collect, prepare, and transport venous blood samples in
such settings. In this case, a rapid test that uses finger stick whole blood sampling may be
more appropriate. Oral fluid testing, either conventional or point-of-care rapid tests, may also
be appropriate in such settings. However, because of the lower sensitivity of oral fluid, testing
on blood samples is preferred, unless clients would otherwise not be tested.
Integration of services may also weigh into your decisions regarding selection of testing
methods. Many clients who are at risk for HIV infection are also at risk for STDs or infection
with viral hepatitis. It may be beneficial for clients, and make your services more valuable to
clients to provide testing for STDs and/or viral hepatitis in conjunction with HIV testing. In this
situation, it may be more a more efficient use of resources to collect blood samples for
laboratory testing for HIV, syphilis, and hepatitis C, as compared with conducting rapid test
for HIV and laboratory tests for syphilis and hepatitis.
Your capacity to conduct follow-up on clients who do not receive test results should also be
considered. If you perform a high volume of tests and/or have a relatively large number of
clients who do not return for their test results, it may not be feasible for you to follow up on
all clients. You need a strategy, such as notification of results by phone, to ensure that clients
receive their test results, but it must be feasible for your staff and agency to manage. Rapid
test strategies also facilitate receipt of results for the vast majority of clients who will be HIV
negative. Employing a testing strategy which links clients to HIV medical care after one or two
reactive rapid tests is another way to ensure that clients receive results and that program
resources are focused on linkage to care, rather than follow-up on clients to ensure that they
receive test results.
Consider your capacity as it relates to performing tests (including sample collection and
preparation) and QA of testing activities in your selection of a testing strategy. Staff must
have the knowledge and skills necessary to collect and prepare samples, as required by the
test strategy (e.g., venipuncture for blood-based laboratory testing or finger stick for point-of-
care rapid testing). You must have the appropriate equipment and supplies to prepare and
transport samples to the laboratory for testing (e.g., centrifuge). Staff must have training and
skills necessary to perform tests and conduct required quality controls, if you plan to use rapid
testing. If a sequence of rapid tests is to be used, your staff must have the knowledge and
skills needed to maintain inventory, proficiency, and QA for both. Your staff must be able to
complete any training or certification required by statute, regulation, or policy.
Staff attitudes toward various testing methods will also impact your ability to adopt and use
them. For example, staff may be resistant to adopting a new testing strategy. They may hold
preconceptions about a variety of factors, such as the accuracy of the test, the ease of
specimen collection, or even which methods of specimen collection clients will accept.
Concerns or fears that staff have about various test strategies are often unfounded and can be
addressed through discussion and education. It is helpful to have staff members talk to peers

from other agencies that have successfully adopted a particular strategy to address such
concerns.
Tip
Staff conducting HIV testing are often a greater barrier in the adoption of a new testing method than
are clients. It is important to educate HIV testing staff on test strategies and learn about their concerns
and fears about adopting a new or modified test strategy.
The characteristics of individual products will also influence your choice of test strategy and
selection of specific products. Understanding how testing will be integrated into workflow
will help you to select the most appropriate products. For example, rapid tests have different
minimum read times (ranging from 60 seconds to 20 minutes). The time interval during which
test results must be read in order to be valid also varies (ranging from 2 to 20 minutes). It may
be desirable to use a product with a longer window during which test results are valid—for
example, if you are performing a high volume of tests at a health fair and you have limited
staff coverage of the event. In this case, you may want to accommodate staff multitasking and
not being able to read the test result at precisely 20 minutes. Operating temperature is
another example of a product characteristic that may be important for you to consider. Rapid
HIV tests have various operating temperatures. You may, for example, be conducting HIV
testing in a on a very hot day. In this case, you would want to have a product that has a high
operating temperature range.
Cost is an obvious consideration. Public health laboratories may perform HIV testing at
relatively low or no charge, particularly if you receive funding from the State or local HD. You
may also be able to purchase rapid test devices at reduced prices, such as through a 340B
program. Rapid HIV tests vary widely in their cost, and in selecting one, you may need to trade
off desirable characteristics for a more affordable product.
Exhibit 5.6 contains a summary of the factors that your agency may consider relative to
selection of HIV testing strategy.
Exhibit 5.6. Factors to Consider in Selecting HIV Testing Strategy
Performance Client-Level Factors Program-Level Factors
• Test sensitivity • Likelihood of • Access to laboratory testing, including acute HIV
and specificity client receiving testing
(consider results • Feasibility of use in various settings
specimen type) • Acceptance of • Capacity to collect, process, and transport specimens
• Ability to detect method of • Integration of services (e.g., provision of STD screening
acute infection specimen in conjunction with HIV testing)
(window period) collection • Capacity to conduct QA
• Ability to detect • Acceptance of the • Capacity to conduct follow-up on clients who do not
and/or test method receive test results
distinguish HIV-2 • Other factors (e.g.,
client perception
of accuracy of the
test method,
preferences)
•
•
•
Product characteristics (e.g., shelf-life or time to results
of rapid HIV tests)
Cost
Other factors (e.g., regulatory or funding
requirements)

The practice examples below are presented to illustrate how various factors could come into
play in your decisions about which test strategies will work best for you and your clients.
Practice Example 5.1. Selecting a Testing Strategy for Individual Clients
Center City Drug User Health Alliance (the Alliance) operates a syringe access program in Center City. The
Alliance also provides HIV testing and linkage services. Glenn regularly uses the syringe access program and is
also a frequent visitor to the community meals program, but you have not seen him for a couple of weeks. He
tells you he has felt too sick to come in. During this visit, you also note that he has not been tested for HIV in
over a year and learn that Glenn has shared syringes and other works (e.g., cookers, cottons, wash) with
several different people. He has also tricked several times for drugs, and never used a condom. Glenn is
currently “couch surfing”. You decide that you will recommend to Glenn that he should be tested for HIV, and
because you suspect that Glenn may have acute infection, you draw blood for testing that will be sent to the
CCHD laboratory. Even though Glenn is currently homeless, he has been a regular visitor to your program for
quite a while, and you believe that he is likely to return to receive his test result.
Practice Example 5.2. Selecting Testing Strategies for Specific Settings
ACME Prevention Services targets young men who have sex with men in Center City. HIV testing is currently
provided in several venues including bars, public parks, a bathhouse and their agency offices. Many of these
men report inconsistent condom use in conjunction with anal sex and there is a relatively high level of drug
use in conjunction with sex, particularly methamphetamine. New diagnosis of HIV infection has been rising
rapidly in this population in the past two years and nearly one-half of all new syphilis cases among this group
are co-infected with HIV. ACME employs several testing strategies.
ACME conducts laboratory-based HIV testing using blood samples for all tests conducted in their agency
offices. Because this population is at very high risk for HIV and the likelihood of acute infection is relatively
high, ACME wanted to employ a testing strategy that would address acute infection. They can also obtain a
specimen for syphilis testing at the same time, which is important given the frequency of syphilis in this
population.
ACME uses rapid tests for testing in bars and public parks, because it is very difficult to get clients tested in
these venues to return to the agency for test results and because it would be challenging to draw, transport
and prepare venous specimens in these settings. Clients with reactive rapid tests results receive immediate
referrals to HIV medical care. However, clients that have negative rapid test results in these venues, but who
may be acutely infected are referred to the agency offices for acute testing. Next day appointments are made
at the time of testing. Contact information is obtained from the client and active follow-up is conducted on
clients who do not keep their appointments for supplemental testing.
The owners of Steam Pit bathhouse would not allow HIV or syphilis testing to be conducted on-site if blood
samples were required. Because the Steam Pit has been identified as a “hub” of a sexual network in the recent
syphilis outbreak, ACME wanted to ensure that that the test strategy that they used would address the
likelihood of acute infection and also provide an opportunity to conduct syphilis testing. For this reason,
ACME decided not to conduct HIV or syphilis testing in the bathhouse, but instead provides education and
risk-reduction counseling and supplies, and refers clients to their agency where blood samples are obtained
for laboratory-based testing. ACME provides next day appointments and offers incentives to encourage
testing.

The example below describes the rationale and process used by Massachusetts Department
of Public Health for transitioning non-clinical HIV testing and linkage providers from using
point-of-care rapid HIV testing to fourth generation laboratory testing.
Beginning June 2012, the Massachusetts Department of Public Health (MDPH), Office of
HIV/AIDS (OHA) implemented 4th generation HIV testing technology and the corresponding
CDC-recommended testing algorithm in the Hinton State Laboratory Institute (HSLI). Previously,
non-clinical testing grantees primarily conducted rapid HIV tests. Reactive rapid test results
requiring a confirmatory test using a blood sample was obtained from clients and submitted to
the HSLI for processing by EIA and Western blot.
The State Lab made the transition to fourth generation HIV testing consistent with CDC
recommendations. Using the new technology allows clients to learn their HIV status in a shorter
period of time, identify infection earlier (within 2 weeks), and link HIV-positive clients to care.
This will improve health outcomes for persons living with HIV and their partners, particularly
those identified in acute stage of HIV infection. Clients identified in the acute stage of HIV
infection have immediate linkage to DIS and assurance of immediate connection to an
infectious disease clinician for disease staging and care initiation, as well as HIV partner services
for the index client. Integral to supporting persons newly diagnosed is referral to a range of
behavioral, positive prevention, and peer support services. HIV testing is provided in the context
of integrated communicable disease screening for STDs, hepatitis C, and vaccinations for
hepatitis A and B.
MDPH service standards explicitly encourage clients to opt for a blood draw and conventional
(i.e., fourth generation) testing if clients report recent or ongoing exposure, and are likely to
return for test results. We recommend conventional testing if blood is to be drawn for hepatitis
or STD testing. Rapid testing is still available, and we encourage use of rapid testing if the client
does not identify recent exposure(s), is unlikely to return for results, and if blood is not being
drawn for other tests. Yet because the fourth generation test is better than the rapid test in terms
of accuracy, sensitivity, and specificity, and the ability to detect both antigen and antibody, and
with a shorter window of detection, in some cases a blood draw is preferred.
MDPH modified our procedures for pre-test sessions to clearly explain to clients the HIV testing
process and the options for testing, including the benefits of conventional testing. Risk
assessment of the likelihood of client to return for results continues according to established
procedures. However, we expect providers to make a specific recommendation to clients
regarding type of test (i.e., rapid or conventional) based on assessment of their risk, how recent
the exposure may have been, and the likelihood the client will return for results. Results are
available to clients within 1 week at the site where HIV testing was conducted.
To prepare non-clinical providers for the shift to fourth generation laboratory-based testing, all
non-clinical providers were required to establish phlebotomy capacity onsite, or to establish
new partnerships that provide this capacity. We required grantees to purchase the necessary
equipment and support training opportunities for direct service staff. We arranged for daily
pick-up of samples from each testing provider to ensure they reached the HSLI within 48 hours

using a single method of transport—UPS CampusShip. HIV testing providers are also required to
ship hepatitis and STD samples to the laboratory through this method to improve the efficiency
of processing and receipt of results.
A series of day-long technical assistance sessions for testing site supervisors and staff providing
direct services were delivered. These sessions addressed the rationale for the transition, science
of the new technology, new policies and procedures associated with the transition to fourth
generation (e.g., preparing samples for submission, shipping), roles and responsibilities of
testing site supervisors, assessment of risk for acute infection and making testing
recommendations, results delivery procedures, and the importance of linkage to care. Regular
monitoring and reinforcing new service policies and procedures will ensure system change and
high-quality services.
- Barry P. Callis
Office of HIV/AIDS, Bureau of Infectious Disease
Massachusetts Department of Public Health
Boston, MA
As you can see, there are many factors that can be considered in selecting a testing strategy.
No single option is best for all agencies, settings, or clients. Your community may be best
served by using multiple testing strategies.

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Chapter 6. Implementing HIV
Testing in Non-Clinical Settings
This chapter addresses implementation of HIV testing. In this chapter we discuss the
following:
The legal and regulatory issues associated with HIV testing
The steps included in the process of testing for HIV
Informed consent, including strategies for obtaining client consent
Interpreting test results, including providing clear messages to clients
Delivery of results, including strategies for delivery of results
Procedures for site set-up, sample collection, and performing tests
Universal precautions and exposure control
Repeat testing
Incentives to encourage receipt of final test results
Quality assurance of testing activities, including training and assessing staff
proficiency
Monitoring and evaluation of testing activities
Conduct testing in accordance with local, State, and Federal statute and regulation
Interpret test results and provide clear and accurate messages to clients about the
meaning of their test results
Select strategies to ensure clients receive test results
Make appropriate recommendations for retesting
Note: Site-specific considerations for HIV testing in outreach settings can be found in
Chapter 8.
Legal and Regulatory Considerations for HIV
Testing
Before initiating a non-clinical HIV testing and linkage program, you must understand the
State and local legal and regulatory requirements and limitations as they apply to HIV testing.
Of particular importance is ensuring that your agency has the legal authority to conduct HIV
testing.

Authority to Perform HIV Testing: All States have regulations or statutes regarding who
may perform HIV testing. In general, testing to diagnose a disease must be performed under
the supervision of a physician or other licensed health care professional. Some cities have
additional regulations. Contact your State or local HD to learn more.
Policies and Regulations About HIV Testing: All States have policies, regulations, and/or
statutes about HIV testing. Many cities have additional policies and regulations. Policies and
regulations address issues such as laboratory certifications or licensure, training or
credentialing of staff members who perform various aspects of HIV testing, provision of
anonymous testing, disease reporting, and consent requirements.
If rapid HIV tests are to be used, you must obtain a certificate of waiver under CLIA. CLIA are
Federal regulatory standards that apply to all clinical laboratory testing performed in the
United States. If you plan to conduct HIV testing at multiple locations or venues, you may
need to obtain CLIA certificates for each of these sites. Additional information about
obtaining CLIA certificates of waiver is available in the Resources section of the Toolkit, or you
can contact your State or city HD to learn more.
State laws and regulations vary with regard to the age at which minors may consent for HIV
testing and treatment without a parent’s or guardian’s consent. Contact your State HD for
specific information regarding the age of consent for HIV testing and treatment.
Conducting HIV Testing
Regardless of the setting, preparing to and actually conducting HIV testing involves the same
basic set of activities, presented in Exhibit 6.1. This chapter focuses on providing HIV testing.
Specifically, this chapter addresses engaging the client, performing testing, and delivering
results. Planning for implementation of HIV testing and linkage programs, including selection
of recruitment, testing, and linkage strategies, is addressed in other chapters of this manual.
Similarly, risk reduction, referral and linkage, and QA are addressed elsewhere in this manual.

Exhibit 6.1. HIV Testing Activities in Non-Clinical Settings
Laboratory Testing Rapid Testing
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Plan testing and linkage program
▪ Recruitment strategies
▪ Testing strategies
▪ Venues and settings for testing
▪ Linkage strategies
Engage clients
▪ Obtain consent
Conduct testing
▪ Site set-up and preparation
▪ Collect specimen
▪ Prepare and package specimen for
submission to laboratory
Deliver results
▪ Retesting recommendation, as applicable
Referral assessment and management*
Risk reduction, as applicable**
Reporting
QA, M&E
•
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•
•
•
•
•
•
•
Plan testing and linkage program
▪ Recruitment strategies
▪ Testing strategies
▪ Venues and settings for testing
▪ Linkage strategies
Engage clients
▪ Obtain consent
Conduct testing
▪ Site set-up and preparation
▪ Perform test according to procedure
Conduct supplemental testing (if applicable)
▪ Prepare and package specimen for
submission to laboratory
Deliver results
▪ Retesting recommendation, as applicable
Referral assessment and management***
Risk reduction, as applicable
Reporting
QA, M&E
*Additional detail on referral assessment and management is provided in Chapter 7: Referral and Linkage to
Health and Prevention Services.
**Additional information is provided in Chapter 4: Risk Reduction.
***Additional detail on referral assessment and management is provided in Chapter 7: Referral and Linkage to
Health and Prevention Services.
Before the Test
Information About HIV and HIV Testing
Clients should be provided with information about HIV and HIV testing that is sufficient to
obtain informed consent for testing. At a minimum, it is suggested that clients be provided
with the following information:
• Overview of HIV testing
 What is being tested (e.g., antibodies), based on the test(s) that will be used
Testing strategies and client options for testing
Procedure for testing
Procedure and timeline for obtaining results
Next steps and procedure associated with HIV-positive results
Next steps and procedure associated with HIV-negative results
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• Benefits of testing
Drawbacks of testing
HIV “basics” (e.g., transmission, prevention)
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Meaning of test results, especially the window period (relative to last exposure and test
strategy used)
Applicable laws (e.g., disease reporting laws)
Sources of additional information and support
Inform clients about the tests and testing strategies used by your agency, as well as their
options for testing. It is suggested that the information on HIV testing presented to clients
represent the tests and testing strategies used by your agency.
Explore with the client the different tests and test strategies available. Explain the benefits and
drawbacks of the tests to help them to help them choose the strategy which will work best for them.
If you suspect that a client may have acute HIV infection, on the basis of symptoms and/or risk
behavior, explain to him or her the process for and benefits of testing for acute infection. Arrange for
the client to have acute HIV testing. Please refer to Exhibit 5.5 for the criteria that may be used to
identify clients who would benefit from acute testing.
It is important to provide clients with an opportunity to ask and have answered any questions
about HIV and the testing process.
You may use one or more modalities to provide clients with this information. Information can
be provided verbally, through video, in writing (e.g., brochure or fact sheet), or through use of
a computer.
Some States and/or cities have statutory or regulatory requirements related to provision of
information in conjunction with HIV testing, including standard required materials that must
be distributed to all clients tested for HIV. Some States also have statutes, regulations, or
other policies regarding provision of information specific to HIV testing provided in non-
clinical settings and/or by CBOs. Contact your State or city HD for information regarding
requirements for informed consent for HIV testing. If you will be using rapid HIV tests, be
aware that you will be required to distribute to each client a subject information booklet prior
to testing. Booklets are provided by the test kit manufacturers.
Select the method for providing information to clients that is most appropriate for the target
population. In selecting a method for providing information, consider the literacy level and
preferred language of your target population, the developmental level of the target
population, and any other culturally relevant factors that inform how health information is
understood by members of the target population.

Tip
Use your organization’s consumer advisory board to get input on informational materials and methods.
Pilot test materials and methods with community members to ensure that the information is easily
understood, culturally relevant, and presented in a manner that is well received by the target
population.
Know State and/or local statutes, regulations, and policies as they pertain to HIV testing, including
requirements regarding informed consent. Contact your State or city HD for additional information.
Consent
It is important to obtain consent from a client prior to performing an HIV test. Consent for HIV
testing should be obtained in accordance with State and local laws and regulations. Some
States or cities require that consent for HIV testing be in writing, signed by a client. Some
States or cities have policies or regulations about consent for testing specific to HIV testing
provided in non-clinical settings and/or by community-based providers. There are a variety of
approaches that you can take to integrating obtaining consent into your workflow:
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Provide clients with written information and consent forms at intake. Clients can review
information prior to being engaged by testing staff. This may help prepare them to ask
questions about the test. Clients can sign the consent form at the time of intake or after
they have had the opportunity to ask questions about HIV testing.
Some agencies use computers to gather information from clients at intake. This is
referred to as computer-assisted self-interviewing (CASI). Information about HIV testing
and information relevant to consent to test can be included in the CASI programming. It
may be possible to include consent as part of the CASI programming.
You could provide clients with information about HIV and HIV testing in your waiting
room (or area that you have designated as a waiting area in the case of outreach
testing). Information can be provided to clients in written (e.g., a pamphlet), video, or
even audio format. You could also choose to present information verbally (or verbally in
combination with videos or written material) by, for example, a health educator.
Information can be provided to a group or to one client at a time. Some agencies find it
most efficient to conduct group education sessions when they have a high volume of
clients, such as you might have at a large community event. In this scenario, individuals
have the opportunity to ask questions of the health educator, as well as the person
performing the test.
You can also provide information and obtain consent from clients, one client at a time.
In this scenario, you would designate one person on staff—it may or may not be the
same individual performing the test—to present information to clients, allow them to
ask questions, and obtain consent for HIV testing.
Contact your State or city HD for information regarding requirements for informed consent
for HIV testing. These requirements may influence your decision about how you approach
consent, including how it is integrated into your workflow.

Maintain documentation of consent, whether obtained in writing or verbally, in the client’s
chart.
If oral consent is used, note consent in the client chart or similar documentation associated with
provision of HIV testing services. It is important to also note the date and the name of the person who
obtained client consent.
If a client elects to be tested on an anonymous basis, his or her name should not be recorded
on a written consent to test.
Tip
Assign clients who opt to test on an anonymous basis with an alpha and/or numeric code. Record this
code on the consent form (if applicable).
Confidential and Anonymous Testing Options
Before HIV testing is performed, clearly explain to clients the measures that are in place to
protect their confidentiality, including who will know their test results (e.g., PS if the result is
HIV positive). If a client is reluctant to provide his or her name, your staff members it may be
helpful to explain to the client in simple and clear language the benefits of confidential
testing.
Use simple and clear language to explain confidential testing to clients, such as the following:
“Confidential testing means that your name and other identifying information will be on your test result
and other paperwork associated with getting your test. All information given will be held in strict
CONFIDENCE according to the laws governing confidentiality. Confidential test results can be released
to other people only with your written permission, except for the health department, as required by law.
Having your name and contact information is important in case we need to get in touch with you about
your test results or to help you to get the health services you need.”
Anonymous testing simply means that an individual is tested for HIV without giving his or her
name. Many States and/or cities have statutes, regulations, or other policies regarding the
provision of HIV testing on an anonymous basis. Some States require that all clients be
advised of their right to be tested without giving their name (i.e., tested anonymously) in
advance of administering an HIV test. Contact your State or city HD for information regarding
provision of anonymous HIV testing.
If HIV testing is provided on an anonymous basis, it is important that you develop a strategy,
such as the use of codes, to ensure that test results are correctly matched to clients.

Tip
Assign clients who opt to test on an anonymous basis with an alpha and/or numeric codes. You could
use adhesive labels preprinted with codes. Adhesive labels can be purchased with codes printed on
sets of labels (e.g., groups of four, six, or eight). This will enable you to label testing specimens,
laboratory requisition forms, and results to ensure that they are all correctly linked to the client and that
numbers or letters have not been inadvertently transposed.
Tip
Use of pseudonyms (e.g., “Jessica Rabbit”) is not recommended because of the potential that multiple
clients will use the same pseudonym, increasing the difficulty in correctly matching test results to
individual clients and the possibility that clients will not receive the correct results.
If a client receives other services from your agency and elects to be tested for HIV
anonymously, it is appropriate to keep HIV testing information separately from any other
client records maintained by your agency.
Performing HIV Testing
You can provide HIV testing in a variety of settings, including the office of a CBO, at a
community venue (e.g., bar or community center), or in an outreach setting (e.g., health fair,
house party). Decisions regarding which settings or venues in which you conduct HIV testing
are appropriately informed by your formative evaluation and made in consultation with your
staff and other stakeholders including, importantly, members of the target population. Your
resources, staff skills and abilities, regulations, community partnerships, and other factors will
also influence where HIV testing can be provided.
Site Set-Up and Preparation
Testing Area: Regardless of where HIV testing is to occur, it is of the highest importance that
the area where HIV testing is provided is private and ensures client confidentiality. The space
used for HIV testing must prevent others from seeing or hearing interactions with the client or
observing test processing, in order to ensure that the client’s confidentiality is protected.
It is essential that the space you use to provide testing also have adequate room and seating
to comfortably accommodate the clients and staff or volunteers providing HIV testing
services. If rapid HIV testing is to be performed, the space must have adequate room to
perform tests and controls, adequate lighting to ensure that tests and controls are performed
and read accurately, and that the temperature is within the manufacturer’s specifications for
operation.1
1
Detailed information regarding the space, temperature, and lighting requirements of rapid HIV tests is available
on the manufacturer’s package inserts.

Tip
To help ensure privacy, you may consider using a white noise machine or a radio set at a low volume
in the vicinity of the space that will be used for HIV testing.
If you are conducting rapid HIV testing, the following conditions must be met:
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Lighting: It is important that the lighting in the area where the tests will be performed
be adequate to allow you to safely and accurately perform the test and read results. If
natural and/or room lighting is not bright enough for safety and to read the results,
bring additional lighting (e.g., a lamp) to the outreach site. For outreach conducted in
parks or other public settings, consider using a high intensity flashlight. As a rule of
thumb, lighting is adequate if standard newsprint held next to the test device can be
read without difficulty.
Temperature: Rapid HIV tests must be conducted within the operating temperature
specified by the manufacturer on the package insert. Use a thermometer to ensure that
the temperature is—and remains—within the proper temperature range. The
temperature at which each test was performed should be recorded. Test kits should be
stored within the storage temperature range specified by the manufacturer on the
package insert. If rapid test kits are to be transported to an outreach site, they must be
transported in a manner which will ensure that they remain within the range of the
specified storage temperature.
Surface Area: Rapid HIV tests must be performed on a clean and level surface. All
testing kit components and controls must be organized. Do not consume food or drink
in the area. If rapid tests are to be used at an outreach site, consider carrying a level with
you to ensure that you are performing tests on a level surface.
Storage and Disposal of Reagents: If you are using rapid HIV testing, reagents must be
stored and disposed of properly. Reagents require refrigeration, and you will need a
refrigerator with necessary temperature controls. Maintain an inventory of testing
supplies, noting the lot numbers, date of receipt, record of storage temperatures,
expiration date, and dates in use. Manufacturer directions should be followed regarding
the expiration date of opened reagents. You should not use reagents from kits with
different lot numbers interchangeably.
Equipment: If you will be testing using laboratory-based tests, specimens may need to
be refrigerated. You will need to obtain a refrigerator with necessary temperature
controls, used only for the storage of samples and/or testing supplies. If you will be
conducting laboratory testing, you will need to prepare samples for testing. For this, you
will need a centrifuge.
Supplies and Materials: Make prevention materials such as condoms, lubricants,
bleach kits, and educational materials available to the client in the private space, as well
as in the waiting area (or on a display table if in a community venue). Some clients may
not want to take condoms or lubricant from the display table where others can see
them.

It is essential that your staff have all of the supplies, materials, and reference information
necessary to provide HIV testing and linkage services, including the following:
•
•
•
•
•
•
•
•
•
Forms and logs (e.g., consent forms, referral assessment, referral forms, testing logs)
Testing supplies and materials (e.g., lancets, bandages, timers, test kits, controls)
Equipment needed for testing (e.g., centrifuge, lamps, sharps container)
Risk-reduction supplies (e.g., condoms)
Educational materials (e.g., brochures)
Business cards and/or other information about your agency
Referral and resource information (e.g., HIV medical providers, crisis intervention)
Incentives (if applicable)
Client satisfaction or feedback questionnaires
Provide clients with a business card printed with your agency name and your contact information so
that clients have a personal and familiar contact if they have questions or concerns after the testing
session.
A sample list of supplies and materials is provided in Template 7 in Appendix D.
Safety: Develop procedures to ensure the safety of testing and linkage staff, as well as client
It is advisable to have a minimum of two staff members on the premises at all times when HI
i
s.
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at
e
n
g
testing is being provided. Supervisors may find it helpful to schedule after-hours testing
advance, and to be aware of when after-hours testing will be provided. It is advisable th
office doors be locked on the occasion that HIV testing and linkage services are provided aft
hours, and staff should have an emergency contact.
For considerations for implementing HIV testing in community and outreach settings, pleas
see Chapter 8: HIV Testing in Outreach Settings.
Specimen Collection and Preparation
Regardless of the HIV testing method used, perform specimen collection and preparatio
correctly and consistently to ensure accuracy of test results. It is essential that your HIV testin
policies and procedures describe the following:
er
•
•
•
•
•
•
•
•
The materials and equipment required to collect specimens and perform testing
Steps required to collect the specimen and prepare it for testing
Steps to perform a test
Limitations of the procedure
Cautions to be observed which may affect the test results
Safety precautions to protect patients and testing personnel
Quality control procedures
Plan for remedial or corrective action to be followed in the event that quality control
results do not fall within acceptable limits

Rapid HIV Tests: For rapid HIV tests, procedures for specimen collection and preparation and
procedures for performing tests are provided by the manufacturer and are included with test
kits. Many public health laboratories have template specimen collection and test procedures
that can be adapted. Please refer to Appendix B: Resources for additional information,
including links to online resources.
Many HDs provide training on specimen collection for venipuncture, finger stick, and oral
samples. Many also provide training on performing rapid HIV tests. Contact your State or city
HD for additional information.
Laboratory Tests: If you are conducting laboratory testing on blood samples, consult with
the laboratory that will be processing the test for the appropriate sample collection and
preparation procedures. The procedure for sample collection and preparation will vary
depending on the tests and testing algorithm used by the laboratory, and according to their
established procedures. It is very important that you follow these procedures precisely to
ensure an accurate test result. Each laboratory has procedures that dictate the following:
•
•
•
•
•
•
The type and size of sample collection tubes to be used. Different tests require different
amounts of sample and different kinds of sample collection tubes. You must use the
correct sample collection tubes to ensure that the sample can be tested.
Preparation of samples. Blood samples must be prepared correctly for testing. You may
be required to centrifuge samples prior to shipment to the laboratory.
Timeframes associated with testing. Depending on the tests used, blood samples must
be processed within a short period of time after they are obtained, generally less than 2
days.
Refrigeration of samples. Depending on how you are required to prepare samples and
the tests performed, you may or may not be allowed to refrigerate samples.
Shipment of samples. You will need to prepare samples for shipment in a way that
ensures the integrity of the sample and is appropriate for biohazardous materials. This
includes packaging them in the correct containers, labeling samples correctly, and
completing the necessary test requisition forms. You may or may not be able to package
and ship HIV test samples with samples for other kinds of tests, such as hepatitis or
syphilis.
Reporting of results. You will need to learn about how and in what timeframe results will
be reported by the laboratory back to you; this will help you to schedule appointments
for results delivery. Laboratories use various ways to report results back to testing
providers, including via mail, secure fax, and electronic methods.
Some laboratories may provide training on sample collection and preparation. Some HDs
may also provide such training. Consult with the laboratory that will be performing HIV
testing.

Testing Procedure
To ensure accuracy of results, it is important that tests be performed correctly and
consistently in accordance with written procedures. It is essential that HIV testing procedures
describe the following:
• The specific steps required to perform the test correctly
Performing external quality controls, including frequency or periodicity
Interpreting patient test results and internal/external control results
Actions that will be taken if results are not acceptable
Documentation requirements (e.g., documenting patient results, control results)
•
•
•
•
Test procedures for rapid HIV tests are available from test manufacturers and are provided
along with HIV test kits. Many public health laboratories have template test procedures that
can be adapted. Many HDs provide training on testing procedures. Please refer to Appendix B:
Resources for additional information, including links to online samples. You may also consider
contacting your State or city HD. They may have template procedures that you can use.
Workflow
Examine the setting in which testing is to be performed relative to client flow to determine at
which points in the workflow specimen collection and testing are most appropriately
performed. Key considerations in determining where in the workflow specimen collection
and testing can be performed include maintenance of client confidentiality and adherence to
QA procedures.
If you are conducting rapid HIV testing, it may be necessary to perform testing in the same
room or area where sample collection occurs. Some testing and linkage providers run the test
under a box or behind a screen to prevent the client from watching the test while it is
running, as this may create unneeded anxiety of the client and may distract from engaging
the client fully in assessing prevention needs or providing risk reduction.
In some settings (e.g., mobile units, community events) space needed to run tests in
accordance with QA procedures may be limited. In this circumstance, it may be necessary and
more efficient to run all tests in a central area. One staff member can take responsibility for
running tests to reduce errors that could compromise the accuracy of test results. If a
common area is used to perform tests, measures may be taken to ensure that client
confidentiality is maintained. For example, it is important that tests not be run in an area that
clients or others pass through. The benefits and drawbacks associated with where sample
collection and performing tests are presented in Exhibit 6.2.

Exhibit 6.2. Benefits and Drawbacks of Workflow Configurations for Sample Collection
and Performing Tests
Configuration Benefits Drawbacks
Sample collection
in same area with
client present; if
rapid testing is
used, test is also
processed in
same area
• Makes efficient use of limited
space
• Requires fewer staff
• Maximizes client privacy and
confidentiality
• Feasible in low-volume
settings
• Minimizes change for mixing
up client samples or test
results
• Staff needs to be trained in all aspects of
testing, including specimen collection and
performing tests, which can be challenging for
QA
• May be challenging to ensure that area used for
multiple uses meets QA standards for safe work
practices
• May increase client and/or counselor anxiety to
run test in the same room
• May reduce the amount of time that staff are
able to spend with client on risk reduction
• May reduce efficiency in high-volume settings
Sample collection
in central area—
client is not
present; if rapid
testing is used,
tests are also
processed in
central area
• Staff can specialize in tasks,
which is beneficial for QA
• Efficiently uses space and
staff resources, particularly in
high-volume settings
• Allows staff to focus time and
attention on client
engagement, including risk
reduction
• Facilitates compliance with
safe work practices when
dedicated use of space
• Requires multiple staff
• May reduce client privacy due to movement of
client from one area to another
• May not be feasible in settings with limited
space
• Increased opportunity for mixing up client
samples and test results
Universal Precautions and Exposure Control
The Occupational Safety and Health Administration (OSHA) has established basic precautions
designed to keep employees and consumers safe when there is the potential to come into
contact with blood or other body fluids (e.g., saliva, urine). OSHA’s Bloodborne Pathogens
standard (29 CFR 1910.1030) requires employers to protect workers occupationally exposed
to blood or other body fluids, as defined in the standard. These are often referred to as
“universal precautions”. Observing universal precautions means that all human blood and
body fluids are considered infectious for bloodborne pathogens, such as HIV, hepatitis B, or
hepatitis C.
Pursuant to the OSHA Bloodborne Pathogens standard, your agency must do the following:
• Establish a written exposure control plan. The exposure control plan must list all of
the job classifications which have occupational exposure, along with specific tasks or
procedures performed by employees in these jobs which result in their exposure. It is
advisable to update the plan at least annually. The plan may also need to be updated if
you make changes to job classifications or procedures. Staff must be given the
opportunity to provide input into the exposure control plan, including identifying
strategies to eliminate or minimize occupational exposure. Information on obtaining
sample exposure control plans is available in Appendix B.

•
•
•
•
•
•
•
•
Implement the use of universal precautions. This simply means that all human blood
and other body fluids are treated as if they are known to be infectious for bloodborne
pathogens, such as HIV.
Provide and ensure employees use personal protective equipment. The first
strategy in practicing universal precautions involves using personal protective
equipment. Latex gloves and gowns or aprons are two common forms of personal
protective equipment used in the context of HIV testing.
Identify and ensure use engineering controls. The second strategy in practicing
universal precautions involves using engineering controls. Engineering controls are
simply devices (e.g., sharps disposal containers, self-sheathing needles, spring-loaded
lancets) that reduce or remove the bloodborne pathogen hazard from the workplace.
Identify and ensure use of work practice controls. Work practice controls simply
means keeping a safe work area through practices such as hand washing, cleaning
contaminated surfaces, and disposal of hazardous waste.
Make hepatitis B vaccinations available to workers with occupational exposure.
Employers must make this vaccination/vaccination series available to all employees with
occupational exposure within 10 days of initial assignment to the job with occupational
exposure. All vaccinations and medical evaluations are to be provided at no cost to
employee.
Perform post-exposure evaluation and follow-up to any employee with an
exposure incident. An exposure incident simply refers to blood or other body fluid
having come into contact with the eye, mouth, other mucous membrane, or non-intact
skin, or through a needle-stick. Evaluation and follow-up involves testing of the source
blood, baseline blood testing of the exposed employee, and counseling. Post-exposure
prophylaxis may also be appropriate. Incidents must be documented.
Affix warning labels and signs to communicate hazards. Warning labels must be
affixed to containers of regulated waste, sharps containers, refrigerators, and other
containers used to store, transport, or ship blood or other body fluids.
Provide information and training to employees. Employees must receive regular
training on bloodborne pathogens, use of universal precautions, and exposure control
and training must be documented.
Additional detail and discussion of universal precautions and exposure control plans are
available from OSHA at http://www.osha.gov.
Staff members who perform HIV testing, including specimen acquisition (e.g., through a
finger stick) are occupationally exposed to bloodborne pathogens. Other staff, such as
janitorial staff who clean up the areas where testing is conducted, may also be occupationally
exposed.
In the context of HIV testing, the most likely occupational exposure will be to blood and
through sharps injuries. Common work practices that increase the risk of exposure or sharps
injury include recapping needles, such as those used to obtain a sample through
venipuncture; failing to dispose of used lancets properly in a sharps container; opening tubes
of blood; or transferring blood or body fluids to test devices. Exhibit 6.3 presents the universal

precautions that should be followed by all HIV testing and linkage providers to protect their
safety.
Exhibit 6.3. Universal Precautions and Safe Work Practices for HIV Testing and Linkage
Providers
•
•
•
•
•
•
•
Wash hands or other skin surfaces immediately after before/after handling blood or other body fluids. If
soap and water is not available, CDC recommends alcohol-based hand sanitizer.
Use disposable gloves (preferably latex) and change gloves between clients.
Do not eat, drink, apply make-up, or handle contact lenses in the work area.
Do not keep food or drink in refrigerators, containers, shelf, cabinets, or countertops where potentially
infectious materials are present.
Disposal of regulated waste: Dispose of lancets, needles, or other fluid-touched items (e.g., gauze) in
proper containers.
Disinfect all work surfaces and items before and after testing with 10% bleach solution or Environmental
Protection Agency-approved disinfectant.
Report exposure to your supervisor immediately if you come into contact with body fluids.
Tip
It may not be feasible to have hand-washing facilities in some HIV testing settings, such as health fairs.
In this case, HIV testing staff can be provided with and use either antiseptic hand sanitizer or antiseptic
towels.
Regulated Waste: The OSHA Bloodborne Pathogens standard uses the term “regulated
waste” to refer to waste, including liquid blood or other body fluids, which requires special
handling. Consider the following items as regulated waste and dispose of them properly:
used rapid HIV test devices or sample collection loops or tubes; used gloves, gauze, bandages;
used needles, lancets, or other sharps; and other items that are contaminated with blood or
body fluid. Sharps should be disposed of in a container which is closable, leak proof, and
labeled as a biohazard. You can dispose of other items in containers which are appropriately
marked. Containers can be obtained through medical supply companies and through
commercial regulated waste disposal companies.
Twenty-six States operate their own occupational safety and health programs under plans
approved by OSHA. These States have standards which are identical or at least as effective as
Federal OSHA standards, including bloodborne pathogens and hazardous communications
standards. Additional information about State-specific plans is available at OSHA’s Web site or
by contacting your State HD. Some States and cities have additional regulations regarding
storage and disposal of medical waste. Contact your State or city HD for additional
information.

Interpreting HIV Test Results
In order to deliver an accurate message about the meaning of HIV test results, it is essential
that your staff be familiar with the test technology used by your agency, relative to the
window period, and the timeframe of the last known or possible exposure. See Chapter 5, the
section titled Overview of HIV Testing Technologies for additional discussion on the window
period, as related to different tests and test strategies.
Laboratory Tests
Reactive Results: A test can be considered positive for diagnosis of HIV only after the results
of both screening and supplemental tests are reactive. If both the screening and
supplemental tests are reactive, the result may be interpreted as HIV positive. It is essential
that clients diagnosed with HIV be linked to HIV medical care and referred to PS, and/or other
prevention services. In addition, it is beneficial for clients to be counseled to assist them in
adopting risk-reduction strategies.
Use simple and clear language to explain test results clients. For example, “The test result shows
that you are infected with HIV.”
If clients are participating in HIV vaccine trials, HIV vaccine–induced antibodies may result in a
false-positive test result. Encourage any client with a positive HIV test result who has been
identified as a vaccine trial participant to contact the vaccine trial site for evaluation or receive
referral to HIV medical care for further evaluation and/or testing.
Nonreactive Results: A non-reactive test result indicates no evidence of HIV infection and
can be interpreted as HIV negative. Depending on the window period associated with the test
that you are using, clients that report recent known or possible exposure to HIV can be
advised that they may have been tested before HIV infection could be detected by the test,
and recommended retesting at an appropriate interval. Additional discussion regarding
recommendations for retesting occurs later in this chapter.
Use simple language to explain the test results, as related to the window period of the test you are
using and recommend retesting, as applicable. For example, “The test result does not show that you
have HIV. It may be too early to tell if you are infected. You should be retested in 1 month.”
Indeterminate Results: On occasion, testing with the Western blot will yield indeterminate
results. Indeterminate test results may be related to recent infection, infection with HIV-2,
concurrent infection with other viruses or diseases, vaccination (e.g., HIV vaccine trial
participants), or problems with the sample or testing procedure. It is essential for clients who
receive an indeterminate HIV test result to be referred for supplemental testing using a
testing method that can detect acute infection or other viral infection. Additional information

on testing that can detect acute HIV infection is available in Chapter 5, in the section titled
Overview of HIV Testing Technologies.
Use simple language to explain the test results, as related to the window period and recommend
supplemental or retesting, as applicable. For example, “Your test result is indeterminate, which means
that the test cannot tell whether or not you have HIV. Because you have been recently exposed to HIV,
I am going to refer to you City Hospital for additional testing.”
Rapid Tests
Reactive Results: Reactive rapid HIV test results indicate that HIV antibodies have bee
detected. The result is interpreted as preliminary positive. Supplemental testing is required t
confirm a diagnosis of HIV infection. Arrange for supplemental testing by either obtaining
sample or making a referral to a clinical provider that can perform supplemental testing. It i
n
o
a
s
o
n
essential that clients with reactive results be linked to HIV medical care and referrals made t
PS (if allowed in your jurisdiction). It is also important to counsel clients and to assist them i
adopting risk-reduction strategies while awaiting supplemental test results.
Use simple language to explain the test results, as related to the testing method you are using.
For example, “The test result was positive. It is likely that you are infected and living with HIV. You
should have a second test to confirm the results.”
Nonreactive Results: If the result of a rapid test is nonreactive, HIV antibodies have not been
detected. The test result is interpreted as negative. Arrange for acute HIV testing, if
appropriate. If acute infection testing is not available, you can arrange for retesting after an
appropriate interval.
Use simple language to explain the test results, as related to the window period and
recommend retesting, as applicable. For example, “The test result does not show signs of HIV
infection. However, you have been having sex without a condom in the past [insert appropriate
timeframe]. You should be retested in [insert appropriate amount of time].”
Invalid Results: If a rapid test yields an invalid result, it cannot be interpreted. Repeat HIV
testing on a new sample obtained from the client. For additional information on invalid rapid
test results, refer to the package insert provided with the test kit by the manufacturer.

Delivering Test Results
If rapid HIV testing is performed, the vast majority of clients will receive their test results on
the same day, during the testing encounter. However, if you use laboratory testing either as
the primary testing method or for supplemental testing conducted in conjunction with
reactive rapid tests, a second encounter with the client will be required so that your client
receives the final test result. It is essential that your agency have clearly defined strategies for
delivery of HIV test results, which can be described in agency policies and procedures for HIV
testing and linkage. There are several strategies that you can consider for delivery of test
results, including the following:
Face-to-Face Delivery of Results: If you use rapid testing, most test results can be delivered
face to face, during the same visit at which the client was tested. If you conduct laboratory-
based testing as your primary test strategy or for supplemental testing conducted for reactive
rapid test results and plan to deliver test results face to face, an appointment can be made
with the client for the follow-up session at the time of the initial test session. Follow-up
sessions can be held at the agency offices, the venue where HIV testing was conducted, or
some other mutually agreed upon location. Consult with the laboratory that performs your
HIV testing to find out how long it will take to receive test results. This will help you to
schedule appointments with clients.
Provide clients with an appointment card (or similar means) with the date and time of the
follow-up appointment clearly indicated. Asking the client to present identification and/or
the appointment card in order to receive test results will help you to that test results are
matched correctly to each client.
Tip
Consider using adhesive labels preprinted with random codes. Adhesive labels can be purchased with
codes printed on sets of labels (e.g., groups of four, six, or eight). This will enable you to label testing
specimens, laboratory requisition forms, results, and client appointment cards with a consistent code
and enable you to double check that results are matched correctly to the client.
If a client has tested anonymously, it is important that you give the client a number or unique
identifier that can clearly be linked to the test result. The client must present that information
in order to receive his or her test results.
If you plan to deliver test results face to face, you will need to identify strategies for following
up with clients to ensure that they receive their final test results. Obtain contact information
(e.g., telephone number, e-mail address, mailing address) from confidentially tested clients to
enable follow-up if they do not keep appointments. Ask clients about how (e.g., in person, via
phone), when (e.g., daytime, weekends), and where (e.g., work, home) they prefer to be
contacted. Clients may also be advised that if they do not keep follow-up appointments, you
will contact them.

It is important that your follow-up procedures protect client confidentiality. Regardless of
whether you use mail, telephone, or other electronic means of contacting a client, it is difficult
to ensure that only the client will have access to the communication. Therefore, it is
recommended that you do not specifically reference HIV test results.
To ensure client confidentiality during follow-up by mail, telephone, or other means of contact, avoid
referencing HIV test results. Until you can confirm a client’s identity, state that you are contacting the
individual with “important health information”. It may also be appropriate to avoid using the name of
your agency, particularly if HIV or AIDS is included in the title.
Your agency must determine how many attempts will be made, and in what timeframe, to
contact a client who has not kept a follow-up appointment. Factors that are key to consider
include the result of the test (i.e., positive or negative) and your agency resources.
It is essential that your agency also emphasize follow-up efforts for clients testing HIV
positive, for example, making one or two attempts to follow-up with HIV-positive test results
in order to ensure that these clients learn their serostatus and are linked to medical care. If
after one or two attempts the client has not been successfully contacted, refer follow-up to
public HD PS.
You may decide to give lower priority to follow-up on clients with HIV-negative test results, or
may prioritize follow-up on clients who are at elevated risk for HIV or who may be acutely
infected. It is important that your agency policies and procedures describe how follow-up is
to be conducted.
Results Delivery by Telephone: You may consider other strategies for delivery of HIV testing
results, including results delivery by telephone. Advise clients of how long the wait period is
until results will be available. If your agency uses these strategies, verification of client identity
is a primary consideration.
If you will be providing HIV test results via phone, your process for delivery of results may
require that the client call in for test results (rather than your agency calling the client). In
order to verify the identity of the client, consider use of a code word, agreed upon at the time
of the test, or by assigning a number or other code unique to that client.
It is recommended that positive HIV results be delivered face to face. However, it may be
necessary or appropriate to deliver positive results via phone. In this situation, counsel the
client regarding the benefits of initiating medical care and the importance of risk reduction to
protect their health and that of their partners. You can also link the client with HIV medical
care. It is important to ensure that the process to link clients to medical care who learn their
HIV-positive test results via phone be clearly described in your policies and procedures.

In the textbox, Jamie Anderson describes the process for results delivery by phone in Kansas.
The Kansas Counseling, Testing and Referral program ensures the proper provision of HIV test
results by training providers on the delivery of both positive and negative HIV test results. Kansas
Department of Health and Environment supervises results delivery efforts by reviewing
submitted HIV test forms, rapid test logs, and Kansas Department of Health and Environment
Laboratory data.
HIV counseling and testing sites have the option to deliver negative HIV test results from
conventional confidential tests either in person or by phone. Sites must provide clients with a
unique confidential personal identification number (PIN) and verify the client’s name, date of
birth, and PIN before results can be delivered.
KDHE allows for agencies to decide, based on work/clinic flow regarding the delivery of negative
HIV test results. Some agencies require clients to call in for results and require the client to
provide a PIN to obtain their result. Agencies which have the staffing capacity often choose to
call clients directly to deliver results. Agencies calling clients have better posttest counseling
rates.
- Jamie Anderson
HIV/AIDS Program
Kansas Department of Health and Environment
Topeka, KS
Results Delivery by Internet: Your agency may consider delivering test results via a secured
Internet Web site. If you use this method, verify client identity not only on the basis of the
client name, but also on the basis of a code or number assigned (e.g., PIN) to that client at the
time of the test that must be entered in order to receive results.
In conjunction with disclosure of HIV-positive results via a secured Web site, provide clients
with a clear message regarding the benefits of initiating medical care and the importance of
risk reduction to protect their health and that of their partners. It is important to provide
referral resources to facilitate linkage to HIV medical care. Clients can be directed to someone
who will provide them with information about test results and to obtain assistance in
accessing HIV medical care. This could be done through an online chat application or through
video-conferencing.
Video-conferencing is another way that you can use the Internet to deliver HIV test results.
Following is a case study from Robin Pearce explaining how her CBO used Skype to initiate
linkage to care.

A client recently given a positive test result from a State clinic drove an hour to seek services and
a diagnosis from us because the State was not following up. We delivered her result in person
and scheduled a subsequent meeting to begin her enrollment paperwork for medical case
management services. The client's current work supervisor had already made it very difficult for
her to make time for medical appointments—the supervisor wanted a letter signed by a doctor
and more information about the sudden need for important medical appointments. It was hard
to find a time to meet with this client, so the linkage coordinator set up a Skype meeting with
her. The face-to-face interaction provided by Skype made the appointment more personal and
gave the coordinator a better sense of the client's feelings during this difficult time. Use of this
technology worked well for this particular circumstance, but could be used more broadly to
feasibly deliver test results, provide counseling to clients and support clients in linkage to care.
- Robin Pearce
Counseling and Testing Coordinator
NO/AIDS Task Force
New Orleans, LA
Written Results: Clients sometimes request written copies of their test results. If written
results of a negative test are to be provided, it is useful for a clear statement about the
meaning of the test results, relative to the window period of the test used, to accompany the
result. It is recommended that written test results be provided on your agency letterhead or a
similar form and clearly state the following:
•
•
•
•
The agency that performed the HIV test
The date of the test
The test result (positive or negative)
Explanation of the result relative to the window period
A sample of a written statement of results provided as Template 2 can be found in
Appendix D. It is not recommended that written results be provided in conjunction with
anonymous HIV tests. It is important to address provision of written test results in policies and
procedures.
Incentives: Client incentives may be useful in encouraging clients to return to receive their
HIV test results. If your agency decides to use client incentives in conjunction with referral and
linkage activities, it is important that the incentives used are appropriate to the client
population. Client input regarding incentives, specifically the form of the incentive (e.g., gift
card), its value, and when and how it will be provided (e.g., at the completion of the initial
medical visit) is useful to helping you make decisions about use of incentives. Your testing
policies and procedures can specifically address the use of incentives, including how
incentives will be purchased, secured, and tracked. Sample procedures for using client
incentives are available in Template 1 in Appendix D.
selection of strategies to deliver results. Incentives are discussed in greater detail in

Chapter 3: Targeting and Recruitment. Refer to this section of the Implementation Guide to
learn more about different types of incentives and the factors you may consider in
determining whether or not to use incentives.
incentives, such as cash. Check with your State, local HD, or funder to learn about applicable
policies or requirements.
Recommendations for Repeat Testing
For clients with an HIV-negative test result, recommendations regarding repeat HIV testing
can be made on the basis of several factors, including the following:
• The timing of the last known or potential exposure
• The window period associated with the test performed
• Ongoing risk behaviors
In order to make the most appropriate recommendation for retesting, it useful to familiarize
yourself with the testing method used by your agency, relative to the window period. If
conventional testing is used, it is important to know the window period associated with the
tests used by the laboratory that performs testing.
Recent Possible or Known Exposure: Clients with negative results from rapid tests or
conventional tests (which do not detect acute infection), but who may be recently infected
are recommended for immediate retesting for acute infection. If testing for acute infection is
not available, recommend retesting at an interval appropriate to the window period of the
test that is used. Clients with very recent or known exposure (within 72 hours) can be offered
baseline HIV testing and linked to a provider that can assess eligibility for nPEP.
If conventional testing was performed and the result was negative, you can reasonably
deliver a negative result if your laboratory uses an algorithm that can detect acute infection.
Recommendations for retesting can be based on ongoing risk. For additional information on
identifying clients who should be recommended testing for acute infection, please refer to
Chapter 5, in the section titled Acute Infection Testing.
Use simple language to recommend retesting associated with a recent exposure. For example,
if acute testing is available, “This test result did not show signs of HIV infection. However, it may be
too soon for this test to detect signs of HIV infection. Since you have recently had flu-like symptoms,
you should see a doctor who can run a test that will detect signs of infection sooner than this test can.”
Or
if acute testing is not available, “The test result does not show signs of HIV infection. It may be too
soon for this test to detect signs of HIV infection. Since you have felt sick over the past 2 weeks, you
should be tested again in 1 month to be sure that acute HIV infection is not the cause of your illness.”

Ongoing Exposure: Clients with HIV-negative test results who have ongoing risk can be
retested annually. It is appropriate for MSM to retest every 3 to 6 months if they have
unprotected sex with multiple partners, anonymous partners, or use drugs in conjunction
with sex.
Use simple language to explain the test results and recommend retesting. For example, “The
test result does not show that you have HIV. If you continue to have sex with anonymous partners
without using condoms, you should be tested again in 3 months.”
Disease Reporting
Report reactive test results to the HD, in accordance with State policy and regulation, and
complete an HIV Confidential Case Report Form. The Adult Confidential Case Report Form
should be completed for clients aged 13 years and older. For clients younger than 13 years, a
Pediatric HIV Confidential Case Report form should be completed. In some States, a
confidential case report can be completed and submitted electronically. All States have laws
regarding the amount of time that HIV testing and linkage providers have to complete and
submit an HIV case report. Contact your State or city HD for additional information and
instructions regarding completion and submission of HIV case reports.
When conducting a single or dual rapid test, followed by immediate linkage to care (i.e., no
supplemental testing is performed), complete the appropriate case report form and submit it
to the HD for reactive HIV rapid test results.
If a client with a positive test result was tested anonymously, complete a case report and
submit it to the HD. Typically, an HIV testing and linkage provider would complete the case
report fully, but would record “anonymous” or something similar in place of the client’s name.
Contact your State or city HD to receive specific instructions on completing case reports for
clients tested anonymously.
Quality Assurance of HIV Testing
Develop written policies and procedures for HIV testing activities. If rapid HIV testing is used,
HIV testing must be performed, at minimum, in accordance with manufacturer instructions
and local, State, and Federal regulations. You must have QA practices in place in accordance
with the CLIA of 1988 and applicable State local licensing and QA requirements. Many HDs
offer QA training for rapid HIV testing; contact your State or city HD for additional
information.

Training2
Ensure that staff members3
conducting HIV testing have received training appropriate to their
responsibilities in performing HIV testing. It is essential that staff performing HIV testing
receive training to do the following:
Provide accurate and complete information necessary to obtain consent for HIV testing
Accurately explain confidential and anonymous testing
Accurately explain testing options, including acute HIV testing
Assess client need for acute HIV testing
Collect, prepare, and transport specimens, including appropriately marking specimens
and laboratory requisitions to ensure results are accurately matched with clients
Perform an HIV test, including procedures performed before, during, and after a test
(rapid HIV testing)
Interpret and explain test results to clients
Adhere to universal precautions and exposure control procedures
Properly and accurately document all aspects of the testing process (e.g., testing logs,
QA logs) and maintain secure documentation
Ensure their safety, as well as that of clients
Comply with State and local policies, laws, and regulations governing testing
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Proficiency
Evaluate, at least annually, staff conducting rapid HIV testing to ensure proficiency in
performing tests and documenting results. If you are using rapid HIV testing, enroll in an
external proficiency program. Your testing procedures must address the measures that will be
in place for staff who fail proficiency examinations. Many HDs have developed tools and
guidelines for assessing the proficiency of staff conducting testing. Please refer to Appendix B
for additional resources for assessing proficiency of staff performing HIV tests.
It is recommended that you enroll in an external proficiency program. Through such a program, a panel
of blinded samples (i.e., some are negative, some are positive, but you will not know which ones) will
be shipped to you periodically. Staff perform tests on each of these samples and record the results.
Results are sent to an external agency for review and scoring. You will be provided with individual
reports for each of your staff, as well as an aggregate report. Some public health laboratories provide
these at low or no cost. The CDC Model Performance Evaluation Program (MPEP) is a good resource
and provides panels free of charge. Additional information on MPEP is available in the Resources
section of the Toolkit.
3

Regularly evaluate staff conducting HIV testing to demonstrate proficiency in communicating
effectively and accurately information about HIV and HIV testing, delivering test results,
window period, and so forth. Direct observation of sessions with clients is an effective
strategy to assess proficiency. If direct observation is not possible, role-plays are an alternative
strategy you can use for assessing proficiency.
Practice Example 6.1. Quality Assurance of HIV Testing Using Role-Plays
ACME Prevention Services (APS) provides HIV testing and linkage services in Center City. Every other month,
APS sets aside a few hours during which HIV testing staff work together to improve their skills. Before each
skill-building session, the testing and linkage program supervisor gathers examples of challenging situations,
such as assessing whether a client is too intoxicated to provide consent, delivering an indeterminate test
result, or conducting a referral assessment with a teenager, and writes brief client scenarios. Each scenario is
presented as a role-play, and the staff takes turns acting as the tester while the supervisor acting as the client.
This helps staff learn from each other and keeps their skills sharp. Testing staff observes and critiques each
other. A few times each year, the outreach testing staff of the CCHD join them in doing role-plays.
Specific QA strategies are described in Chapter 9: Quality Assurance and Monitoring and
Evaluation. Please refer to the section of that chapter titled “The Quality Assurance Plan” for a
discussion of how each strategy is most appropriately used. It is important that staff be
observed at regular intervals (e.g., annually), and more frequently after initial training (e.g.,
monthly for the first 3 months).
Documentation and Record-Keeping
Client files, testing logs, assessment forms, and any other documents that contain
confidential information must be kept secure. Documents containing confidential
information may be addressed in your policies and procedures (see the section on Policies
and Procedures presented in Chapter 9: Quality Assurance and Monitoring Evaluation for
additional discussion).
Rapid HIV tests require that HIV testing linkage providers obtain a CLIA certificate. You may be
required to obtain multiple CLIA certificates if you are conducting HIV testing at multiple sites.
Additional licensing may be required by State and or local regulation. All licensed laboratories
are subject to periodic inspection and review by Federal and/or State authorities.
Documentation of HIV testing and associated QA activities, including proficiency reports, will
be examined by reviewers. You will need to keep careful documentation of all training,
testing, and QA activities, because these documents will be evaluated by reviewers. For rapid
HIV testing, your agency will need to keep documentation of the following:
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Staff training and proficiency assessments (for sample collection, test performance,
proficiency testing)
Inventory of test kits and controls (i.e., lot number, dates received/opened)
Quality control results (i.e., performance of external controls)
Log of daily tests (i.e., date/time of collection, test run time, read time, results)
Storage temperature log for tests/reagents

It is essential that the person responsible for supervision of HIV testing activities and who is
acting as the laboratory director under CLIA review these documents regularly. Records
should be maintained according to the CLIA certificate, or pursuant to State/local policy or
regulation (whichever is longer). Many HDs have sample logs and other tools that can be
adapted for local use. Contact your State or city HD for additional information. Refer to
Appendix B: Resources for links to sites where you can download sample QA logs and quality
control procedures.
Keep consent forms (if applicable), test results, referrals, and other information in the client
chart. The client chart may be maintained for as long as required by State or local policy or
regulation.
Conduct reviews of charts regularly (e.g., annually) to evaluate their completeness and
accuracy and more frequently after initial training (e.g., monthly for the first 3 months).
Sampling (e.g., a random sample of five charts for each testing staff member) is appropriate if
it is not feasible to review all client charts. Specific QA strategies are described in Chapter 9:
Quality Assurance and Monitoring and Evaluation. Please refer to The Quality Assurance Plan
for a discussion of how each strategy is most appropriately used.
It is essential for staff to review data regularly (e.g., quarterly) to assess the extent to which
HIV testing strategies help you to identify new infections, help clients learn their HIV test
results, and link to care as efficiently as possible. By evaluating, on a regular basis, the extent
and ways in which HIV testing strategies and practices help you to achieve program goals and
objectives, you will be able to refine practices to ensure that the needs of your clients are met.
evaluate HIV testing practices. Tools also included in that section will help you conduct a yield
analysis to better understand how well your program is working (including use of various test
technologies and practices associated with testing/result deliver) and to guide you in
discussions about program improvement.

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Chapter 7. Referral and Linkage to
Health and Prevention Services
This chapter addresses referral and linkage from HIV testing services to medical, prevention,
and other health services. In this chapter we discuss the following:
Various kinds of referral services
The steps involved in referral planning and management
Strategies for facilitating linkage to services
Developing and maintaining partnerships for referral services
Strategies for documenting and monitoring referral and linkage
Use of incentives to facilitate linkage to HIV medical care
Quality assurance of referral and linkage activities, including training and assessing
staff proficiency
Monitoring and evaluation of referral and linkage activities
Select the best referral and linkage strategies for your program and clients
Build partnerships to enable you to provide more comprehensive services to meet
client needs
Document and monitor referral and linkage activities
What Is Referral and Linkage?
A primary goal of HIV testing in non-clinical settings is to link clients with HIV infection to HIV
medical care as soon as possible. Linkage to HIV medical services facilitates better health
outcomes for HIV-infected individuals. Referral and linkage to medical and risk-reduction
services is also an important HIV prevention strategy. The risk of acquiring or transmitting HIV
infection is influenced by a number of behavioral, physiological, and environmental factors.
Addressing these factors through referral to and linkage with risk-reduction and other
prevention services can have a significant impact on reducing the likelihood of HIV
transmission or acquisition, for both the individual client and the community.
You serve clients who have multiple, and sometimes very complex, needs that challenge
them relative to linking with HIV medical care, risk reduction, or support services. Your agency
may be able to provide clients with needed medical and risk-reduction services onsite.
However, addressing these needs appropriately and effectively may fall outside the expertise

of your program. By working with clients and partner agencies in the community, you can
support your clients and give them the best chance for maintaining the behaviors and
physical health that can reduce the acquisition and spread of HIV.
Definition
The spectrum of definitions for referral and linkage ranges from the relatively simple act of
providing information to a more complex process that facilitates and documents a client’s
entry to, or engagement with, services.
Referral is the process by which a client’s immediate needs for medical care or risk-reduction
services are assessed and prioritized, and the client is provided with information and/or
assistance in accessing referral services. A referral may be either passive or active. Linkage
takes a further step by ensuring and verifying that the referral was successfully completed.
Passive Referral: In a passive referral, a client is provided with information, such as
agency name and location, about one or more referral services. It is then up to the client
to make decisions about whether and which services to access and how to access them.
Active Referral: An active referral begins with assessment and prioritization of a client’s
immediate needs for medical and/or risk-reduction services. In an active referral, a client
is provided with assistance in accessing referral services, such as setting up an
appointment or being given transportation.
Linkage: Linkage means that a referral has been verified as having been successfully
completed. If a client keeps his or her first appointment or receives the referral service (if
the referral requires keeping only a single appointment), the referral can be considered
as having been successfully completed. Optimally, feedback on a client’s satisfaction
with referral services may be a useful part of the linkage process.
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Practice Example 7.1. Active Versus Passive Referrals
Peter, an APS test and linkage staff member, has just delivered test results to Simone. She is HIV negative, but
her risk screen indicates that Simone has multiple sex partners and was recently treated for chlamydia,
suggesting that Simone may be at elevated risk for HIV acquisition. Peter believes that she would benefit from
STD screening and possibly some additional risk-reduction services. Peter conducts a referral assessment.
Simone accepts a referral to STD screening and Peter makes an appointment for her at the Center City
Community Health Center (C3HC) that afternoon. He provides her with a taxi voucher and gives her a VIP
card, which includes his name and contact information along with the name, location, and phone number of
C3HC’s clinic supervisor. Giving that card to the receptionist at the health clinic guarantees that Simone will
be seen immediately, without a wait. Peter calls the taxi to transport Simone to the health center. Peter
provided an active referral to STD screening.
The referral assessment also indicates that Simone often uses alcohol, marijuana, and ecstasy, particularly
when she is having sex. Peter suggests to Simone that she might benefit from drug and alcohol addiction
services. He tells her about a couple of different programs. Peter gave Simone brochures about both
programs, along with contact information. Peter provided Simone with a passive referral to substance use
disorder treatment services.

Implementing Referral and Linkage
Regardless of whether a client is newly diagnosed with HIV infection, has been previously
diagnosed, or is HIV negative, the steps to making a referral and ensuring linkage to medical,
risk-reduction, and/or other services follows the same basic process. When conducting needs
assessment and referral planning and management, you will follow these steps:
Assess Referral Needs: Identify the factors that are most important in terms of their
influence on a client’s ability or willingness to engage in medical care or risk-reduction
services. In assessing referral needs, examine HIV risk behaviors (e.g., sex with
anonymous partners, diagnosis with an STD) and prevention practices (e.g., condom use
during receptive anal intercourse), environmental factors (e.g., access to sterile syringes,
stability of housing), and psychosocial factors (e.g., experience with domestic violence,
mental illness). Consider how these factors might be addressed by medical care, risk
reduction, or other services.
Prioritize Referral Needs: There are often multiple factors that influence a client’s
ability or willingness to reduce risk that influences a client’s health or that impact a
client’s ability or willingness to accept and access referral services. In the context of HIV
testing and linkage services, it is probably not possible or appropriate to address all of
these factors at one time. It is better to focus referral and linkage activities on addressing
the factors that can make the greatest impact relative to risk reduction and in keeping a
client healthy.
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Examine a client’s willingness or ability to accept and complete a referral. If a referral services is
not consistent with a client’s interests or priorities, the referral is less likely to be successfully
completed.
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Plan the Referral: Identify the strategies or methods you will use to facilitate a
successful referral. Help the client to identify challenges that he or she may have in
completing referrals (e.g., cost, lack of transportation). Identify strategies to overcome
these challenges.
Facilitate Access to Services: Provide clients with both information and support
necessary to access referrals. Information about the referral can, at minimum, include
information about the referral agency (e.g., name, address, telephone number, contact
name, hours of service, cost), eligibility, and the processes and timelines for making and
getting appointments. Practical support provided to clients can minimally address the
identified challenges to accessing referral services.
Follow Up and Confirm Linkage: Assess whether the client successfully completes a
referral (i.e., has been linked to the service) and obtain client feedback, if possible. If the
client was not successfully linked to services, attempt to determine the reasons for this
and provide additional assistance, if appropriate. A client may consent to follow-up, and
you can obtain a signed authorization for release of information from the client. The

authorization for release of information can be specific to the referral (i.e., the individual
providers with whom client information, including HIV test results, are shared) and may
be named on the release. A sample authorization for release of information is included
as Template 3 in Appendix D.
received the services they needed, whether these services were satisfactory, and other information
about their experience with the referral service or provider of the referral service. This can help a
program better support and meet the needs of each client, as well as future clients.
Document Referral and Linkage Activities: It is essential that referrals made and
linkage completed be recorded in a client’s file or chart. You may also wish to maintain a
referral log to help staff follow up on referrals made and assess their completion.
Strategies to monitor the completion of referrals and document linkage are addressed in
the section titled Documenting and Monitoring Referrals and Linkage.
Your program may have staff who specialize in referral and linkage or may have linkage
programs. In this case, your staff may perform some or all of the steps of the referral and
linkage process, particularly for clients with positive test results or diagnosed with HIV
infection.
Linkage with HIV medical care, as soon as possible after learning of a positive test result, is an
essential outcome of HIV testing services. For individuals with a positive HIV test, early entry
into HIV medical care can improve health and quality of life. Viral suppression resulting from
use of antiviral medications helps to prevent new infections. Clients with a positive HIV test
result can also be referred to PS. PS is a public health strategy in which HD staff notify partners
of clients with a positive HIV test result of possible exposure and provide them with
opportunities to learn their HIV status.
Linkage to HIV Medical Care
In some agencies, HIV testing staff members often provide clients with referrals to and
assistance with accessing HIV medical care. These staff may or may not have received training
on a specific referral strategy. However, your staff can provide referrals and support linkage to
medical care, provided they have adequate knowledge of HIV medical care resources; the
skills and resources necessary to assist the client in accessing medical services; and sufficient
time and resources to conduct follow-up on referrals to medical care. Recommendations for
training for staff performing referral and linkage services is provided in the section in this
chapter titled Quality Assurance of Referrals and Linkage. There are a number of specific
linkage strategies which have been evaluated and shown to be effective in facilitating linkage
to HIV medical care. Some of these strategies follow a specific protocol or set of procedures.
Obtain feedback from clients about referral services. Clients who were successfully linked to
services can provide valuable information about the referral services, including whether the client
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Referral and Linkage for Clients with a positive HIV Test

They may also require staff members providing linkage to complete one or more specialized
trainings on the protocol or set of procedures, have completed other training as a
prerequisite, or possess a specific set of skills and abilities. These strategies may also be useful
for improving your agency’s linkage to risk reduction and other services.
Linkage Case Management: Linkage case management involves intensive, short-term
assistance to facilitate entry into care. A linkage case manager helps clients to develop a
personalized plan to acquire needed services.
Antiretroviral Treatment and Access to Services (ARTAS) is one model of linkage
case management. ARTAS is for individuals who have recently been diagnosed with
HIV. ARTAS consists of up to five sessions with a client within the period of 90 days
or until the client is successfully linked to HIV medical care, whichever comes first. A
client may be transitioned to a medical case manager for longer-term assistance
and support.
In the following example, Ben Tsoi describes how New York City uses ARTAS and Motivational
Interviewing to improve linkage rates. Additional information about ARTAS is available in the
in Appendix D: Resources.
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ARTAS is a strengths-based case management strategy to enhance linkage of HIV-infected
persons to HIV primary care. The New York City Department of Health and Mental Hygiene (NYC
DOHMH) provided trainings on ARTAS to its funded testing programs to increase agency
capacity to link an HIV-infected client to care. Because familiarity with motivational
interviewing techniques, especially responsive listening, is helpful to program staff in building
rapport, encouraging communication with the client, and in strengthening the client’s
investment in the medical linkage process, the NYC DOHMH also provided training in
motivational interviewing to all its funded HIV testing programs. The knowledge learned from
these trainings can also be applied to other HIV testing activities, such as recruiting clients, and
helping clients reduce activities that expose them to HIV.
- Ben Tsoi
Director of HIV Testing
Bureau of HIV/AIDS Prevention and Control
New York City Department of Health and Mental Hygiene
Queens, NY
• System Navigation: In system navigation, clients are assisted with navigating the
complex health care system, thereby facilitating access to and utilization of medical, risk
reduction, and other services. The objectives of system navigation are twofold: (1) to
provide direct assistance to the client in accessing services; and (2) support the client in
building the knowledge and skills that they need to access and use the health care
system on their own. Navigators are sometimes, but not always, peers—people living
with HIV who have successfully accessed medical, risk reduction, and other services.
Additional information about systems navigation is available in Appendix B: Resources.

In the examples below, Jon Stockton illustrates how Washington State uses ARTAS to
strengthen linkage to care, and Angela Wood describes how a CBO in Washington, DC
employs Linkage Navigators to improve linkage and retention rates.
Washington State Department of Health has proposed a model to improve and strengthen
active referrals for newly diagnosed clients by integrating the ARTAS intervention into existing
testing protocol. Publicly funded sites providing targeted HIV testing services will be expected to
ensure that newly diagnosed HIV clients are referred and linked to HIV medical care. Staff
providing HIV testing services will be cross trained in the ARTAS intervention and will be able to
implement the intervention for newly diagnosed individuals.
Under the existing testing protocol, staff are to ensure that newly diagnosed clients are provided
or referred for medical evaluation, including services for other bloodborne pathogens,
antiretroviral treatment, HIV prevention, and other support services. The existing results delivery
protocol associated with positive results will stay intact, but will be enhanced and expanded to
include ARTAS session one activities. ARTAS session one activities will be provided in conjunction
with delivery of positive HIV test results, with the overall goal of linking individuals to HIV
medical care. Session one activities include the following:
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Introduce the goals of case management and ARTAS
Discuss client concerns about their HIV diagnosis
Begin to identify personal strengths, abilities, and skills, and assess others’ role in impeding
or promoting access to services
Encourage linkage to HIV medical care
Summarize the session, the client’s strengths, and agreed upon next steps
Plan for next session(s) with the medical care provider and/or tester
It will be the test counselor’s responsibility to ensure that the client is linked to medical care. If
the client decides to seek medical case management as their entry point into medical care, then
the tester will ensure that a referral is made and tracked to ensure that the client makes an
appointment with HIV medical case management. Agencies providing HIV testing services are
required to establish a memoranda of understanding and procedures with medical case
management programs to ensure that medical case management and testing staff have a
communication plan in place to verify that the client has successfully linked to medical care.
- Jon Stockton
HIV Counseling and Testing Coordinator
Infectious Disease and Reproductive Health
Washington State Department of Health
Olympia, WA

Family and Medical Counseling Service, Inc. (FMCS) employs linkage specialists to ensure that
individuals diagnosed with HIV are successfully and expediently linked with HIV medical care in
our primary care clinic. Once the linkage specialist connects with the client, the individual
receives immediate (same day) access to a new patient appointment that includes the initial
intake/assessment, a complete new patient lab panel, and initiation of the treatment plan. The
linkage specialist stays with the individual until the appointment is complete, and continues to
conduct follow-up activities to ensure successful completion of the first appointment with the
assigned primary care provider. For individuals our testers encounter who were previously
diagnosed with HIV, the linkage specialist attempts to verify enrollment in care and/or reengage
the individual in care and support services. Once connected to services at FMCS, individuals
have full access to an array of HIV services, including mental health, substance abuse, medical
case management, food bank, nutritional support, and treatment adherence counseling in
addition to primary medical care.
- Angela Wood
Chief Operations Officer
Family and Medical Counseling Service, Inc.
Washington, District of Columbia
• Outreach and Peer Support: Outreach and peer support services are linkage services
provided by and for individuals living with HIV. Peers can play an integral role in
recruiting HIV-positive people into services, particularly individuals from hard-to-reach
populations, clients who have been reluctant to enter into HIV medical care, or
individuals who have left medical care.
Peer support can be provided through one-on-one interactions or in groups. Peer
support helps HIV-infected individuals to engage in health care through direct support,
and build the skills necessary to manage their HIV and obtain needed medical care or
other support. Peer support is appropriate for HIV-infected individuals with varying
ranges of need for support. Peer support is not necessarily time limited.
It is not advisable to use peer support as the main strategy for coordinating and
facilitating access to HIV medical care, risk reduction, or other services. Peer support can,
however, be an important complement to other linkage strategies, such as medical case
management. Additional information on outreach and peer support is available in
Appendix B: Resources.
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You may also use other strategies available to facilitate referral and linkage to HIV medical
care. These strategies have not necessarily been formally evaluated, but they are currently
being used by HIV testing and linkage providers and appear promising.
Comprehensive Risk Counseling and Services: CRCS is designed to provide intensive,
client-centered risk-reduction counseling to individuals who have more complex needs,
such as substance use disorders or mental illness, and who have difficulty in achieving
risk reduction. In CRCS, clients receive assistance and support in developing a
personalized risk-reduction plan and are also provided with support in accessing referral
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services. CRCS is intended for HIV-positive and high-risk HIV-negative clients. Some HIV
testing and linkage providers are using staff trained to provide CRCS to facilitate linkage
for all HIV-positive and high-risk negative clients. Additional information on CRCS is
available in the Appendix B: Resources.
Partner Services: PS provides an important opportunity for linkage to care. PS staff, often
called DIS, can play an important role in linking HIV-positive individuals to HIV medical
care, risk reduction, and other services. When conducting interviews with an HIV-
infected index client or newly diagnosed partner, it is essential that PS staff assess
whether or not the individual is receiving HIV medical care. If not, the client or partner
can be referred to or linked with HIV medical care. It is important for PS staff to have up-
to-date information about HIV medical care providers and/or linkage resources. In the
following text box, Jon Stockton describes how PS staff are trained and employed to
support linkage.
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PS staff in Washington State will be cross-trained in ARTAS intervention and will act as a
“backstop” to ensure linkage to medical care for newly diagnosed individuals. In Washington
State, it is the responsibility of the HIV tester to ensure that newly diagnosed persons are linked
to HIV medical care. PS, however, plays an important role in backstopping testing providers in
linking HIV-infected persons to medical care. During the course of providing partner services, PS
staff assess whether clients are successfully linked to medical care. If a client has indicated that
he or she has not been linked to medical care either through testing services or case
management, then PS will initiate linkage using the ARTAS intervention.
- Jon Stockton
Olympia, Washington
Medical Case Management: Medical case management has as a primary objective to
engage and retain HIV-infected individuals in HIV medical care through coordination of
services and follow-up of medical treatments. Some HIV testing and linkage providers
also operate medical case management programs, often at the same site where HIV
testing is provided, and clients with a positive HIV test result can be easily linked to
medical case management programs. Additional information about medical case
management is available in Appendix B: Resources.
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Referral to Partner Services
A key function of PS is to notify the sex and drug-injecting partners of HIV-positive individuals
about their exposure to HIV.1
PS facilitates HIV testing of exposed partners, as well as linkage
to medical and risk-reduction services. Therefore, ensuring HIV-infected individuals are
contacted by PS is an important prevention strategy.
Strategies that can be used to help clients with a positive HIV test result access PS include the
following:
Referral to Public Health: You can refer a client with a positive HIV test result to the
public health agency. PS staff (or DIS) will contact the client and conduct an interview to
elicit information necessary to notify his or her partners.
Some HIV testing and linkage providers have arrangements with their HD to have PS
staff onsite while tests are being conducted. This may be a useful strategy if your
program conducts a high volume of tests and identifies a relatively large number of
clients with a positive HIV test result. It may not be feasible to have HD staff “outposted”
to your program on a regular basis. However, it may be feasible to have PS staff onsite
during special events or attend testing offered in particular venues where it is likely that
a relatively large number of clients will be diagnosed.
Some HIV testing and linkage providers have arrangements with their local HD to have
PS staff on call, such that when an individual is diagnosed with HIV, PS staff can be
paged to the testing site relatively quickly. This approach may be most feasible when
the PS service area is relatively small. This may not be feasible, for example, if an HD PS
program covers multiple counties. Following you will find an example of how PS staff
are posted at targeted testing events in Washington State.
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1
For more information on PS, please consult: Centers for Disease Control and Prevention. (2008).
Recommendations for Partner Services programs for HIV infection, syphilis, gonorrhea, and chlamydial infection.
Morbidity and Mortality Weekly Report, 57(RR-19).

In Washington State, local health jurisdiction (LHJ) sites include PS staff when planning targeted
testing events to ensure newly diagnosed persons are linked to medical care and additional
ancillary services as appropriate.
A local HD in Washington State ensures that a worker trained in PS participated in planning and
conducting outreach testing events. This approach is intended to ensure timely linkage for
individuals testing preliminary positive (i.e., rapid test reactive) during an outreach event. This
approach also ensures that clients have an opportunity to talk with someone trained in PS to
discuss the goals for and values of PS, as well as the importance of linking to medical care. If PS
staff could not be present during an outreach event, then the LHJ would ensure that PS could be
available by telephone for persons testing preliminary positive. The goal of outposting PS staff
for outreach events was to make certain that the client would be immediately linked to PS and
to minimize efforts to locate clients after the testing event. The local HD initiating this strategy
experienced great success in initiating contacts and providing PS for newly diagnosed persons.
- Jon Stockton
Olympia, Washington
Partner Elicitation: In most States, public health agencies have legal authority for
conducting partner notification. However, in many States, non-clinical HIV testing and
linkage providers may be permitted to elicit partners from HIV-positive clients, and then
forward partner contact information to the public HD.
If you elect to have HIV testing and linkage staff conduct partner elicitation, develop
policies and procedures to address this, including the process for forwarding
information to the public HD. There may also be training or certification requirements
associated with conducting partner elicitation. Contact your State or county public HD
for additional information.
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Clients Previously Diagnosed With HIV
You may find that you sometimes perform HIV testing for individuals who have already been
diagnosed with HIV. Previously diagnosed clients may disclose knowledge of their HIV status
to testing staff before or after testing. The strategies described above may also be used to
help link previously diagnosed individuals to care.
While ARTAS was specifically designed for and evaluated for use with newly diagnosed
individuals, some HIV testing and linkage providers are adapting this for use with previously
diagnosed individuals. Carefully evaluate an intervention for suitability in meeting the specific
needs of clients and evaluate the adaptations. Information about adapting interventions is
available in the Resources section of the Toolkit.

Staff providing services to previously diagnosed individuals might find it useful to assess the
specific issues and challenges associated with a client’s willingness or ability to initiate or
continue HIV medical care. This will help to ensure that a previously diagnosed client receives
the kind of support needed to successfully enter (or reenter) HIV medical care.
Some previously diagnosed clients may be very reluctant to enter care or have particularly
complex issues which prevent them from entering or remaining in care. Effectively addressing
these issues may be beyond the capacity of your agency. Identify and form relationships with
other resources, such as enhanced linkage programs or patient reengagement programs that
can provide clients with needed support. Linkage policies and procedures can specifically
address linkage for previously diagnosed individuals.
Pregnant Women
Pregnant women who are diagnosed with HIV infection can be linked to specialty medical
care so that they can receive appropriate HIV medical treatment and obstetrical care and
prevent perinatal transmission. Your program, particularly if it targets a population which
includes women of childbearing age, might find it useful to identify and form relationships
with HIV medical providers who can provide appropriate care to pregnant women, including
prenatal care. In some communities, this might include other agencies that have linkage
programs specifically for HIV-positive women who are pregnant. Your referral and linkage
policies and procedures can address linkage for HIV-infected pregnant women.
Adolescents
Adolescents may present a particular challenge with respect to linkage to HIV medical care
due to a variety of factors, including limited health literacy, lack of understanding of the
health care system, fear of revealing their HIV status to parents or guardians, or lack of health
insurance. Both adult and pediatric HIV clinics typically treat HIV-positive adolescents.
However, there is some evidence that teens treated at pediatric clinics are more adherent to
antiretroviral therapy when compared to teens treated in adult clinics.2
Your program,
particularly if it targets a population which includes adolescents, might find it useful to
identify and form relationships with HIV medical providers who can competently address the
HIV medical needs of adolescents. In some communities, this might include other agencies
that operate linkage programs specifically for adolescents. Linkage policies and procedures
can address linking adolescents to such services.
The following example comes from Los Angeles, where a youth-specific linkage program is in
place to improve linkage among youth aged 12 to 24.
2
Agwu, A. L., Siberry, G. K., Ellen, J., Fleishman, J. A., Rutstein, R., Gaur, A. H., et al. (2011, November 7). Predictors
of highly active antiretroviral therapy utilization for behaviorally infected HIV-1-infected youth: Impact of adult
versus pediatric clinical sites. Journal of Adolescent Health. doi:10.1016/j.jadohealth.2011.09.001

The Strategic Multisite Initiative for the Identification, Linkage, and Engagement in Care of
Youth with Undiagnosed HIV Infection (SMILE in CARING for YOUTH) is a youth-focused (12 to
24 years of age) collaboration between CDC, National Institute of Child Health and Human
Development of the National Institutes of Health, and the Adolescent Trials Network. The Los
Angeles County Department of Public Health, Division of HIV and STD Programs, and the local
Adolescent Medical Trial Unit, Children’s Hospital of Los Angeles (CHLA), have collaborated to
implement this program since 2009.
The department of public health has established an explicit data sharing plan directly with
CHLA’s linkage specialist in order for her to follow up with eligible HIV-positive youth through
their HIV testing site. The linkage specialist only has access to testing data and is the only
individual with access to client-level data (CHLA cannot view the data). The linkage specialists
contacts the testing sites to determine the disposition of each youth and offer assistance for
linking HIV-positive youth to care if they have not already been linked. In addition, the linkage
specialist also developed memoranda of understanding with HIV testing providers so that they
can refer HIV-positive youth directly to her for further support and linkage to care activities. The
linkage specialist provides client-centered counseling, meets with clients, provides transport,
accompanies them to appointments, and provides follow-up services. She links clients to care at
youth-friendly and competent HIV specialists in Los Angeles County.
This program has improved linkage to care among youth in large part because of the strong
relationship between the hospital, linkage specialist, the public health department, and
community-based HIV testing providers. As the program becomes more successful and gains
trust in the community, there has been an increase of HIV testing providers referring young HIV-
positive clients to the linkage specialist. We look forward to the success of this program and
intend to replicate or expand the successful parts of this project with all individuals.
- Sophia Rumanes
Los Angeles, CA
Incentives
Client incentives may be useful in encouraging clients with a positive HIV test results to enter
or reenter medical care for HIV. The HIV Prevention Trials Network study 065 (HPTN 065) is
being conducted to assess the feasibility of a community-level testing, linkage to care, plus
treatment strategy (TLC+). Component strategies, including linkage to care, are being
evaluated for effectiveness. Included in this study is the evaluation of use of financial
incentives to increase successful linkage to care. A newly diagnosed client is given a gift card
for completing confirmatory testing at the site where HIV medical care is provided and
another gift card at the completion of an initial visit for evaluation with a medical care
provider. Anecdotal data from one site suggests that financial incentives facilitate entry into

care.3
Additional information on HPTN 065 is available on the HPTN Web site at
http://www.hptn.org/research_studies/hptn065.asp.
If your agency decides to use client incentives in conjunction with referral and linkage
activities, it is important that the incentives used are appropriate to the client population.
Obtain client input regarding incentives, specifically the form of the incentive (e.g., gift card),
its value, and when and how it will be provided (e.g., at the completion of the initial medical
visit). Your linkage policies and procedures can specifically address use of incentives,
including how incentives will be purchased, secured, and tracked. Sample procedures for
using client incentives are available as Template 1 in Appendix D.
selection of strategies to facilitate linkage to care. Incentives are discussed in greater detail in
Chapter 3: Targeting and Recruitment. Refer to this section of the Implementation Guide to
learn more about different types of incentives and the factors you may consider in
determining whether or not to use incentives.
incentives, such as cash. Check with your State, local HD, or your funder to learn about
applicable policies or requirements.
Referral and Linkage for HIV-Negative Clients
High-risk HIV-negative clients may benefit from additional risk-reduction services. Provide
high-risk HIV-negative clients with a brief behavioral risk-reduction intervention during the
testing visit, if feasible. It may be more appropriate to refer them to a program that can
provide these services. However, some clients will benefit from additional risk-reduction
services, including behavioral interventions. Your agency may or may not be able to provide
risk-reduction services onsite.
For high-risk HIV-negative clients, conduct a more in-depth discussion and exploration of
client needs relative to risk reduction in the context of referral assessment and planning. The
referral assessment is useful for identifying important factors implicated in their HIV
acquisition risk and the services most appropriate to address these factors. Referrals can be
made in response to the findings of this assessment, and as your agency capacity and local
resources allow.
The most important factors implicated in HIV risk will be specific to the target population and
individual clients. The capacity to provide services to address these factors will also vary
locally.
3
Project Inform. (2011, August). TLC+: Best practices to implement enhanced HIV test, link-to-care, plus treat (TLC-
Plus) strategies in four U.S. cities. San Francisco, CA: Author. Retrieved from
http://www.projectinform.org/pdf/tlc_implementation.pdf.

Focus and prioritize referral and linkage activities: Research conducted by the Center City University
indicated that MSM most likely to become HIV infected are those that have HIV-infected sex partners
and who rarely/never use condoms. This research also indicated that methamphetamine use was
highly correlated with acquisition of HIV.
APS has an MOA with an LGBT outreach program that provides counseling and treatment support for
MSM who use methamphetamine. As a result, facilitating access to services to address this need may
be prioritized, and agency effort focused on linking such clients to substance use treatment services.
Follow-up would be conducted by APS to confirm linkage to treatment.
Referrals could also be made to intensive behavioral interventions (e.g., CRCS provided by the testing
and linkage provider) or other risk-reduction services (e.g., PrEP provided by a local health center).
However, APS would make referrals but would not follow up to confirm linkage.
Depending on your agency capacity and local resources, you may also provide assistance
with linking to these resources. Your staff may or may not have received training on a specific
referral strategy (e.g., CRCS). However, your staff can provide referrals and support linkage to
risk-reduction services, provided they have adequate knowledge of risk-reduction resources;
the skills and resources necessary to assist the client in accessing services; and sufficient time
and resources to conduct follow-up on referrals to these services. Your referral and linkage
policies and procedures can specifically address linkage for HIV-negative clients.
Choosing a Referral and Linkage Strategy
In choosing a referral and linkage strategy, consider several factors. In this section, we will
discuss these factors in detail.
Client Needs and Challenges
In order to identify the strategy that will result in linking clients to services, you must identify
the issues and challenges which facilitate or hinder referral and linkage for the target
populations. Also, seek to identify the issues and challenges which are unique to the target
populations. Addressing identification of client-perceived barriers and facilitators to linkage
as part of formative evaluation activities will help you to select the best strategy for their
target populations.
Clients with relatively complex needs or multiple challenges that make it difficult to link them
with medical care, risk reduction, or other services may benefit from more intensive and
longer-term assistance and follow-up. Linkage case management or system navigation may
be the best match to client needs. Clients that are reluctant to enter care or who are members
of a highly stigmatized population may benefit from peer outreach and support. Some
programs successfully enlist clinical staff, such as community health nurses and social
workers, in reaching out to and engaging individuals in care. In many areas, there are linkage
support services specifically targeted to HIV-infected individuals. However, hospitals,

community clinics and substance use disorder providers often offer such services to help
clients, including those who are HIV negative, engage and stay in needed services.
Agency Capacity
Some HIV testing and linkage providers also offer other services, such as medical case
management or CRCS. If this is the case with your agency, you may be able to leverage those
program resources to support referral and linkage of HIV testing clients.
Other testing and linkage providers are colocated with medical or other risk-reduction
services. In this case, clients may require less intensive support and assistance to access
services. Your HIV testing staff may have the skills and resources necessary to link clients to
colocated services.
Community Resources
In some communities there may be other resources available to assist your clients in linking to
services, such as patient navigators affiliated with HIV medical care programs or outreach and
peer support programs offered by another organization in your community. Some
communities may also offer population-specific linkage assistance (e.g., formerly
incarcerated), which may be of benefit to clients. Become familiar with other referral and
linkage resources in the community. This will ensure that your clients have access to the kinds
of support and assistance best suited to helping them to successfully link to medical care, risk
reduction, and other services. It will also help your HIV testing and linkage providers to make
the most effective use of your agency’s resources.
It is unlikely that one single referral and linkage strategy will result in successfully linking all of
your clients to needed services because clients have complex and evolving needs and unique
challenges. For this reason, consider using a mix of referral and linkage strategies. HIV testing
staff or staff members that function specifically as linkage coordinators may successfully
deliver some strategies. Other staff within your agency may be able to deliver other
strategies, such as medical case management. Partnership with other providers or agencies in
the community may be required to deliver other strategies, such as assistance in reengaging
individuals who have not been retained in HIV medical care. The following case study details
New Jersey’s approach to improving linkage to care and coordination of services through a
multiprovider collaborative.
The New Jersey Department of Health and Senior Services (NJDOH) has begun implementation
of the Patient Navigators Program. The idea for the patient navigation came of out of New
Jersey’s HIV planning group (HPG). In 2010, the NJ HPG formed the Collaboration and
Integration Workgroup, which was charged with identifying strategies to support and
encourage program coordination and service integration (PCSI). One of the first issues this
workgroup addressed was HIV testing in non-clinical settings. At the time, community-based
providers in New Jersey were conducting HIV testing using rapid tests. Clients having a reactive

rapid test results needed to have confirmatory testing by Western blot, to confirm an HIV
diagnosis. This meant that clients had to wait five to seven days for supplemental test results
and then had to return to the agency where they were tested to learn their results and receive a
referral to HIV medical care. The workgroup realized that many patients were not returning to
testing sites to learn their final test results and, as a consequence, were not receiving referrals to
or getting linked with HIV medical care.
The HPG Collaboration and Integration Workgroup’s findings resulted in action by NJDOH to
breakdown long-standing prevention and care silos and mobilize the State’s HIV Test and Treat
initiative. In the same way, the group focused on integrating HIV, STD, TB, and viral hepatitis
services and acknowledging HRSA’s and CDC mandates on identifying new positives and
linkage to care. The workgroup moved to integrate HIV prevention, care, and support services
beyond the planning level into a strategic operational approach. Its vision was to get key
stakeholders committing to collaborate on increased access to care. The HPG recommended
electing three individuals to represent NJ in the north, central, and southern parts of the State to
serve as regional at-large representatives. Ultimately, NJDOH’s goal is to link every non-clinical
HIV testing site to a second different rapid test for confirmation of a positive within a clinical site
and an immediate linkage to care (same or next business day), promoting unfettered access to
HIV care.
Collaboratives formed to make effective linkage a reality on the local level. Each collaborative
has among its members diverse representation from service providers in that region, including
AIDS service organizations, CBOs providing HIV testing, community health centers, substance
abuse prevention and treatment providers, mental health service providers, and other health
and social service providers (e.g., food and nutrition services, housing assistance). Diversity in
membership in the collaborative ensured coordination and seamless provision of health and
other support services needed by clients in each of the regions.
New Jersey’s first regional collaborative was implemented in a three-county area of
southeastern New Jersey, anchored by Atlantic City. AtlantiCare, southeastern New Jersey’s
largest health care provider, serves as the lead agency and clinical hub for this regional
collaborative. Jean Haspel, an advanced practice nurse with AtlantiCare’s Regional Medical
Center’s Infectious Disease Services, serves as the lead convener behind this regional
collaborative. Haspel led the formative work, beginning in November 2010, inviting and
encouraging providers from the surrounding three (Atlantic, Cape May, and Cumberland)
counties to participate in the collaborative. She ensured that the appropriate people—decision
makers—were invited to and participated in the collaborative enabling the collaborative to act
quickly and efficiently in addressing identified issues and challenges.
In addition to AtlantiCare, this regional collaborative includes representation from three
federally qualified health centers (FQHCs), all of the CBOs providing HIV testing, drug treatment
providers, and community-based providers of food/nutrition services. The collaborative is
working actively to expand membership to include two additional FQHCs, mental health service
providers, and providers of housing and transportation services.

NJDOH currently funds six patient navigators statewide. To support the patient navigators, the
NJDOH established the regional collaboratives to ensure “no patient would be left behind”, that
all individuals living with HIV would have access to and receive support and be engaged in the
continuum of services to address their health and psychosocial support needs. Key was
eliminating the Western blot confirmatory test that took 5 to 7 days for results, and introducing
rapid testing to New Jersey eliminated a major barrier to testing, receiving results and
immediate linkage to care. The patient navigator closed the loop with a focus on partner
services, engagement, adherence and reengagement through collaboration. Participating
agencies sign a single MOA which outlines the goals for the collaborative and participant roles
and responsibilities within the collaboratives.
Even while the collaboratives continue to grow and evolve, they have developed an approach to
address the linkage to care issue identified by the Collaboration and Integration Workgroup—
linkage to and retention in care among individuals living with HIV. The model of care
coordination put into use as a result of regional collaboration implementation includes the
following:
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Community-based testing providers will refer clients to AtlantiCare for HIV medical care on
the basis of an initial, single reactive rapid test result.
Testing providers will actively assist clients to access care.
Clients will be provided with “red carpet treatment” at the care facility to expedite entry to
care (the goal is same or next business day appointments).
A patient navigator (who must, minimally, have a bachelor’s degree in social work,
psychology, public health, or be a registered nurse) performs a second rapid test. If that
second rapid test is reactive, the patient navigator will also arrange for supplemental
testing, including CD4 and viral loads, along with screening for gonorrhea and syphilis.
The patient navigator will link clients with a medical case manager.
The patient navigator will schedule follow-up patient appointments with physicians.
Appointments are typically available within 1 week.
Because CBOs are critical to ensuring engagement in care, the patient navigator will work
with CBOs to follow up on patients who are out of care. Patients will be asked to sign a
release of information, which permits participants in the collaborative to share
information necessary to facilitate care coordination.
The NJDOH and the HPG are working actively in the remaining clinical sites to get the patient
navigators up and running. However, there are important lessons to be learned from the efforts
to establish this first patient navigator:
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Have patience and be persistent—building relationships that will be productive and
sustainable takes time.
You must have decision makers at the table in order for the collaborative to work
effectively and efficiently.
You must acknowledge turfism and territorialism and address this directly, and probably
on an ongoing basis.

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You must to define procedures, and identify a point person to deal with issues and
problems that affect service provision, so that that they can be proactively addressed and
do not fester.
The HPG is a critical component to the success of the collaborative. The involvement of the
HPG helps keep everyone focused on the fact that we are all on the same team and that
we share the goal of improving services and ensuring access to care.
The impact of the collaboratives and the patient navigation relative to enhancing linkage and
facilitating care coordination will be evaluated. Currently the NJDOH is developing an
evaluation plan which is expected to examine initial engagement and retention in care;
adherence to ARV; testing of partners and community viral load. Examination of the root causes
as to why people drop out of care is also a priority.
- Loretta F. Dutton
Research Scientist
New Jersey Department of Health and Senior Services
Division of HIV, STD and TB Services
Trenton, NJ
The results of your formative evaluation activities may also factor into your decisions
regarding selection of referral and linkage strategies. Additional discussion of formative
evaluation is presented in Chapter 2: Getting Started—Preparing to Implement HIV Testing
and Linkage in Non-Clinical Settings. In particular, review the section titled Formative
Evaluation and Implementation Planning. Tools that will help you to identify and select
referral and linkage strategies are also included in that section.
Community Partnerships and Referral
Resources
Identify resources and work both within your own agency and with other community
partners to ensure that clients have access to and can receive needed services. In order to
develop appropriate referral and linkage systems, do the following:
Assess Referral and Linkage Needs: Identify the referral needs for your target
population. Consider the factors most likely to influence the risk for acquiring or
transmitting HIV. Identify the specific challenges and issues that impede successful
linkage to services. Consider input on referral and linkage needs from
consumers, elicited through formative evaluation;
current clients;
HIV testing and linkage staff;
other providers serving the target population(s);
funders may also have specific requirements regarding referral and linkage.
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Assess Agency Capacity: Identify services that are or can feasibly be delivered by your
agency. Consider if the services that are provided by your agency are appropriate to and
can meet client needs, and can effectively address the factors that influence risk for HIV
transmission and acquisition. Ease and proximity should not dictate where clients are
referred for services.
Identify Referral and Linkage Partners: Identify appropriate partners to address
identified needs. In selecting appropriate partners, consider client acceptability. Clients
must find the partner agency and the services that it offers acceptable in terms of
accessibility (i.e., location, wait time, availability of appointments, costs),
confidentiality,
cultural, linguistic, and developmental appropriateness.
Depending on the needs of the clients and the capacity of partners, you may require two or
more partners to provide needed referral and linkage services. Input from consumers, clients,
and staff aid in assessing acceptability of potential partners.
4. Establish Partnerships: Assess partner agency capacity for providing services resulting
from referral and linkage activities (i.e., Can they handle an increased volume of clients?).
Gauge their willingness to enter into a partnership (e.g., Will they accept appointments
from your agency? Are they willing to participate in monitoring the success of referral and
linkage activities?)
Hold joint program orientations with referral and linkage partners. Include all staff involved in referral
and linkage staff, not just supervisors or program managers. This can help ensure that staff providing
referral and linkage services have a mutual understanding of available services, expectations for
partnership, and can become familiar with each other and can begin to build relationships.
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5. Operationalize the Partnership: Regardless of whether partners are internal (i.e.,
another department in your agency) or external (i.e., another agency in the community),
clearly articulate the expectations for the partnership, as well as the processes and
procedures that will be used to make referrals and facilitate linkage.
Formalize key partnerships with MOA/MOU. MOA/MOU help to ensure that roles and responsibilities of
partners are clear and that clients receive needed services. Key partnerships are those that provide
essential services for your clients (e.g., HIV medical care) on a regular and ongoing basis; in which
each partner has specific responsibilities (e.g., expediting client appointments); or through which
resources or information is shared (e.g., data to confirm linkage).
It is important that HIV testing and linkage providers formalize key referral relationships with
MOA/MOU. MOAs are statements of commitment between partner agencies or organizations
to collaborate or coordinate on a program. This agreement delineates the expectations for

the partnership, along with specific roles and responsibilities of partners. An MOA/MOU for
referral and linkage can address the following:
The specific services to be provided by each partner (e.g., HIV medical care; CRCS)
How services are to be provided (e.g., referral clients will receive expedited
appointments)
What information/data will be shared and through what mechanisms or processes (e.g.,
confirmation of linkage by return of referral forms)
How and when partners will communicate (e.g., monthly meetings)
Parties responsible for monitoring the partnership for each partner agency
Partnership agreements can be reviewed for renewal at least annually. A sample MOA/MOU is
available as Template 4 in Appendix D.
Referral Resource Guide
HIV testing and linkage clients may have a wide range of referral needs. Many of these referral
needs can probably be addressed through referral and linkage to a small number of main
partners. It may be helpful, however, to have information about a variety of community
resources, and staff should have knowledge of these resources. A referral resource guide is
one tool for organizing and presenting essential information about referral resources.
It is essential that the information contained in the referral resource guide be relevant to
addressing client needs. A referral resource guide can include the following:
Name of provider/agency
Services provided, including culturally appropriate services
Populations served
Culturally specific services
Location and service area
Cost of services
Eligibility requirements
Appointment procedures
Hours of operation
Location/travel instructions, including accessibility by public transportation
Name of a specific contact person, with telephone, fax, and e-mail address
It is important that the referral resources be kept up to date, and the entire resource guide be
reviewed periodically (e.g., biennially) to verify information about referral providers.
It is essential that your referral resource guide be appropriate and accessible to all of your
staff. Discourage individual staff from keeping their own repository of resources and contacts.
A good referral guide is centralized to the organization and not to individual staff.
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Keep referral resources up to date and inform all staff about these resources. It is essential for
HIV testing and linkage staff to discuss referrals and share information about referral providers. This
will help to ensure that your resources are kept up to date, issues and concerns with partner agencies
are identified and addressed proactively, and client needs can be appropriately addressed. Making
referral and linkage a regular agenda topic for staff meetings or case conferencing activities can
facilitate discussion and sharing information.
Documenting and Monitoring Referrals and
Linkage
Documenting Referrals
It is important for your staff members to document all referrals made for an individual client.
Referrals can be documented in the client chart, and the following information about the
referral(s) may be noted:
Date of referral
Name of testing and linkage staff making the referral
Type of referral
Referral provider
Assistance and/or incentives provided to help the client complete the referral
Date of completed referral (i.e., linkage was accomplished), if applicable
Reasons that the referral did not result in linkage (e.g., client feedback on challenges to
accessing services or satisfaction with services), if applicable
If a referral requires follow up to ascertain whether the client was successfully linked to
services, a copy of the authorization of release of information may also be included in the
client chart.
A referral log is used by some agencies to document, in a centralized tool, referrals made and
to track the status of referral completion (i.e., linkage). Instead of—or sometimes in addition
to—recording referral information in client charts, referrals made by all testing and linkage
staff are recorded in a single location. A referral log can facilitate follow-up of referrals, such as
when one staff member contacts a referral provider to follow up on all referrals made to that
provider, instead of having individual staff members follow up individually on the referrals
they made. If you use a central referral log, use a code or unique identifier instead of a client’s
name to ensure confidentiality.
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Monitoring Linkage
Your agency will need to confirm completion (i.e., linkage) for some referrals that you make.
This is particularly important, as it relates to HIV medical care for clients who are living with
HIV. The main strategies for assessing whether clients are linked to services are client self-
report and confirmation from referral providers.
Client Self-Report: You may sometimes have ongoing contact or interactions with clients,
such as if a client is participating in CRCS. The next contact with a client after a referral is made
provides an opportunity for asking the client whether he or she was linked to the service. This
also provides a good opportunity for obtaining clients’ feedback about any challenges they
encountered and their satisfaction with the services received. While client self-report is an
acceptable means to confirm linkage, clients sometimes tell us what we want to hear rather
than what actually happened. For this reason, provider confirmation is a more ideal means to
confirm linkage.
Provider Confirmation: Provider confirmation of linkage is a more objective way for
confirming linkage. There are various options to confirm linkage:
Telephone or E-mail Confirmation—In this case, the referral provider is contacted by
your HIV testing and linkage staff and asked to confirm linkage. It is recommended that
only specifically authorized staff at the referral agency provide confirmation of linkage.
In the case of linkage to medical care, a physician, clinical social worker, or nurse
practitioner is the appropriate authorized party.
Tip
If you intend to confirm linkage via telephone or electronic communications, linkage policies and
procedures must specifically address how the confidentiality and security of such transmissions will be
ensured in compliance with State/local policies or regulations and the Health Insurance Portability and
ountability Act.
Referral Forms—Referral forms or similar tools, such as “kick-back” cards, can be used so
referral providers can confirm that clients received referral services. Staff initiating the
referral process may complete the paper form. The referral provider then returns the
form (e.g., via mail or secure fax) upon successful linkage. A sample referral form is
provided as Template 5 in Appendix D. An advantage of referral forms or similar tools is
that they can provide clients with a reminder about the referral, such as the time and
date of their appointment. However, such forms can also be easily misplaced by clients.
Acc
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If any client-identifying information is to be shared between agencies, confidentiality must be
observed and a written release of information obtained from the client.
Data from laboratory reporting of CD4 and viral load tests can help to verify entry into HIV
medical care. These data can provide useful information for evaluation of the success of
referral and linkage activities. These data may not be available to your agency at the client

level due to confidentiality protections. Exceptions may be when clients receive HIV medical
care within the same agency that provided testing. Contact the State or city HD for additional
information.
Quality Assurance of Referrals and Linkage
Develop written policies and procedures for referral and linkage activities and ensure that
staff members have the training necessary to perform referral and linkage activities. Some
HDs provide training on and/or have tools available for conducting QA of HIV testing and
linkage programs.
Training
Ensure that staff4
conducting HIV referral and linkage has received training appropriate to
their responsibilities:
It is important for staff performing referral and linkage to receive training and education
on the following:
Referral and linkage planning and management, including the specific steps in the
referral and linkage process, as defined in agency policies and procedures
Evidence-based linkage model (e.g., ARTAS), if applicable
Properly and accurately documenting all aspects of the referral and linkage process
and maintaining confidentiality
Obtaining authorization for release of information
Factors that influence a client’s willingness or ability to use referral services
Community resources necessary to meet client needs
Proficiency
It is important that staff conducting HIV referral and linkage be evaluated to demonstrate
proficiency in assessing referral and linkage needs, planning and managing referrals, and
conducting follow-up to verify clients successfully completed referrals. Direct observation of
sessions with clients is an effective strategy to assess proficiency. If direct observation is not
possible, role-plays are an alternative strategy for assessing proficiency. Client charts may also
be reviewed to assess the extent to which referrals were appropriate to client needs, whether
and what type of assistance was provided, and whether referrals were successful (i.e., the
client was linked to services).
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Specific QA strategies are described in Chapter 9: Quality Assurance and Monitoring and
Evaluation. Please refer to The Quality Assurance Plan for a discussion of how each strategy is
most appropriately used. It might be useful for staff to be observed at regular intervals (e.g.,
annually), and more frequently after initial training (e.g., monthly for the first 3 months).
Documentation and Record-Keeping
Your agency will need to keep documentation of the following:
Staff training and proficiency assessments, including orientation to referral and linkage
policies and procedures
Referrals made and linkage verified
Authorizations for release of information
Client satisfaction with services to which they were referred/linked
Incentives, if applicable
Conduct reviews of client charts regularly (e.g., annually) to evaluate their completeness and
accuracy relative to referral planning and management and more frequently after initial
training (e.g., monthly for the first 3 months). Sampling (e.g., a random sample of five charts
for each testing staff member) is appropriate if it is not feasible to review all client charts.
Additional information on documentation and record keeping is presented in Chapter 9:
Quality Assurance and Monitoring and Evaluation (refer to the section titled The Quality
Assurance Plan).
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referral and linkage strategies are successful in linking clients with needed services. By
evaluating the extent to and ways in which referral and linkage strategies help you to achieve
program goals and objectives, you will be able to refine practices to ensure that the needs of
your clients are met.
evaluate HIV referral and linkage practices. Tools are also included in that section to help you
conduct a yield analysis to better understand how well your program is working (including
use of various referral and linkage strategies), and to guide you in discussions about program
improvement.

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Chapter 8. HIV Testing in Outreach
Settings
This chapter addresses HIV testing and linkage services in outreach settings. In this chapter
we discuss the following:
Overarching considerations associated with providing HIV testing and linkage in
outreach settings
Steps and issues to consider in planning to conduct testing in an outreach setting
Different kinds of outreach settings and venues, including the benefits and drawbacks
of each
Planning for implementation of HIV testing and linkage in specific kinds of outreach
settings, including:
Mobile testing units
Large community events
Other venues such as parks, bars, and bathhouses
Building relationships with gatekeepers and other partners needed to support HIV
testing and linkage services in outreach settings
Quality assurance of HIV testing and linkage services in outreach settings, including
training and assessing staff proficiency
Monitoring and evaluation of HIV testing and linkage in outreach settings
Assess and build community support for HIV testing in outreach settings
Plan for implementing HIV testing and linkage in outreach settings
Please note: This chapter is designed to complement—but not replace—other chapters of
this guide. Refer to other chapters for additional, detailed information on various aspects of
HIV testing and linkage.
As a result of your formative evaluation, you will have collected data that you need to identify
the specific venues or settings in which to provide non-clinical HIV testing and linkage
services to your target population, as well as the recruitment strategies that will most
effectively engage your target population. If you are reading this chapter, you have likely
decided that using a mobile van or conducting HIV testing in a venue such as bar or club is
the best way to reach your target population.

In this chapter we explore and provide guidance for HIV testing in various types of outreach
settings, including large venues (e.g., health fairs and gay pride events); mobile units; and
other outreach settings such as public sex venues (e.g., bath houses, parks, bars), churches,
and shelters. This chapter is designed to complement—but not replace—other chapters of
this guide. Refer to other chapters for additional, detailed information on various aspects of
HIV testing and linkage, including planning for implementation of HIV testing and linkage
programs (Chapter 2); selecting recruitment strategies (Chapter 3); selecting testing strategies
(Chapter 5); implementing HIV testing, including procedures for performing testing and
universal precautions (Chapter 6); and ensuring quality assurance (Chapter 9). Similarly, the
tools included in this chapter are intended to complement—and not replace—tools
presented in other chapters. For example, you should not use the planning tool included in
this chapter in place of the planning tools included in Chapter 2.
HIV testing and linkage services involve the same basic activities, regardless of the setting or
venue in which the services are provided:
Plan your HIV testing and linkage strategy
Recruit clients
Conduct HIV testing
Deliver results
Provide referrals/facilitate linkage
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Overarching Considerations for HIV Testing in
Outreach Settings
The way that you conduct these activities in an outreach setting will be a bit different than
the way that you conduct these activities in your agency. Conducting testing in outreach
settings requires some adjustments in the way that you plan for implementation, such as
setting up your site, packing up/breaking down your site, and adjusting QA procedures. Since
you will be operationalizing testing and linkage services somewhat differently than you
would in your agency, your staff/volunteers may also require a slightly different set of skills or
knowledge to conduct services.
Please bear in mind that the information and tools provided in this chapter will likely need to
be tailored to the specific settings or venues in which you are providing testing and linkage
services. It is highly unlikely, for example, that the implementation plan and associated set of
procedures that you develop for testing at a health fair will also work for HIV testing that you
conduct at bathhouse. If you are providing services in venues which are similar, such as
several bars, each may require a slightly different plan of implementation owing to
differences in the physical environment (e.g., size, lighting, number/placement of doors,
clientele, flow of patrons).

Planning
If you are conducting HIV testing in an outreach setting, you are providing services in a
setting or venue which is owned by someone else, or over which someone other than you has
authority. A critical first step in outreach-based testing is establishing trusting relationships
with the individuals or entities with the authority to provide you with access to particular
venues or settings (i.e., venue gatekeepers). For example, if you want to provide HIV testing
and linkage services in a specific bar or club, you will need to obtain the permission of the
owner or manager. You will also likely need the cooperation of bartenders, bouncers, or
others to conduct HIV testing in that venue. Members of the target population, other service
providers, or other stakeholders act as community gatekeepers and may be instrumental in
facilitating introductions to and in establishing your credibility with owners or other
authorities.
Public environments, such as parks, typically require you to obtain permission from local
government authorities, such as a county commission. In working in public venues, it is also
important that you establish a relationship with and maintain ongoing cooperation with local
law enforcement officials. This is particularly true if you are providing services in an
environment in which illegal activities, such as drug selling or sex work, occur. The
cooperation of law enforcement will help to ensure that participation in testing services does
not put clients at risk for arrest, and it will also ensure the safety of your staff. Public
environments may also require that you obtain permission from neighborhood associations
or other quasi-governmental entities. In identifying individuals or entities with which you
need to establish partnerships, look to your community or consumer advisory board, staff,
volunteers, and partner agencies to help you to identify the individuals and entities that you
need to target and suggest strategies that will help you to successfully gain access to various
settings and venues.
Building relationships needed to gain you access to various settings and venues may often be
a long process, requiring months or even years to effect. To gain entry to a particular venue or
setting, you need to do the following:
Establish your credibility with those individuals or entities that control access: You
need show that you are a trusted partner in the community and that your services will
provide a concrete benefit to the community. Members of the target population, staff,
and community partners can be instrumental in demonstrating that you are trustworthy
and will be a good partner.
Persuade venue gatekeepers about the need for HIV testing services and the value
of doing so in a particular venue or setting: Some business owners, community
members, or officials may be skeptical that HIV testing services are needed or may not
be aware of the impact of HIV in their community. Others may be concerned that
providing HIV testing services will drive clients away or interfere with business. Others
may hold misconceptions about HIV testing and linkage services, and by consequence,
have unfounded fears (e.g., HIV testing services will bring drug users to their
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neighborhood). Many may not understand what will be involved in HIV testing in a
particular venue and setting, and you will need to explain what those services might
look like.
Consult with venue gatekeepers in the planning of outreach HIV testing services,
and maintain open communication with them before outreach HIV testing
activities/events: Consult with gatekeepers in planning your outreach testing activities.
They can help you to understand their particular setting, make suggestions about how
and where you HIV testing services can be provided, and facilitate the cooperation of
others that will ensure that you have a successful outreach testing event. Gatekeepers
may also have conditions for you, such as not conducting HIV testing onsite or not
conducting testing with blood samples. It is important that you honor these conditions.
Over time, as you gain trust and experience, it may be possible to renegotiate.
Follow-up with gatekeepers after an outreach HIV testing event: Plan on following
up with gatekeepers subsequent to outreach testing events, or if outreach testing at a
particular venue is outgoing, at regular intervals (e.g., monthly). This will allow you to
obtain feedback from gatekeepers about how well the event went, any concerns that
they have, and suggestions for improvement. It will also allow you to provide feedback
to gatekeepers about the value of HIV testing services in that venue (e.g., the number of
high-risk individuals tested or number of new positives identified).
Write a note of thanks to gatekeepers, event organizers, or managers/owners of venues after outreach
events. Expressing your appreciation to gatekeepers and other partners will help them understand how
much you value their cooperation and the value of their partnership. You can also use it as an
opportunity to share with them what was accomplished through the event and to solicit feedback from
them.
Review with gatekeepers the need to/value of continuing services in their
venue/setting: Monitor the productivity of HIV testing at individual sites on a regular
and ongoing basis (see Chapter 9, the Yield Analysis section for additional information
and tools to help you to monitor site productivity) to help you identify the extent to
which various HIV testing sites are contributing to achievement of your program
objectives in terms of high-risk clients tested, identification of HIV-positives, and linkage
to care. If a particular site is productive, this may speak to the need to continue or
expand services at that site. Monitoring data may help gain the cooperation of the
gatekeeper for this. On the other hand, the site may not be as productive as anticipated.
In this case, monitoring will help you to explain to the gatekeeper why you will be
discontinuing or scaling back HIV testing services.
In the following textboxes, Ainka Gonzalez describes AID Atlanta’s partnership with a local
bathhouse, and José De La Cruz explains how the Desert AIDS Project engages the
community to build partnerships, recruit volunteers, and extend organizational reach.
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Providing services in bathhouses can be an effective way to reach members of your target
population if bathhouses are popular meeting places for high-risk MSM in your community. In
planning to provide testing and other prevention services, AID Atlanta found it essential to work
with the general manager (GM) of the bathhouse. The management was very supportive of AID
Atlanta and of HIV and STD testing and prevention. They strongly encouraged staff and
customers to take advantage of the services we offered. The bathhouse already had condoms
available, but the management was interested in the information and resources about services
that AID Atlanta could provide.
The GM facilitated our accessing the bathhouse and encouraged staff and patrons to take
advantage of the services we offered. The GM did, however, give AID Atlanta some specific
conditions for providing prevention and testing services. Some of the rules were that all testing
must be done by men, as women were not allowed in the club. Because of this, we had to ensure
we had enough male staff available before scheduling a testing event. Also, when we used
blood testing for HIV or syphilis, we had to deliver results offsite. This was out of consideration
for the business and to ensure the safety of all patrons. In some cases, the STD staff would meet
with those men who were tested at other locations and give them their HIV test results. When
planning to introduce programs in this environment, your agency should work closely with
managers and clients in order to ensure appropriate and effective services are provided.
- Ainka Gonzalez
Prevention Programs Manager
AID Atlanta
Atlanta, GA
At Desert AIDS Project (D.A.P.), although we employee several paid staff in our Education,
Testing & Prevention Department, we rely on the dedication of between 20 and 25 volunteers to
support our efforts. In fact, D.A.P. remains one of the few AIDS Service Organizations in
California able to staff its free and confidential testing sites almost exclusively with volunteers.
Trained and certified through the California State Office of AIDS, our Testing Program volunteers
made a vital contribution to our ability to continue HIV testing free of charge without
substantial interruption following the 2009 California State HIV/AIDS Program budget cuts.
Our Volunteer Coordinators leverage many different partnerships to identify volunteers.
Knowing the benefits of our services, many of our volunteers are former and current clients,
former staff or interns, members of our agency’s target populations, residents of our service
area, professionals in the healthcare field, or associated with our clinical and social service
collaborators. By building relationships with community partners such as homeless shelter and
substance abuse facility case managers, resort managers, leaders of community non-profit
organizations, faith-based and other community leaders, we build trust and credibility in the
community. This not only grants us access to provide services at these venues but also
introduces us to community members willing to serve as volunteers. The donation of volunteer
time represents a significant monetary savings while increasing our ability to serve and

interface with the community. In addition, experience teaches us that at-risk individuals are
more likely to talk to and take advice from prevention education and testing volunteers who are
part of their community rather than “outsiders”. Ultimately, this networking extends our
organizational reach despite limited resources while cultivating in volunteers a sense of pride
and accomplishment for contributing to their own sense of well-being.
- José De La Cruz
Community Health Educator
Desert AIDS Project
Palm Springs, CA
Implementing HIV Testing in Outreach Settings
Planning HIV Testing in Outreach Settings
If providing HIV testing in a community venue or outreach setting, visit the location in
advance of a testing event to do the following:
Get a clear picture of the environment in which you will be conducting testing. This
is especially important to do before the first time that you conduct an HIV testing event
at a particular venue or setting. It helps you to understand the best way to manage
client flow, as well as how and where to engage clients, and identify strategies which
will ensure client privacy and confidentiality.
Identify appropriate space for HIV testing. The space in which you will be doing
testing must be appropriate to the testing strategy that you will be using. The space
must be private and ensure client confidentiality. It might also be useful for you to
identify a path by which the client can leave the testing area without having to go back
through a public area. For example, a side door of a club which opens into a side parking
lot, or a back door on a mobile unit. If you are using a rapid test strategy, you will need
to have access to a level surface and an area where food and drink are not being
consumed. For mobile units, avoid placing the van on an incline.
Understand how procedures and QA practices will need to be modified for the
setting. You will need to determine how you will need to set up for testing to ensure
that you are able to provide services that are compliant with program standards and can
meet Federal and State regulations. For example, if you are providing rapid HIV testing,
you must ensure that the lighting in the area where testing will be performed is
adequate. If it is not, you will need to plan for addressing this, such as bringing your own
lamps or other light sources. You will also need to determine whether you will need to
add the site to your existing CLIA certificate.
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Tip
When testing in outdoor venues, bring along fans. The sound generated by the fans will help to block
noise and help maintain patient privacy. Fans will also help to circulate air in a tent. If you are
performing rapid HIV tests, this may help to regulate the temperature.
If you are conducting laboratory-based testing, have a plan for sample processing
and shipping. If, for example, you are testing late at night, you need to determine how
you will store the sample and/or ensure that it is received by the laboratory for
processing in accordance with their procedures.
Ensure that you have the cooperation of others present at the site, such as
bartenders or other agencies also providing services at that site, and that
everyone understands roles and responsibilities. It is important that you establish
rapport with others who will be present at the site or in the venue prior to conducting
HIV testing in an outreach site. You may need their assistance in directing clients or in
managing difficult situations (e.g., handling an intoxicated client).
You may also need or want to coordinate services. If you are providing HIV testing
and another agency is providing other health or prevention services, such as screening
for STDs, clients may get more benefit if you coordinate your services with those of
other agencies. It is important that clients know you and others from your agency who
will be involved in HIV testing, what they should expect, and who they should come to
with questions or concerns. Knowing what services other agencies at the event can offer
can help to ensure that your clients receive other services from which they can benefit.
In the following textbox, David Ponsart explains how his CBO builds relationships with
venue management and community members to grow their collaborative partnerships
and increase referrals.
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What makes Arab Community Center for Economic and Social Services’ (ACCESS’s) efforts
unique is that we do not use display tables, matching outreach shirts, or present ourselves as the
agency conducting testing for the evening. We have a long established relationship with venue
management and patrons because the staff and volunteers of the project are in and of the
community we serve. We frequent the venues sometimes without service provision as the main
objective, but rather to build rapport with both venue management and patrons. We offer a
very client-centered, nonjudgmental, and sex-positive message and dialogue with our
community partners while we make testing and counseling available. This has led to stronger
community relationships, enhanced trust, and the ability to test for both STDs and HIV in venues
previously thought to be closed to this form of service provision. We provide condom and lube
distribution via specially created outreach packs, and written materials are available in both
English and Arabic. We have gone to great lengths to create and strengthen relationships with
other HIV service providers and frequently provide STD testing services in conjunction with the
HIV testing provided by another agency. This collaboration has resulted in an exponential
growth in collaborative partnerships and completion of referrals, as well as reduced or
eliminated duplication of services in different venues and target populations.
- David Ponsart
Counseling, Testing and Referral Manager
Community Health and Research Center,
Arab Community Center for Economic and Social Services
Dearborn, MI
Identify and plan for safety during the outreach HIV testing event. Pay extra
attention to ensuring the safety of staff providing services in outreach venues. It may be
useful for outreach testing activities to be planned and scheduled well in advance, and
supervisors should be aware of the times and locations for HIV testing events as well. As
with testing provided in an office, it is encouraged that a minimum of two staff
members be at the outreach venue at all times when HIV testing is being provided. If HIV
testing is provided in an uncontrolled environment such as a park, staff should never be
alone or out of view from other HIV testing and linkage staff while they are with clients.
Provide cellular phones and emergency contact information to staff testing in
outreach settings, and a supervisor should be on call to address emergencies,
should they arise. It is essential that staff have identification badges and distinctive
articles of clothing, such as project T-shirts, so that they can be easily identified by
clients and others, such as law enforcement officials. Additional suggestions for safety
procedures are included in Template 6 HIV Testing and Linkage Policies and Procedures,
located in Appendix D.
Plan for dealing with emergency situations. In the event that clients need crisis or
emergency services, it might be useful for staff to have information regarding 24-hour
crisis intervention services, such as hotlines or contact information of specific individuals
they can contact to get immediate assistance for clients.
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• Plan for staffing of the event. The size of the event and the layout of the venue will
impact the number of staff and/or volunteers that you will need for each outreach
event. You will need to ensure that your staffing plan is adequate and that you have
back-up plans for unforeseen circumstances, such as illness of staff. Outreach events are
often conducted after hours, so you may need to make special arrangements regarding
staffing. Work with your agency staff to determine who will be able to work an event.
Discuss overtime, compensatory time, or flex time for staff.
Ensure that at least one staff person signed up for an outreach event has experience delivering an HIV-
positive result and can be on hand to coach other employees.
Before and After an Outreach Event
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Arrival: For each scheduled testing event, arrive enough in advance of the event to
ensure that you have adequate time to properly set up the site, and to identify any
potential challenges. When you plan and advertise an outreach testing event, it is
important that you show up on time and adequately prepared. You need set up for
services early enough that it will not interfere with either your clients’ or gatekeepers’
business, or compromise the safety of your staff. You also need time to adjust your plans
to respond to any unanticipated circumstances (e.g., one of your volunteers cancelled at
the last minute, the air conditioner on your mobile van is broken).
Ordering and Packing Supplies: It is essential that all of your program staff members
who provide HIV testing services receive orientation to where HIV testing supplies and
materials are stored. It may also be useful for them to receive instructions on packing
supplies and materials needed for HIV testing in community venues and outreach
settings, including which supplies and materials are needed for which settings.
If you are conducting rapid HIV testing and will be arranging for supplemental testing for reactive rapid
test results, be sure to bring the supplies and equipment necessary to obtain and prepare samples for
supplemental testing and to properly train staff ahead of time.
Tip
When conducting outreach testing on a mobile testing unit (MTU) it is essential that you get out of the
van. Set up a table in front of the van. Walk around the block to announce your service. You should not
rely on signage. Some agencies offer condoms, lube, magazines, or other items that will attract
members of the target population to the MTU.
• Transport of Supplies and Equipment: Transport testing supplies and equipment to
and from outreach venues in an appropriate manner. If rapid HIV tests are used, the test
and control kits can be transported in an insulated bag or cooler to ensure that they
remain within the temperature range specified by the manufacturer. Incentives, if used,
may be best transported in a locked box. Take inventory of supplies, including

incentives, and equipment at the conclusion of the outreach testing event to ensure
that everything is accounted for and nothing is left behind. Please refer to Appendix D,
Template 7 for an Outreach Testing Supplies and Materials Checklist.
Hazardous Waste Disposal: You will need to plan for hazardous waste disposal. This
includes transporting used sharps or biohazardous waste. It may be necessary for you to
transport waste which is soaked in blood or other body fluids back to your agency for
proper disposal.
Storage and Management of Forms and Paperwork: Client files, testing logs,
assessment forms, and any other documents that contain confidential information
created and/or accessed at outreach events must be kept secure during transport to and
from these venues. It is essential that documents containing confidential client
information be returned to your agency offices and secured as soon as possible after
conclusion of the HIV testing event. Such information may not be left in cars or other
unsecured locations, unless absolutely necessary. Transport of forms, paperwork, and
other documents containing confidential information can be addressed in your
implementation procedures (see the section titled Policies and Procedures presented in
hapter 9: Quality Assurance and Monitoring and Evaluation for additional discussion).
ecommended Activity
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Use lock boxes or locking brief cases to store confidential documents while being transported
to and from outreach sites. If it is not possible to return confidential documents to your agency
immediately at the conclusion of an outreach event, as might be the case with very late night or
weekend outreach activities, ensure that a supervisor is aware of and has approved arrangements for
temporary storage (e.g., the site supervisor takes possession of the documents and stores them in his
home, in a lockbox) and that all confidential documents are returned to your agency as soon as
possible. You may wish to consider purchasing a locking file cabinet that is placed in a designated staff
person’s home or at a particular venue if testing regularly occurs during hours or in locations which
e it infeasible to immediately transport confidential documents back to your agency.
Supervision: It is advisable for a single individual participating in the outreach testing
event to be named as site supervisor or team lead. It is not at all unusual for unexpected
events to occur in conjunction with outreach settings. Clients sometimes become
unruly, staff may be unable to interpret rapid test results, or a client may be
experiencing a crisis. One person can have authority to make such decisions about how
best to deal with such circumstances, rather than the whole group. The person
designated as site supervisor may have direct and immediate access, such as via cell
phone, to a program manager or supervisor, should they need additional assistance or
authorization.
Before implementing HIV testing in an outreach setting, conduct a systematic planning
process. Thoughtful planning will help to ensure that you are well prepared to implement
outreach testing, and that you can provide services which are quality assured.
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Tools and Templates: Outreach HIV Testing Planning Tool
The tool that follows can assist in the development your outreach-based testing program. It will help
you to identify any challenges to implementation and plan to address these challenges.
Tool 3. Outreach HIV Testing Planning Tool
Tool 3 is designed as a guide for and a tool to document your efforts to plan HIV testing and
linkage in outreach settings or venues. Using this tool will also help you to identify potential
challenges to implementation and strategies to address these challenges. This tool
supplements—but does not replace—other planning tools included in this Implementation
Guide.
About Tool 3: The Discussion Questions for Program Planning and Implementation
correspond to key factors and issues that you need to address in planning to undertake HIV
testing in an outreach setting or venue. It is recommended that you do not begin providing
outreach HIV testing services until you have completed planning.
This tool should be completed in conjunction with discussion with staff members who
provide HIV testing and linkage, as well as others, such as consumer advisory board members
or members of your board of directors. Multiple perspectives will result in richer discussion, a
deeper understanding of program planning issues and program operations, as well as better
ideas and strategies to ensure a successful program.
How New Programs Can Use This Tool: This tool is designed to assist you in planning
outreach HIV testing and linkage activities. This tool will help you to assess community
support and identify key partnerships, assess the feasibility of providing services, and plan for
how those services can be delivered. It will help you to identify any gaps in your knowledge or
resources that will need to be addressed to ensure the success of your outreach testing
program.
How Established Programs Can Use This Tool: If you have already implemented HIV
testing, or even if you have already implemented outreach-based testing, you can use this
tool to help you to plan implementation in new settings or venues or for new target
populations.
may find this tool helpful for use with local grantees or contractors. You could use tool in
providing technical assistance to agencies that are just beginning to implement HIV testing in
outreach settings or for agencies that seem to be struggling with implementing these
services. Some HDs or other funders may wish to have grantees or contractors complete this
tool at the beginning of a project (e.g., as a component of a funding proposal) or when they
add new sites or venues.

Instructions for Completing Tool 3. Outreach HIV Testing Planning Tool
What is the purpose of this tool? Tool 3 guides and documents your planning efforts as they relate to testing in outreach
settings.
Who should complete this tool? Managers or coordinators of HIV testing programs can complete this tool, in collaboration with
staff and/or volunteers, consumer advisory board members, and others involved in planning, implementation, and evaluation of
your program.
When should this tool be completed? Before you implement services in outreach settings or before you begin testing in new
venues or with new target populations.
How should this tool be completed? In the top portion of Tool 3, record the following information in the designated cells:
Agency/Program: Record the name of the agency and/or program completing this tool.
Discussion questions relevant to planning and implementation of HIV testing and linkage in outreach settings are presented in
the left column:
Answers to Discussion Questions: Record a summary of your discussion about each of the corresponding questions in the
left column.
Strategies, Gaps, and Next Steps: Brainstorm about the strategies and practices that could best address your findings and
record them in this column. Include gaps in knowledge or resources for which you will need additional information, along
with next steps to address these gaps.
Tool 3 has been completed to illustrate how the tool may look when completed.
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Tool 3. Outreach Testing Planning Tool
Agency/Program: ACME Prevention Services, Center Point Participants:
Program • ACME Prevention Services program director
Target Population: White and African American IDUs over 30 • Center Point program coordinator
years of age living in North Center City • Center Point outreach coordinator
Date Completed: May 15, 2012
Discussion Questions for
Program Planning and Answers to Discussion Questions Strategies, Gaps, and Next Steps
Implementation
Partnerships and Community Support
Who are the gatekeepers to the
setting or venue?
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Neighborhood Association
Business Owners Association
Center City Community Drug User
Alliance
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ACME currently provides outreach in the Riverside neighborhood
and will present our plan to the Neighborhood Association at
their June meeting.
Center City Alliance currently partners with us on outreach. They
are on board with this plan.
From whom or what do we need
to obtain permission to provide
HIV testing at the setting or
venue?
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Neighborhood Association
Center City Police
Get clarification regarding whether/what authorization is needed
from CCHD for us to be able to conduct outreach testing.
How are we perceived by
potential partners? By the
surrounding community?
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Positive reputation with the
Neighborhood Association and Center
City Alliance
No relationship with Business Owners
Association currently
Police are aware of our outreach efforts
and occasionally hassle staff and
clients during outreach
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ACME currently provides outreach in the Riverside neighborhood
and will present our plan to the Neighborhood Association at
their June meeting. Center City Alliance member is on ACME
Board.
Board member is also member of Business Owners Association;
he will explore the association’s concerns and report back in May.
Executive director, board chair, and chair of Neighborhood
Association will meet with police to present plans and discuss
concerns.

Tool 3. Outreach Testing Planning Tool (continued)
Program Planning and
Implementation
Answers to Discussion Questions Strategies, Gaps, and Next Steps
Partnerships and Community Support (continued)
What are the concerns or fears
about HIV testing among
potential partners? In the
• Business Owners Association does not
want “stigma of AIDS” associated with
local businesses
• Center City Police do not want to deal
with crowd control
• ACME executive director, ACME board member, and members of
our community advisory board (CAB) will provide presentation to
Business Owners Association to persuade them of impact of HIV,
value of HIV testing, and community support for HIV testing.
• Executive director, board chair, and chair of Neighborhood
Association negotiated “trial period” with police to persuade
them that fears are unfounded.
Site/Event Assessment
Will the venue or setting attract
individuals other than your target
population?
• The aquarium in the park is a hangout
for teenagers and young adults
• The band shell is a popular area for
public sex
HIV testing will be made available to anyone seeking such services.
We will prepare and carry educational materials and referral resources
that are appropriate to younger people and MSM.
What kind of traffic (e.g., how
many people) can you expect in
the venue or setting and in what
timeframe?
• Drug User Alliance syringe exchange
well established and attracts roughly
50 individuals every Tuesday
• Area is near local businesses, bordered
by residential; moderate traffic, except
on Friday and Saturday nights when
heavily trafficked
• Partnering with the Alliance on Tuesday will allow us to do highly
targeted testing.
• Friday and Saturday nights are too heavily trafficked for our
capacity. More difficult to reach members of target population.
We should explore partnership with CCHD.
Is alcohol or drug use a
consideration?
• Active users and secondary exchangers
in conjunction with Alliance syringe
exchange
• Friday and Saturday nights alcohol use
is high, as there are many bars in the
area
Adapt assessment currently used by the Alliance to assess client
ability to consent to testing.

Implementation
Site/Event Assessment (continued)
Will other service providers be
working at the setting or venue?
At the same time?
• Drug User Alliance currently provides
syringe exchange
• CCHD periodically conducts outreach
• Visiting Nurse conducts health checks
in the area
• Currently partner with the Alliance for outreach. Will partner for
outreach testing.
• Obtain CCHD schedule and coordinate.
• Contact Visiting Nurse to obtain schedule and discuss plans for
HIV testing and to ascertain whether they can also provide
hepatitis C testing, which is of high interest to the clients.
Client
Will the venue or setting provide
adequate confidentiality?
Syringe exchange is currently conducted
out in the open in Riverside Park near the
old band shell; there are no existing
structures that could be used for testing
Set up a tent near the old band shell; this would protect client
privacy.
adequate and appropriate space
for testing?
There are no existing structures that could
be used for testing; the Alliance’s van is too
small and will not work for testing
• Set up a tent near the old band shell; this would allow us to set
up and perform testing in a more controlled environment. We
will also need to bring a level (to make sure that the work surface
is flat and level), folding tables, and folding chairs.
• If we conduct testing on Friday or Saturday nights, natural light
will not be adequate. We will need high intensity lamps (battery
operated) to read rapid test results.
Are there any restrictions or
conditions that impact the kind of
samples you can collect or the
kind of tests you can run?
• No restrictions from gatekeepers
• Temperature control of rapid tests may
be difficult during July and August
• Client preferences unknown
• Obtain insulated carry-backs for tests and controls; thermometer
for use in the field.
• Conduct focus group with CAB to learn whether they will accept
finger stick blood collection.

Implementation
Client (continued)
Will we need any special supplies
and equipment?
• Need to temperature control rapid
tests and controls
• Need to provide shelter, work surface,
chairs, and so forth
• Purchase thermal insulated carry bags and thermometers.
• Rent tent from Events R Us. Look into cost of purchasing for long
term after pilot is completed.
• Add tables, chairs, thermometers, sharps disposal containers,
biohazard bag, and testing supplies (e.g., lancets, bandages) to
packing list for outreach.
What adjustments will we need to
make to our written procedures
and quality assurance practices?
• We will need to ensure that the
temperature during transport of rapid
test kits and controls stay within range
as specified by the manufacturer
• We will need an alternate plan to
ensure temperature control of tests
and control kits during July and August
• We will need to revise our existing
procedures to reflect the procedures
that we will use for this outreach site,
including client recruitment, transport
of supplies, site set-up (to ensure
confidentiality and privacy), quality
control of rapid testing, delivery of
results, referral of clients with reactive
results, and transport of confidential
client records
• Adjust testing and control logs to allow staff to record
temperature before and during transport. Note if temperature
falls out of range.
• During July and August we will partner with the CCHD for HIV
testing events. We will transport testing supplies on the mobile
van to ensure that they remain within temperature range.
• Consult with the Center City Public Health Laboratory to
determine how the Riverside site needs to be added to CLIA
certificate.
• ACME testing and linkage coordinator will draft procedures.
Prevention program manager will review/edit draft and schedule
an orientation for all staff/volunteers who will be conducting
outreach-based testing.

Program Planning and Answers to Discussion Questions Strategies, Gaps, and Next Steps
Implementation
Conducting Testing
How will we manage client flow? •
•
Potential testing clients will be
exchanging syringes and getting
hygiene packs from Alliance members;
Alliance van (i.e., “the love bug”) is
parked near the band shell
The tents have only one opening
•
•
•
•
ACME outreach staff will approach clients at the point of syringe
exchange. Alliance outreach staff will promote testing and refer
to ACME outreach staff, stationed nearby.
ACME outreach staff will lead clients to the tent for testing. ACME
will set up a table near the tent, and another outreach worker will
provide education and risk-reduction supplies for clients waiting
to be tested. We will also provide beverages to clients as they
wait for testing. Only one client will be allowed to enter the tent
at a time.
We will angle the opening of the tent to face away from the
syringe exchange so that others are not able to see who goes
into or comes out of the tent.
To ensure privacy for clients with reactive test results, the tent
will face the south side of the park, which borders Riverside
neighborhood. Clients will not need to pass back through the
syringe exchange.
How will clients get test results? •
•
According to our formative evaluation,
this population will have difficulty
returning to our agency for test results
Alliance outreach workers tell us that
some clients are very regular in coming
to the syringe exchange and others are
not
We will make referrals
reactive result.
to HIV medical care, on the basis of a single
How will clients be linked to HIV
medical care?
•
•
We will be referring to care on the basis
of reactive rapid test
Center City Hospital currently requires
documentation of supplemental tests
to confirm HIV infection
•
•
•
We will contact our linkage coordinator via cell phone to set up
an expedited appointment with the Center City Hospital HIV
Clinic.
We will provide clients with taxi vouchers and will call for a taxi.
We will negotiate with the Center City Hospital to accept clients
on the basis of a reactive rapid test.

Quality Assurance and Monitoring and Evaluation
Prior to conducting HIV testing in an outreach venue for the first time, you may find it useful
to have developed written policies and procedures for conducting outreach-based HIV
testing. Those procedures should address all of the aspects of program operations as with a
fixed site, but must be tailored to reflect how services will be adjusted for the outreach venue,
including those described in the section above (e.g., transporting confidential client
information). Refer to Chapter 9: Quality Assurance and Monitoring and Evaluation for
detailed discussion of development of policies and procedures. Sample policies and
procedures are available as Template 6, located in Appendix D. You can adjust this sample to
reflect your agency’s policies about HIV testing and linkage in outreach settings. Develop
policies and procedures specifically for outreach HIV testing, and you may need to develop
policies and procedures for each outreach venue.
Training
Ensure that staff1
members conducting HIV testing in outreach settings have received
training appropriate to their responsibilities. Training or orientation may include the
following topics:
HIV/AIDS “basics” (e.g., local epidemiology, transmission, prevention)
State and local statutes, regulations that govern HIV testing and linkage
Orientation to site-specific procedures
Engaging clients
Providing accurate and complete information necessary to obtain consent for HIV
testing
Explaining accurately confidential and anonymous testing
Collecting, preparing, and transporting specimens, as applicable
Performing tests, including procedures performed before, during and after a test is run,
if applicable
Interpreting and explaining test results to clients
Risk reduction, as applicable
Referral planning and management
Adhering to universal precautions and exposure control procedures
Exposure control policies and procedures
Properly and accurately documenting all aspects of the testing process (e.g., testing
logs, quality assurance logs) and maintaining secure documentation
Safety procedures, including managing volatile or emergency situations
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
1

Some States or cities have specific requirements for training or certification associated with
conducting HIV testing in outreach settings. Staff performing or supervising HIV testing and
linkage services in outreach settings may need to complete State- or city-mandated trainings
or certifications. Contact your State or local HD for more information about statutes,
regulations, and policies associated with provision of HIV testing and linkage services.
Proficiency
Evaluate staff conducting HIV testing in outreach settings to demonstrate their proficiency in
recruiting clients, communicating information about HIV and HIV testing accurately and
effectively, and delivering test results. Staff or others new to HIV testing in outreach settings
benefit from “shadowing” more seasoned staff. In this way, they can observe how to
approach clients, use messages to engage clients and encourage HIV testing, as well as
conduct the testing process itself. Given the generally more public nature of HIV testing in
outreach settings, it is generally feasible for the site supervisor to directly observe how staff or
others engage clients or provide HIV testing. This is a good way to assess proficiency and
allows for relatively immediate feedback to be given.
In the example below, Barry Callis describes how Massachusetts employs field consultants to
assess service quality.
MDPH, OHA, is deeply committed to supporting a highly effective public health system of
prevention and integrated communicable disease screening services for HIV, STDs, and viral
hepatitis C infections. Two co-administered methods to assess the quality of services are to
conduct field observations and service assessments for client engagement and recruitment
activities performed by grantees.
Field observation and service assessments provide an opportunity to reinforce performance
expectations and recommend adjustments to service delivery. This protocol-driven method of
quality assurance is used to objectively verify service availability as scheduled, and to evaluate
the performance of direct-care staff, including knowledge, skills, responsiveness to client
presentation, and adherence to established standards of care.
In the pilot phase of the quality program, we assembled a group of diverse community
representatives who corresponded to client population groups (including persons living with
HIV disease) to conduct field observation and service assessments. The field consultants were
essentially “secret shoppers” of HIV/AIDS prevention services. The OHA tasked these individuals
to assess the availability of services as advertised or described in work plans, as well as the
breadth and accuracy of HIV, STD, and viral hepatitis knowledge of direct care staff. All field
consultants received 4 hours of orientation and training to the quality management system,
and received field supervision from senior staff in the Prevention and Screening Unit of the OHA.
Field consultants were trained in OHA’s prevention and screening service standards for
conducting client engagement and recruitment activities. These service standards include the
importance of arriving on time and staying the duration of the session as scheduled. At each

visit, field consultants assessed the accuracy of information provided and use of active
engagement and health navigation skills and supports (referral and linkage to available
screening and care services) as indicated.
After each quality session, field consultants completed standardized reports to summarize
impressions and feedback, including action steps to improve services. The written reports were
reviewed and approved by supervisors prior to review with the grantees. After three sessions
were conducted over the course of 6 months, the pilot was demonstrated to be successful. This
function was moved to OHA contract management and technical assistance staff as a
component of their routine program monitoring function. Field observation and service
assessments are both announced and unannounced based on the nature of the service being
assessed.
We have expanded this method of quality assurance by assessing group-level interventions
using MDPH program and capacity building staff in order to provide the necessary technical
assistance and improve the delivery and quality of prevention services for HIV-positive
individuals. Objective feedback has been valuable for grantee program supervisors and MDPH
to plan professional development activities for grantee staff and to reinforce and acknowledge
excellence. Future field observation and service assessments are planned for HIV, STD, and viral
hepatitis screening sessions utilizing the same methodology.
Field observation and service assessments have provided a reliable and constructive strategy to
recognize merit of integrated prevention programming, to confirm service quality, address
deficiencies, and inform future capacity building and technical assistance opportunities.
Creative and diverse program monitoring strategies are essential to ensure excellence in public
health practice.
- Barry P. Callis
Director, Prevention and Screening Unit
Office of HIV/AIDS, Bureau of Infectious Disease
Massachusetts Department of Public Health
Boston, Massachusetts
Debriefing among staff at the conclusion of an outreach testing event can help to identify
what worked well and what did not. This can help you to plan for improvements to future
outreach events. This strategy can also help staff to learn from each other about which
strategies or approaches most successfully engage clients, obtain consent, provide results,
and so forth in these types of settings. In this way, staff skills and confidence to provide HIV
testing in outreach settings can be improved.

HIV testing in each outreach venue in which HIV testing is provided is successful in helping
achieve program goals and objectives related to testing high-risk populations, identifying
new infections, and linking individuals to care.
evaluate your performance at individual outreach sites. Specifically, the yield analysis will help
you understand how well each site is performing.
Considerations for HIV Testing in Mobile Units
MTUs are typically large vehicles (e.g., large vans, trailers, campers) that have been specifically
built for or adapted to provide health services, including testing for HIV. These types of
vehicles have become instrumental in providing HIV testing services to high-risk populations
(e.g., IDUs), populations difficult to reach through fixed-site testing programs in non-clinical
settings, and/or populations who do not access HIV testing in health care settings. Key
benefits and drawbacks of HIV testing using MTUs are presented below in Exhibit 8.1.
Exhibit 8.1. Benefits and Drawbacks of HIV Testing Using Mobile Testing Units
Benefits Drawbacks
•
•
•
•
Offers increased mobility to provide HIV testing
and linkage to increase access to services in areas
of high HIV prevalence, and for hard-to-reach
and/or transient populations
Provides increased privacy and safety when
compared to services offered in other outreach
settings
Allows for provision of other screening (e.g., STD
testing), clinical services, and other services that
could not feasibly be conducted in other
outreach settings
Allows for use of test strategies that may not be
feasible in other outreach settings (e.g.,
venipuncture for conventional testing)
•
•
•
•
•
Requires establishing and maintaining
partnership with law enforcement officials and
others (e.g., local businesses) to ensure
authority/permission to operate MTU and
conduct HIV testing and linkage
Costlier method for outreach HIV testing and
linkage due to cost of purchase/rental and
maintenance of MTU, staffing, and other costs
Safety of staff and clients is an increased concern
compared with most fixed sites
Must monitor location to ensure that you
continue to reach high-risk population
Requires additional staff, compared with fixed
site, in order to appropriately manage client
recruitment, client flow, and safety
Tip
Consider developing an MOA with another organization to augment the services that your agency can
provide to clients tested for HIV.

Below, Robin Pearce explains how NO/AIDS Task Force uses an MTU to bring testing to people
in New Orleans.
Our mobile unit has two private rooms and can bring testing almost anywhere. The
driver/coordinator is certified to provide testing and is fluent in Spanish and English. We use this
unit for awareness events at universities and community events, and for targeted testing for
IDUs, homeless, and migrant day laborers. The van is one of a kind in our region of Louisiana,
and we often use it to collaborate with other CBOs. The CareVan has a low positivity rate, but
the flexibility and visibility it gives our program is exceptional.
- Robin Pearce
CTR Coordinator
NO/AIDS Task Force
New Orleans, LA
There are a variety of vehicles that you can use as a mobile HIV testing unit. On the basis of
your resources, you may consider purchasing a specialty vehicle that is already outfitted to
provide health services (e.g., it has multiple rooms or partitions and a bathroom). Alternately,
you could adapt a vehicle for use as an MTU by, for example, partitioning the interior to
enable increased confidentiality and quality assured testing services. MTUs are designed with
various configurations, in terms of size; storage capacity; and the presence of amenities (e.g.,
a galley with sink, refrigerator, microwave, fresh water tank, air conditioning units) Your
agency’s budget for an MTU may dictate what configuration is most feasible for your
program. MTUs are available for purchase new or used, and can be found using a quick
Internet search. If owning an MTU is not feasible for your agency, consider forming a
partnership with another organization, such as a community health clinic or HD that has a
mobile van you can rent or borrow. You may also wish to explore partnering with that agency
to expand the range of services that can be offered along with HIV testing, or to increase your
ability to access your target population.
It is important to calculate the cost and maintenance of your mobile testing unit in your
program’s budget, as the MTU will serve as your primary source of transportation and location
of services to your target population. Other cost factors to consider include the following:
Insurance
Fuel
Vehicle maintenance (including the generator, plumbing, etc.)
Licensing
Storage of vehicle
Waste disposal
Permits (parking)
Your agency must also obtain proper parking permits for your vehicle during working hours A
hired driver or qualified staff member may be able to serve as your MTU driver, and it might
•
•
•
•
•
•
•

be useful for these individuals to also possess working knowledge of your mobile units’
maintenance basics. In addition, have policies in place for which staff members have
authorization to operate the MTU and appropriate insurance for both personnel and the
vehicle. It is important that you address these prior to conducting your first outreach event.
Exhibit 8.2 provides potential questions and solutions you may face with implementing HIV
testing in MTUs.
Exhibit 8.2. Considerations for Mobile Testing Units
Questions to
Consider
Potential Solutions
How will we recruit
clients for testing?
• Station one or two staff members outside of the van to recruit and engage clients
and distribute promotional items, educational materials, and risk-reduction
supplies to clients. The size and configuration of your MTU will determine the
number of individuals (staff and clients) that the MTU can accommodate at any
given time.
• Have your MTU staff team canvass a two- to four-block radius of the community
where your target population is found and perform outreach to encourage
community members to seek or accept HIV testing.
• Set up a table with risk-reduction supplies, pamphlets, and promotional materials
near the mobile unit to attract potential clients. As individuals approach your
table, tell them about your services and refer them to your MTU for HIV testing
and others services, as applicable.
How will we manage
client flow?
You need at least one staff member posted at the door to regulate who enters the
MTU. Depending on the size of the event/crowd, it may be helpful to have two staff
members regulating entry.
How will we ensure
privacy and
confidentiality?
• Cover windows for areas that will be used for testing to protect the privacy and
confidentiality of clients. This can be done using window shades, darkening
contact paper, or any other material that prevents anyone outside the mobile unit
from perceiving the activities occurring within the van.
• Route clients into the MTU through one door and route them out of the MTU
through another door, if possible.
How will clients
receive test results?
• Rapid HIV testing: negative results provided same visit.
• Rapid HIV testing: referral to care on basis of one (or two) reactive results.
• Return MTU to same location and deliver results at next outreach event.
• Provide results via phone.
• Schedule appointment at your agency for results.
What arrangements
do we need to make
to ensure testing is
conducted in a
quality-assured
manner?
• MTU interior temperature must be regulated to ensure that HIV test supplies (kits,
controls) remain within operating temperature.
• Do not store kits and controls on the mobile unit. They should be stored in a
temperature-regulated environment.
• Do not park on an incline. Rapid tests must be performed on a level surface. Carry
a level on the MTU.
How will we ensure
clients are linked to
medical care?
• Provide clinical services on MTU (if feasible).
• Coordinate with mobile early intervention program (if available).
• Negotiate with HIV medical provider for expedited appointments.

Exhibit 8.2. Considerations for Mobile Testing Units (continued)
Questions to
Consider
What do we need to
do before and after
outreach?
•
•
•
Potential Solutions
It is essential that the MTU be thoroughly inspected (e.g., tires, lights,
compartments, fluid levels, brakes) prior to departure to safeguard against any
vehicular issues that may arise during your outreach event.
Remove and return to your agency all confidential information (e.g., client files)
and store them according to your agency procedures.
Take an inventory of supplies and materials on the MTU both before and after
outreach activities to ensure that you have adequate supplies and that everything
has been returned.
How will we
safety?
address •
•
•
Clearly establish who is authorized to use the MTU and for what purposes.
Do not allow clients to use the MTU for other purposes (e.g., to use restroom
facilities).
Park your mobile unit in an area of your target neighborhood where you are least
likely to disrupt any community activities or events or interfere with business
(either the clients or local businesses).
Considerations for HIV Testing at Large Events
HIV testing at large events entails testing at community events or high traffic locations such
as health fairs, pride festivals, or house balls. Key benefits and drawbacks of HIV testing at
large events are presented below in Exhibit 8.3.
Exhibit 8.3. Benefits and Drawbacks of HIV Testing at Large Events
Benefits Drawbacks
•
•
•
•
•
•
•
Are often good opportunities to market your
agency/services and build relationships with
community partners that will enable you to more
effectively meet the needs of your target
population.
Can be useful in building awareness about HIV and
your services in the community.
Allows for testing large numbers of individuals in a
relatively short period of time.
May allow you to access new target populations or
populations that you have been less successful in
engaging.
May allow you to leverage the resources of event
organizers to promote your agency and your
services.
May limit the test strategies that can be used (e.g., if
temperature cannot be controlled, it is not feasible
to collect finger stick or venous samples).
May enable the provision of other screening and
health services which are of value to your target
population (e.g., STD screening) by other
participating agencies.
•
•
•
•
•
•
•
May result in relatively few high-risk
individuals (members of target population)
being tested and few HIV-positive individuals
(i.e., cost-benefit).
May require more staff than fixed site.
Privacy/confidentiality may be difficult to
ensure compared to services offered in fixed
sites.
Environment is often not well controlled and
may be unpredictable. May be difficult to
manage client flow, depending on size and
type of event.
Clients may be pressured by friends or others
to consent to HIV testing.
Safety of staff and clients increased concern
compared with most fixed sites, particularly if
crowd is large and alcohol or drugs are being
used.
Requires additional staff, compared with fixed
site, in order to appropriately manage client
recruitment, client flow, and safety.

There are many factors to consider when selecting and/or deciding to offer testing at a large
event. You may be invited by members of the local community or event organizers to provide
HIV testing and linkage services at an event that has already been planned, such as a health
fair. This may allow you to reach a relatively large number of individuals with HIV testing
services, and to do so in a more cost-effective manner than if you were planning a large event
on your own. If others are organizing the event, you may be able to leverage their resources
for promotion and marketing. For example, you may be able to include information about
your agency and its services in marketing materials prepared by the event organizers. You
may be able to pool the resources of multiple partner agencies to promote and hold the
event, allowing you to have a larger and “splashier” event than if you were to host the event
on your own.
Another route to testing in large venues is to develop your own testing event. This can be
time and resource intensive. Please see the following example from Jeff Hitt for more
information on developing and implementing a large-scale testing event.

The fourth annual HIP HOP for HIV Awareness intervention was held in the City of Houston in
July 2010. Persons were offered routine testing for HIV, syphilis, gonorrhea, and chlamydia, but
could opt out of one or more tests. Urine specimens were collected for gonorrhea and chlamydia
at clinical sites including the Greenspoint Mall location. Over the course of 27 days, a total of
15,460 persons were tested for HIV, with 113 persons identified as HIV-positive (0.73%), 35 of
which were newly identified infections; 8,871 persons were tested for syphilis with 209 persons
testing positive (2.36%), 52 of which were new cases; 5,755 persons were tested for
gonorrhea/chlamydia with 144 persons testing positive for gonorrhea (2.50%), 733 persons
testing positive for chlamydia (12.74%), and 105 persons testing positive for both gonorrhea
and chlamydia (1.82%). At least 80% of those persons testing positive for HIV, syphilis, and
gonorrhea and/or chlamydia were African American.
The success of this intervention is the collaborative efforts of local government, nonprofit and
for-profit entities and the number one local hip hop radio station in Houston (97.9 The Box). HIP
HOP for HIV is an intervention established as a mechanism to provide free and confidential HIV
and STD screening to youth and young adults through a well-planned, well documented, and
well executed event. The target population for this intervention is primarily African American
youth and young adults. For the past 2 years the intervention has used the Incident Command
Structure developed out of the Office of Emergency Management. Persons are tested for HIV,
syphilis, gonorrhea and chlamydia. They also are required to participate in a 45-minute
educational session that includes interactive games and condom demonstrations. Several
immunizations were also offered. Many clients were prophylactically treated onsite by medical
staff based on a risk assessment. Counseling specialists provided HIV and syphilis test results. All
persons participating received a ticket to the HIP HOP concert that took place on July 31, 2010,
where 15,000 young people were entertained by local and national hip hop music’s most stellar
performers. In between performances, audience members were provided with alarming
statistics about the prevalence of HIV in the African American community on a wide screen
hanging overhead. Crystal Jean, an HIV-positive woman, shared her story and HIV status with
the concert attendees.
- Jeff Hitt
Manager, HIV/STD Prevention and Intervention
HIV/STD Prevention and Care Branch
Texas Department of State Health Services
Austin, TX

Another example of providing testing in large venues is described below in a case study from
Angela Wood of Washington, DC.
Family and Medical Counseling Service, Inc. (FMCS) currently provides HIV testing to individuals
accessing services at the Department of Motor Vehicles (DMV) in Washington, DC. This
comprehensive program utilizes rapid testing and provides immediate access to follow-up care
services for persons with preliminary reactive test results and immediate access to behavior
change support services for high-risk HIV-negative individuals.
Washington, DC has an estimated HIV prevalence rate of 3.2%, and only 50% may be aware of
their infection. After a review of HIV prevalence data, we determined that the implementation of
HIV testing in large public sites may be a feasible strategy to promote and engage individuals in
HIV testing services. We identified the DMV, which provides driver’s license and automobile tag
services to over 150,000 residents annually, as an ideal location to reach a cross-section of
individuals in our target community. We considered the following factors in the selection of our
site:
•
•
•
•
Location: The DMV office we selected is located in our target community (a high-incidence
area) and is in close proximity to our office, which is ideal for facilitating linkage to care.
Consumer volume and wait time for service: The District of Columbia has a total of six
DMV offices. We selected one of the highest volume sites that provides a service package
that is accessed by the general public (i.e., driver license and tag renewal). We excluded
sites that focus on a specific service (e.g., an inspection center). The center also has an
acknowledged wait time greater than 30 minutes.
Space: Several of the sites that we identified met our first two criteria, but did not have
adequate space. We selected a site with the appropriate space to house our testing team.
Proximity to our primary care office: Critical to the success of our HIV testing strategy is the
ability to provide immediate linkage to care for individuals testing reactive. As a result, we
selected a DMV site that is within 15 minutes of our primary care office.
Our program model is designed to promote HIV testing and increase the number of DC residents
who know their HIV status. FMCS staff promote HIV testing among 100% of consumers
accessing services at the Penn Branch DMV, offer 100% of persons receiving services at the Penn
Branch DMV access to HIV testing while they wait to receive DMV services, conduct HIV testing
for 100% of individuals who volunteer to receive testing, and link 100% of individuals who test
preliminary reactive to primary medical care and support services.
Given that this program reaches a diverse group of residents, we decided to implement a testing
strategy that builds on an existing HIV campaign in our area. The district’s Ask for the Test
campaign is designed to increase the number of residents who receive testing as a part of
routine primary care. As such, our testing strategy includes messaging that is designed to
normalize HIV testing, reduce the stigma that is associated with risk-based testing, dispel myths
about current HIV testing behavior by primary care physicians, and increase awareness of
existing HIV testing services in the district.

Linkage to care for individuals who have a reactive test result is a key component of our
program strategy. Our program staff attempt to link people to care on the same day that a
reactive test result is received. Individuals with a reactive test result at the Penn Branch DMV are
immediately connected to the HIV testing/linkage specialist staff at FMCS. The Penn Branch
DMV is located a short drive away from our offices. Our HIV testers can either dispatch a FMCS
vehicle to the DMV to escort a client to services at our offices or other community sites or the
client can travel to our offices by car or public transportation. Both of these strategies allow for a
discrete connection to care while protecting client confidentiality in the DMV. At no time will our
linkage specialist and DMV HIV testing staff meet together with a client inside of the DMV.
The inclusion of ongoing program evaluation is critical to the success of any testing program,
but is it imperative to the implementation of HIV testing in public service venues such as the
DMV. FMCS implements a practical program evaluation and continuous quality improvement
program that is designed to measure progress toward five selected quality improvement
indicators: HIV offer rate, acceptance rate, testing rate, positivity rate, and linkage to care rate
for the program in the Department of Motor Vehicles.
On a daily basis our program staff manually collect and report the number of individuals
accessing services at the DMV during our hours of operation, the number of individuals who are
offered and who accept HIV testing at the DMV, and the number of individuals testing HIV
positive. This information is submitted to our program coordinator and is entered into an Excel
database that calculates the offer rate, acceptance rate, HIV testing rate, and positivity rate.
- Angela Wood
Chief Operating Officer
Washington, DC
If you have decided to perform HIV testing at a large event, Exhibit 8.4 will provide you with
several logistical issues to bear in mind.
Exhibit 8.4. Considerations for Testing at Large Events
Questions to
Consider
Potential Solutions
How will we recruit
clients for testing?
• One to two staff members can “work” the event, promoting your services and
directing prospective clients to the area you have set up for testing.
• Set up a table with risk-reduction supplies, pamphlets, and promotional materials
to attract potential clients.
• Promote your services in the community in advance of the event. Focus on areas
of the community and venues which serve members of your target population or
people who might be attracted to an event.
• Ask the event organizers to include your services in any promotional or marketing
materials used for the event (e.g., advertise your agency and services on the event
Web site).

Exhibit 8.4. Considerations for Testing at Large Events (continued)
Questions to
Consider
How will we
client flow?
manage •
•
Potential Solutions
You need at least one staff member to direct clients, posted at the front of your
designated area.
Work with the event organizer to determine how large a crowd is expected. Plan
your coverage of the event so that you have at least one or two staff members
who can promote services and manage client flow, while one or two additional
staff members perform testing services.
How will we ensure
privacy and
confidentiality?
•
•
•
Work with the event organizer to place you in a low-traffic area so that clients can
have privacy during testing.
Often the noise generated from large crowds or music may be adequate to make
your conversations with your client more private. However, you may consider
bringing in your own white noise machine or radio to keep testing sessions
private.
Negotiate with the event organizer to be placed in a booth or area where the
client will have direct access to an exit, such as the rear door of a club which exits
directly into the parking lot.
How will clients
receive test results?
•
•
•
•
Rapid HIV testing: negative results provided same visit.
Rapid HIV testing: referral to care on basis of one (or two) reactive results.
Provide results via phone.
Schedule appointment at your agency for results.
What arrangements
do we need to make
to ensure testing is
conducted in a
quality-assured
manner?
•
•
•
You may choose to bring a cooler with you to store reagents or samples during
the event. This must be carefully monitored to ensure proper temperatures are
kept during the event (especially on hot days).
Bring lamps to ensure adequate lighting to read rapid test results. Bring a level to
ensure that rapid testing is performed on a level surface.
Bring tables and chairs (if not supplied by the event’s organizers) to ensure that
you are able to set up an area which provides adequate space and condition for
testing.
How will we ensure
clients are linked to
medical care?
•
•
•
Make an appointment for the client while the client is there.
Obtain contact information from the client to allow you or someone from your
agency (e.g., a linkage specialist) to follow up with them.
Provide assistance in keeping a same-day appointment (e.g., taxi voucher).
What do we need to
do before and after
outreach?
•
•
Secure confidential information in a lockbox and return to your agency according
to your agency procedures.
Take an inventory of equipment, supplies, and materials both before and after
has been returned.
How will we address
safety?
•
•
Establish a plan, in advance,
extreme circumstances, you
event.
Establish a plan, in advance,
are being pressured to test.
for dealing with unruly clients or too large a crowd. In
may need to consider shutting down and leaving the
for dealing with clients who are intoxicated or who

In the example below, Neena Smith-Bankhead discusses the benefits and drawbacks of
testing in large community events.
Providing HIV testing services in the community is a strategy for increasing education about HIV,
and decreasing the stigma about HIV and HIV testing in various communities. However, in a
time of shrinking resources and with a focus on reaching the highest risk people within our
communities, conducting HIV testing events may not be feasible for every organization. We
have received HIV testing requests from large churches in the past that would have a primary
focus on members of the church, with very little involvement and participation from the
surrounding community, yielding very little, if any, new positive cases. Upon review of the
potential event by our staff, we determined that it was more feasible for our agency to focus the
majority of our testing resources on those locations and events that were likely to help us
identify new positive cases, and if experience suggests that a low turn-out rate, low-risk
activities, or low HIV positivity will be found at a location, we may offer to provide information,
testing coupons, and other HIV educational resources to that community, and suggest that
those who want to be tested for HIV come into the office to get assessed and tested. We have
noticed that our HIV testing rate, among all populations of people that we serve, is much higher
when they come INTO the office than when we go out into that community, suggesting that
sometimes those who come out for community events may not be at the highest risk, even if
they are coming from a high-risk area, and those who come into our offices are more at risk.
In planning outreach events, AID Atlanta assesses the feasibility and added value of such events
by asking ourselves the following questions:
1. How many people to you expect your event will serve?
2. Who will your event target? (Which target population will be the focus of your event?)
3. Is the community surrounding the organization involved in the effort and invited to
participate and access services?
4. How do you plan to promote the testing event?
5. Do you, as an HIV testing organization, have the appropriate resources (staff, test kits,
space at the proposed site for confidential services) to effectively manage the proposed
event?
6. Has anyone ever conducted HIV testing at that location in the past? What was the positivity
rate or level of risk activity of those who came out for testing?
7. Can the people at this location otherwise access HIV testing?
8. Will this be a one-shot testing event, or a regular testing location?
We match our responses to these questions against our available resources to provide HIV
testing and ensure that this location meets the needs of AID Atlanta’s testing plan and the goals

of our funding source. Although HIV testing is one way to address fear of testing, reduce HIV
testing stigma, and provide HIV testing services within a community, other strategies, including
providing HIV information, conducting workshops or presentations, providing “FREE” HIV
testing coupons, and condom distribution, which includes distribution of HIV and testing
information, may also be options that can meet some of the needs of your community partner.
You may also suggest another HIV testing organization to the community organization that
may have a different target population and has greater ability to serve that organization more
effectively.
- Neena Smith-Bankhead
Director of Education and Volunteer Services
AID Atlanta
Atlanta, GA
Ultimately, the decision of whether to offer testing may come down to costs associated with
the event relative to the benefits (i.e., the number of high-risk individuals tested and the
number of HIV diagnoses made). If you must exhaust your test kit supply and staff resources
in order to provide testing, and in doing so you will not identify any new infections or many of
the individuals that you test are at low risk for HIV, you may need to decline the event or
partner with another agency to share the resource burden.
Rather than performing HIV testing at an event, you may also consider sending a few staff
members to the event to provide information and referrals to direct people back to your
agency if they would like to be tested. This helps to preserve your resources, but it also allows
you to take advantage of an opportunity to increase awareness about the impact of HIV in the
community and for you to promote your agency and its services.

Considerations for Testing in Population-
Specific Venues
While health fairs and similar events can present opportunities to test large numbers of
people, you are more likely to encounter individuals at high risk for HIV, especially your target
population, and identify a higher positivity rate at more specialized venues where high-risk
individuals congregate and/or where high-risk activities are likely to occur (e.g., parks, bars,
shelters, bathhouses). Key benefits and drawbacks of HIV testing in population-specific
venues are presented below in Exhibit 8.5.
Exhibit 8.5. Benefits and Drawbacks of HIV Testing in Population-Specific Venues
Benefits Drawbacks
• May result in higher
seropositivity compared
with other
venues/settings
• May provide access to
high-risk populations who
do not use other HIV
testing services
• Is often a good
opportunity to raise
awareness in the target
community about HIV, HIV
testing, and your agency
• May limit the test
strategies that can be
used (e.g., not feasible to
conduct rapid HIV testing
in a very dark
environment)
• May not be feasible to
provide other screening
services (e.g., syphilis
testing)
• May result in fewer tests performed compared with other
venues/settings
• Patrons or management may reject HIV testing if it interferes with sex or
drug use
• Requires establishing and maintaining partnership with gatekeeper,
venue management, law enforcement, or others to ensure continued
access
• Privacy/confidentiality may be difficult to ensure compared with
services offered in fixed sites
• Must monitor location to ensure that you continue to reach high-risk
population
• Environment often not well controlled and may be unpredictable; may
be difficult to manage client flow, depending on size and type of venue
or setting
• Client consent to test may be challenging (e.g., if alcohol or drugs are
being use)
• Safety of staff and clients increased concern compared with most fixed
sites
• Requires additional staff, compared with fixed site, in order to
appropriately manage client recruitment, client flow, and safety
• Linkage to care may be challenging, particularly if testing is provided
after regular business hours
In the following textbox, you will find an example of testing in gay bars from a CBO in New
Orleans.
NO/AIDS Task Force offers rapid HIV testing at gay bars (and one bathhouse) in New Orleans
every week of the year (Mardi Gras is the only exception). We have established MOUs with the
owners/managers to set up testing rooms in the second story or other private space in the bar,
such as a dressing room or large storage closet. Per protocol, the Louisiana Office of Public
Health approves the site before we can test in the space. Most of the bars offer HIV testing twice
a month, though schedules vary depending on special events and holidays. NO/AIDS’ venue
testing model uses a “greeter” and one or two certified HIV counselors. The greeter distributes

condom packs (condoms, lube, instructions, and our fixed-site testing hours) and recruits bar
patrons for testing. The counselors wait in the private space for clients to come to them to
receive the test and counseling services. If a client’s test is preliminary positive, the OraSure
testing is done onsite. Some patrons are not comfortable getting tested in this environment, but
many are. In 2011, 488 people received an HIV test in nine bars and one bathhouse. Of this
group, 17 people received a preliminary positive result (a positivity rate of 3.48%). Venue-based
testing helps us meet people who wouldn’t come to a clinic on their own or who don’t think
about getting tested. Over time, we’ve learned that consistency and maintaining a positive
relationship with bar owners, bartenders, managers, and the community is key to the success of
this testing strategy.
- Robin Pearce
Counseling and Testing Coordinator
NO/AIDS Task Force
New Orleans, LA
Some venues can be difficult to access without a gatekeeper. Therefore, identifying a
gatekeeper and using social networking can become essential to the success of your testing
program. For example, if your target population is young, African American MSM, try to build
relationships with influential members of that community in order to gain access to settings
or venues where you can provide HIV testing to the target population. Also note the following
considerations found in Exhibit 8.6 when testing at population-specific settings:
Exhibit 8.6. Considerations for Testing at Population-Specific Settings
Questions to
Consider
Potential Solutions
How will we
recruit clients for
testing?
• One to two staff can “work” the venue or event promoting your services and
directing prospective clients to the area you have set up for testing. Approach
individuals and small groups with your “pitch”.
• Set up a table with risk-reduction supplies, pamphlets, and promotional materials to
attract potential clients.
• Promote your services in the community in advance of your outreach testing event.
Get gatekeepers to help you (e.g., a bartender or disc jockey).
• In some venues where drugs or alcohol are in use and it may be difficult to obtain
consent, it may be preferable to set up appointments for testing at a later time
rather than conducting testing onsite at the venue.
How will we
manage client
flow?
• You need at least one staff member posted at the front of your area where testing is
provided to direct clients. Depending on the size of the venue and the size of the
crowd, you may need additional staff.
• Plan your outreach team so that you have at least one or two staff members who
can promote services and manage flow, while one or two additional staff perform
testing services.

Exhibit 8.6. Considerations for Testing at Population-Specific Settings (continued)
Questions to
Consider
How will we
ensure privacy and
confidentiality?
•
•
•
Potential Solutions
Ask to set up in a low-traffic area (e.g., a back room of a club) so that clients can
have privacy during testing.
Find out if you can be placed in a private room. Depending on your venue, loud
music and other noises can help keep your conversations with your client more
private. If you are unable to be placed in a private room, consider bringing in your
own white noise machine to keep testing sessions private. On the other hand, if you
are testing in venues, such as nightclubs or bars where loud music is the norm, you
will want to ensure that the volume of background noise does not interfere with
your interactions with the client.
Ask to conduct testing in an area where the client will have direct access to rear
door to parking lot or other exit area. If outdoors in particular, set up where clients
will not have to walk back through crowds. You may need to check with the owner
or other authorities that it is acceptable to designate that door as a private exit and
can block off other paths to that door.
How will clients
receive test
results?
•
•
•
•
Rapid HIV testing: negative results provided same visit.
Rapid HIV testing: referral to care on basis of one (or two) reactive results.
Provide results via phone.
Schedule appointment at your agency for results.
What • Bring a cooler with you to store reagents or samples during the event. This must be
arrangements do carefully monitored to ensure proper temperatures are kept during the event
we need to make (especially on hot days).
to ensure testing is • Bring lamps or flashlights to ensure adequate lighting to read rapid test results.
conducted in a There are good high intensity lamps that are battery operated.
quality-assured • If you are providing testing outdoors, you will also need to ensure that testing is
manner?
•
conducted in a sheltered area. Consider using a tent or canopy.
Bring tables and chairs (if not available onsite) to ensure that you are able to
conduct testing an area which provides adequate space and conditions for testing.
How will we
ensure clients are
linked to medical
care?
•
•
Make an appointment for the client while the client is there. Obtain contact
information from the client to allow you or someone from your agency (e.g.,
linkage specialist) to follow up with them.
Provide assistance in keeping a same-day appointment (e.g., taxi voucher).
a
What do we need
to do before and
after outreach?
•
•
Secure confidential information in a lockbox and return to your agency according to
written procedures.
Take an inventory of equipment, supplies, and materials on both before and after
has been returned.
How will we
address safety?
•
•
Establish a plan, in advance, for dealing with unruly clients or too large a crowd. In
extreme circumstances, you may need to consider shutting down and leaving the
venue.
Establish a plan in advance for dealing with clients who are intoxicated or who are
being pressured to test.

In the following textbox, Jamie Anderson explains how Kansas uses assistance from
behavioral intervention specialists to support and expand testing services. Below, Royale
Theus describes the Michigan AIDS Coalition’s practices for providing testing in bars.
The Kansas Department of Health and Environment PS Program often assists HIV counseling
and testing sites during outreach or testing events. Assistance from behavioral intervention
specialists (BIS) comes when a community-based organization or health department may be
experiencing staffing shortages for HIV testing. This is an opportunity for BIS staff to offer testing
for gonorrhea, chlamydia, and syphilis at the same time they are testing for HIV. Additionally,
BIS are often called upon to act as a support for staff not comfortable with delivering their first
positive result.
- Jamie Anderson
HIV/AIDS Program, Kansas Department of Health and Environment
Topeka, KS
In the bar setting, most clients are going to be under some kind of influence. Our staff tries to get
to the bar early to get the clients as they come into the door. This has been a best practice for our
agency, and we are usually present from 10 p.m. to 2 a.m. If a client is too inebriated to give
consent, we don’t provide a rapid test to the client in the bar. It can be a dangerous situation to
test clients in these venues; therefore, staff members must be observant in these types of
settings. We also allow clients the option to test in the bars or to come to our agency at a later
time. We explain the risks of testing and receiving results in these types of settings.
Since we don’t have a mobile unit, all work is done inside the bar, so we have a great
relationship with the bar owners and managers who provide us with a confidential space to test
patrons. Bar owners and managers realize the services our agency provides are needed and try
to accommodate us as much as possible. They were initially apprehensive about us using the
rapid test, with regards to finger stick and blood, but we reassured them of our secure policies
and procedures for working in these venues. The DJ also makes announcements to bar patrons
that our agency is there and provides the agency contact information via microphone. Our staff
has also been consistent and we have not had much turnover, which has helped with client
familiarity at these venues.
- Royale Theus
Director of Programs
Michigan AIDS Coalition
Detroit, MI

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•
•
•
•
•
•
Chapter 9. Quality Assurance and
This chapter addresses quality assurance of HIV testing and linkage services. In this chapter,
we discuss the following:
Quality assurance, including the purpose and rationale for conducting QA
Standards for HIV testing and linkage services
Policies and procedures for HIV testing and linkage program
Strategies for conducting QA
Cultural competence, including strategies for providing culturally competent services
Strategies for program improvement
Develop and implement a QA plan for your HIV testing and linkage program
Develop policies and procedures for your HIV testing and linkage program that will
help to ensure that you provide high-quality services
Apply data from monitoring and evaluation activities to program improvement
Please note: The information and tools included in this chapter are designed to
complement information and tools presented in other chapters of this Implementation
Guide. There are recommendations for training and education, procedures, and QA
practices associated with each of the component activities of HIV testing and linkage (e.g.,
recruitment, testing, linkage). Therefore, in building your QA plan, refer to other chapters in
this guide.
In this chapter, we explore and provide guidance for ensuring the quality of your HIV testing
and linkage program. This chapter addresses overarching QA issues and practices, including
developing a QA plan for your HIV testing and linkage program. The information and tools
included in this chapter are designed to complement information and tools presented in
other chapters of this Implementation Guide. There are recommendations for training and
education, procedures, and QA practices associated with each of the component activities of
HIV testing and linkage (e.g., recruitment, testing, linkage). Therefore, in building your QA
plan, it is important that you refer to other chapters for additional, detailed information
regarding QA of each of the component activities: recruitment strategies (Chapter 3);
implementing HIV testing, including procedures for performing testing and universal
precautions (Chapter 6); referral and linkage (Chapter 7); and implementing testing and
linkage in outreach settings (Chapter 8).

What Is Quality Assurance?
QA is a key aspect of successful programs. It is important for your agency to assess the extent
to which the services you provide are responsive to program standards and are delivered
according to established procedures. QA activities help to ensure the effectiveness of your
HIV testing and linkage program and that services that you provide are responsive to client
needs.
Definition
QA is a planned and systematic set of activities designed to ensure that clear expectations for
program operations are established, policies and procedures are adhered to, and work
products fulfill expectations. The subject of QA, for the purposes of this Implementation
Guide, is HIV testing and linkage services.
Implementing Quality Assurance
The process of QA includes six component steps:
1. Identify the products and/or services that will be the subject of QA.
2. Set standards of service.
3. Develop policies and procedures based on meeting the standards.
4. Provide education and training.
5. Assess adherence to established policies and procedures.
6. Develop strategies for supporting adherence.
Standards of Service
Standards of service are evidence-based guidelines about what services may be provided and
how those services can be delivered. Suggested standards of service for HIV testing and
linkage programs are presented in Exhibit 9.1.

Exhibit 9.1. Suggested Standards of Service for HIV Testing and Linkage in
Non-Clinical Settings
Targeting and Recruitment
•
•
•
Decisions regarding targeting and recruitment should be data-driven and employ epidemiological,
geographic, behavioral, social, contextual, and demographic data, as available.
Employ recruitment strategies appropriate to engaging the target population in HIV testing and linkage
services.
Strive to identify the greatest number of new HIV-positive individuals as possible.
Testing
Employ a testing strategy that will identify HIV infection as early as possible, and which is responsive to
client needs and agency capacity.
Provide information about HIV testing to all clients.
Provide information about the availability of anonymous HIV testing services to clients who do not wish
to give their names for testing.
Obtain consent for testing, in accordance with State and local laws and regulations.
Risk Reduction
Provide clients diagnosed with HIV infection with risk-reduction messages.
Provide or refer high-risk clients to risk-reduction services responsive to their particular needs and
priorities.
Referral and Linkage
Link clients diagnosed with HIV infection to HIV medical care.
Refer clients diagnosed with HIV infection to PS.
Assess client referral needs and provide assistance, as feasible, to access services.
Employ referral and linkage strategies appropriate to client needs.
Document referral efforts and their outcome.
Quality Assurance and Evaluation
Adhere to local, State, and Federal policies, laws, and regulations that govern provision of HIV testing and
linkage services.
Provide services that are culturally, linguistically, and developmentally appropriate.
Ensure that staff and volunteers have necessary knowledge and skills for their responsibilities.
Conduct QA and evaluation.
Apply data from M&E activities to program improvement.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Policies and Procedures
Policies are rules that guide decisions and actions. Procedures are a set of actions or steps to
be taken, intended to achieve a described outcome or result. Develop policies and
procedures for your program and commit them to writing. It might be useful for all staff,
volunteers, and consultants involved in the provision of HIV testing and linkage services to be
oriented to the policies and procedures. It is essential that policies and procedures be
reviewed periodically (e.g., annually), or as changes warrant, and revised as necessary.

Develop policies that address to whom and under what circumstances HIV testing and
linkage services will be provided. It is important that your policies also address confidentiality,
conduct, and safety. You can find recommended topics for HIV testing and linkage policies in
Exhibit 9.2.
Exhibit 9.2. Recommended Topics for HIV Testing and Linkage Policies
•
•
•
•
•
•
•
Client eligibility for services
Service fees (if applicable)
Provision of services to minors
Provision of testing to clients who are not competent to provide consent (e.g., due to use of alcohol or
other drugs)
Disclosure of test results, including providing clients with copies of HIV-negative test results
Confidentiality of client records, including who has access to such information/ records and under what
circumstances
Staff conduct (e.g., use of alcohol by staff conducting testing in bars; sexual activity between staff and
clients)
Develop procedures that provide a detailed, step-by-step description for each point of the
HIV testing and linkage process. You can find recommended components of HIV testing and
linkage procedures in Exhibit 9.3.
In the example provided for Tool 2, Part II, ACME Prevention Services (APS) used formative evaluation to
determine which strategies would help them to implement an effective HIV testing and linkage program for
their target population, IDUs over the age of 30 years. Use of Tool 2 helped APS to organize and apply the
findings of their formative evaluation to program planning.
Exhibit 9.3. Recommended Components of HIV Testing and Linkage Procedures
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Site set-up and preparation, including provisions to maintain client privacy
Transport of testing supplies, including devices (if applicable)
Recruitment of clients
Engagement of clients
Consent
Collecting and preparing samples
Running HIV tests (preanalytic/analytic/postanalytic phases), as applicable
Results disclosure
Risk reduction
Referral service assessment and planning
Linkage to HIV medical care for clients with a positive HIV test result (distinguish between newly and
previously diagnosed, if applicable), including authorization for release of information
Referral to PS for clients with a positive HIV test result Referral to risk-reduction and other services
Record keeping and security of client records (including transport, if applicable)
Data collection and entry

Many HDs have template policies and procedures for HIV testing and linkage services that can
be adapted for use in other programs. Sample policies and procedures are available in as
Template 6 in Appendix D. You can use this as the basis for your own policies and procedures,
revising it as needed to suit your particular needs. HDs and other agencies often have
requirements regarding policies and procedures for HIV testing and linkage programs. They
may also provide examples or templates that you can (or must) use. Appendix B: Resources
provides information, including links to online resources for policies and procedures for HIV
testing and linkage.
Your agency may have only one policy and procedure for HIV testing and linkage services, or
you may have multiple policy and procedures, depending on how and where services are
provided, who provides services, and workflow. For example, a program may develop one
policy and procedure for HIV testing and a separate policy and procedure for linking clients
with a positive HIV test to care. Separate policies and procedures are appropriate if you
provide HIV testing and linkage services in multiple venues, such as a fixed site and a mobile
van.
Staff Training and Education
The effectiveness and quality of HIV testing and linkage services is predicated upon having
such services provided by qualified and well-trained staff. Some programs use volunteers to
provide some or all aspects of HIV testing and linkage services. Anyone who provides HIV
testing and linkage services must possess the knowledge, skills, and abilities necessary to
perform assigned roles and responsibilities, and should receive appropriate training. It is
essential that successful completion of training by staff and/or volunteers be documented.
Volunteers should possess the knowledge, skills, and training necessary to competently perform their
responsibilities. Have volunteers complete any education and training requirements that must be
completed by paid staff performing the same roles and functions.
Key topics of training for staff providing HIV testing and linkage services, as well as their
supervisors, include the following:
•
•
•
•
•
•
•
•
•
HIV/AIDS basics (e.g., local epidemiology, transmission, prevention)
State and local statutes, regulations that govern HIV testing and linkage
Collecting and preparing samples for testing
Performing tests, including procedures performed before, during, and after a test is run,
if applicable
Exposure control
QA activities and processes
Recruitment strategies
Risk reduction
Referral and linkage planning and management

Please refer to the relevant chapters for additional training needs associated with provision of
recruitment, testing, and linkage.
It is essential that supervisors and/or program managers receive education and training on
testing technologies to facilitate making decisions about which technologies and approach is
the best fit for your target population and with the capacity of your agency. This will also help
supervisors to evaluate the proficiency of staff in such areas as delivery of test results and
making recommendations for retesting. It is also important for supervisors and/or program
managers to receive training and education on specific models and/or procedures for
conducting recruitment, testing, and linkage. Please refer to the relevant chapters for
additional information on training for supervisors.
It may also be useful for supervisors and/or program managers to receive education that
assists them in building relationships with other partners, including service providers.
Supervisors can benefit from an in-depth understanding of the activities and program
components which fall within their purview, regardless of whether they are directly involved
in provision of services. Supervisors can benefit from training on techniques for supervision
and coaching, particularly to support practice improvement.
Some States or cities have specific requirements for training or certification. Staff or others
performing or supervising HIV testing and linkage services at your agency may need to
should complete State- or city-mandated trainings or certifications. Contact your State or
local HD for more information about statutes, regulations, and policies associated with
provision of HIV testing and linkage services.
There are no Federal requirements or regulations regarding the educational attainment or
credentialing of staff performing the various components of HIV testing and linkage.
However, some States and cities do have statutes or regulations regarding who can perform
or oversee certain HIV testing and linkage activities, most notably HIV testing. Contact your
State or local HD for more information about statutes and regulations associated with HIV
testing and linkage.
There are several key qualities or abilities that are useful for HIV testing and linkage staff and
volunteers, including supervisors, to possess:
Literacy: The ability to read and follow procedures is important, particularly with respect
to running HIV tests, interpreting results, and keeping accurate records.
Organizational Skills: Strong organizational skills are important, especially if client
volume is high, testing and linkage services are being conducted in a busy setting (e.g.,
a health fair), or when a staff member is responsible for performing or overseeing
several tasks or activities simultaneously.
Ability to Make Decisions: Good decision-making skills are important for accurately
interpreting test results; successfully linking clients with care, prevention, or other
services; and recognizing and handling problems effectively.
•
•
•

• Communication Skills: Staff and others providing testing and linkage services must be
able to communicate effectively with clients (e.g., meaning of test results), accurately
and clearly convey information to clients, or give clear instructions to staff and others
performing HIV testing and linkage services.
The Quality Assurance Plan
It is essential that your QA activities be guided by a written plan. The purpose of the QA plan
is to provide a roadmap for QA activities. The plan will describe the methods, processes, and
timelines for assessing or reviewing adherence to the program’s policies and procedures.
Your QA plan can also describe the processes and mechanisms for applying the findings of
QA activities to program improvement (i.e., supporting adherence).
Your QA plan and QA activities may address the following domains:
Responsiveness to needs and priorities of the target population and individual clients,
including service accessibility, cultural competence of services/materials, and client
satisfaction with services
Compliance with written policies and procedures
Staff performance and proficiency
Supervision of staff
Responsiveness to program guidelines and performance measures
Record keeping, including maintenance of confidentiality and security
Community resources
It is essential that all staff or volunteers receive an orientation to the QA plan and associated
processes and procedures.
It is also important that your QA plan clearly describe the method(s) that will be used to
assess or review program operations and service provision in each of the domains of QA. Your
QA plan may also describe the frequency of assessment, the parties responsible for and/or
involved in assessment or review of services, and processes and mechanisms for applying
findings to program improvement.
There are a number of strategies or methods that you may use in conjunction with QA
activities. Both qualitative and quantitative approaches are appropriate. Strategies and
methods for QA include the following:
Chart Reviews: It is important to record relevant and required information about a
client (e.g., test results and referrals made) in his/her chart, and that the information is
accurate and complete. Periodic review of client charts (usually a sample) will allow
supervisors to evaluate this. Supervisors may also use chart review to assess staff
performance (e.g., whether information on completed referrals and risk reductions plans
has been recorded in client charts).
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Direct Observation: Observation of workflow, recruitment, risk-reduction counseling,
testing, or other aspects of HIV testing and linkage are useful in assessing compliance
with policies and procedures, inefficiencies in workflow, and staff proficiency in
performing particular tasks. Direct observation of HIV testing and linkage activities may
be guided by written procedures and findings documented.
Role-Plays: When direct observation of services is not possible or appropriate (e.g.,
because it would interfere with provision of services), role-plays may be a good
alternative. Role-plays provide an opportunity to observe staff skills and performance
and provide timely, critical feedback. Role-plays can be conducted among peers or
between a supervisor and peers. For a practice example of using role-plays, see Chapter
6, Exhibit 6.1.
Team Meetings: Team meetings can be used to review HIV testing and linkage
activities, discuss problems or concerns, and identify solutions. It may be useful for
meetings to occur at regular intervals (e.g., monthly); notes, including action items, can
be taken and distributed promptly; and follow-up information can be provided on
action items.
Case Conferencing: Case conferencing involves discussion of one or more individual
clients, typically those that have been challenging. Case conferences are used to identify
solutions or strategies to ensure client needs are addressed appropriately and in a
timely manner. Case conferences can also aid in identifying areas for program
improvement.
Client Feedback: Through surveys (e.g., brief written questionnaires) or interviews, HIV
testing and linkage providers can learn about client perception of and satisfaction with
services; challenges with accessibility; extent to which services were culturally
competent; and other factors. Surveys or interviews can be conducted periodically (e.g.,
every 6 months for 2 weeks at a time) or on an ongoing basis.
Materials Review: Client educational materials can be reviewed at regular intervals
(e.g., annually) to assess cultural, linguistic, and developmental appropriateness. It is
appropriate to involve community advisory boards or other representatives of the target
population in review of materials.
Community Resource Review: Community referral resources can be reviewed
periodically to ensure that referral providers can appropriately address client needs and
priorities. Eligibility criteria, fees, and contact information can also be reviewed and
updated.
Record Review: It is essential that program records which contain confidential
information (e.g., referral logs) be reviewed at regular intervals (e.g., at the end of every
month) to ensure staff adhere to confidentiality policies and procedures. The
completeness and accuracy of records can also be assessed through record review.
Rapid testing also requires regular review of records, such as quality control logs. Please
refer to Chapter 6 for additional information on QA of rapid HIV testing, including
recordkeeping requirements associated with point-of-care rapid HIV testing.
Service Data Review: It is important that HIV testing and linkage service data be
reviewed at regular intervals (e.g., monthly). Service data can help to assess program
(e.g., timeliness of return of test results) and staff performance (e.g., success in

facilitating linkage) and suggest areas where program improvement efforts may be
focused. It is also essential that service data be reviewed with HIV testing and linkage
staff to ensure accurate interpretation and to aid in using data for program
improvement. Refer to the section titled Monitoring and Evaluation for Program
Improvement for additional information on conducting a yield analysis.
Tip
Use the findings of a review of service data to guide you in deciding which QA strategies to use. This
will help you to focus your resources and make the best use of various strategies. For example, review
of service data may indicate an unacceptably high proportion of clients with a positive HIV test result
that are not successfully engaged in medical care. Reviewing your data may suggest that direct
observation of one or two linkage staff, rather than all staff, may be appropriate.
QA activities are most effective and useful when conducted on a regular and scheduled basis.
QA of testing and linkage can be incorporated into existing routine programmatic QA
activities as appropriate.
The following two examples of QA come from Maryland and the District of Columbia. The
former is an overview of the HD’s QA plan, the latter a case study on QA practices from a
CBO’s testing program at the Department of Motor Vehicles.
Quality assessment and improvement (QA/I) is a continuous process that examines the activities
of Maryland’s HIV Testing Program according to existing or established standards. Program
standards and practice recommendations are detailed in the HIV Testing Policies and
Procedures Manual produced by Maryland’s Infectious Disease and Environmental Health
Administration (IDEHA). The goal of the QA/I process is to increase the quality of outcomes and
elevate the level of client satisfaction with HIV testing services.
Maryland’s HIV Testing Program employs multiple strategies and tools to monitor and improve
the quality of HIV testing provided in non-clinical and other settings. Included among these
strategies are site visits, evaluation of counselor knowledge, observation of staff performing
testing and prevention counseling, client satisfaction surveys, and for agencies performing rapid
HIV testing, competency, and proficiency examinations. Guidelines and tools for QA/I strategies
are included in the HIV Testing Policies and Procedures Manual.
Annually, each agency that provides HIV testing in cooperation with Maryland’s IDEHA receives
a site visit. During each site visit, IDEHA program monitors review a range of issues, including
staffing, program promotion, and recruitment strategies; compliance with program standards
for HIV testing (e.g., confidentiality issues, delivery of results, referral planning and
management; record keeping; data security), program evaluation, and fiscal management.
Agencies conducting rapid HIV testing also undergo a complete review of their rapid testing
program, which includes assessment of compliance with State and Federal regulations; review
of rapid testing procedures and quality control practices; record keeping and reporting; and
participation in Maryland’s Rapid HIV Testing Competency and Proficiency Program.

The IDEHA requires that every active counselor complete, annually, a Counselor Knowledge
Evaluation (CKE) administered by testing site supervisors. In order to pass, test counselors must
achieve a score of at least 75%. The CKE consists of questions about basic HIV/AIDS knowledge,
HIV antibody testing, HIV testing and counseling skills, Maryland State laws, and standards for
giving HIV test results. Individuals that are not successful in meeting the standard must
complete remedial steps, which may include retaking the Level 1 Prevention Counselor Training
provided by IDEHA.
The Counselor Observation Evaluation is another strategy to ensure that test counselors
maintain a high level of competency for conducting prevention counseling associated with HIV
testing. Several domains are addressed through the Counselor Observation Evaluation,
including professionalism; counseling skills; effectiveness in supporting risk reduction planning;
skills in providing results disclosure and associated referral planning and management.
Counselor Observation Evaluations are performed by HIV testing site supervisors and according
to guidelines issued by the IDEHA.
The Client Satisfaction Survey (CSS) is one of the most important measures of good quality
service. The CSS measures client satisfaction with the availability and accessibility of services,
the quality of services (e.g., technical competence, complete and accurate information, results),
and behavioral elements (e.g., respect, understanding, fairness, confidentiality). Testing
providers must administer the survey every other year. Results of this survey are analyzed and
returned to each site so that they know what they are doing well and where they need to take
measures to improve.
- Jenna McCall
Deputy Chief, Center for HIV Prevention
Maryland Department of Health and Mental Hygiene
Baltimore, MD
FMCS implements a practical program evaluation and continuous quality improvement
program that is designed to measure progress toward five selected quality improvement
indicators: HIV offer rate, acceptance rate, testing rate, positivity rate, and linkage to care rate
for the HIV testing program in the Department of Motor Vehicles. The quality improvement
indicators are included in our organizational quality improvement plan.
On a daily basis, our program staff manually collect and report the number of individuals
accessing services at the DMV during our hours of operation; the number of individuals who are
offered and who accept HIV testing at the DMV; and the number of individuals testing HIV
positive. This information is submitted to our program coordinator and is entered into an Excel
database that calculates the offer rate, acceptance rate, HIV testing rate, and positivity rate.
Our program design is consistent with the Plan, Do, Study, Act model and emphasizes the
importance of consistent measurement of progress toward identified program goals; the

identification and implementation of corrective actions when program performance falls below
identified goals; and the ongoing monitoring of identified measures to ensure that changes
positively impact progress toward identified goals.
The HIV testing manager reviews progress toward the indicators on a monthly basis. When
actual performance falls below the identified benchmark/expected goal, our quality
improvement and/or quality assurance process is initiated. For example, if our testing rate
(testing rate means the client received testing at the DMV/requested testing at the DMV) falls
below 80%, the HIV testing manager may conduct further study to identify factors that are
contributing to low performance.
The review may include analysis of aggregate and individual performance data, electronic chart
audits, and individual and group discussions with staff. If the review reveals a group-level
problem, corrective actions target the entire staff. If the review reveals an individual staff issue,
the manager may initiate further chart audits, direct observations, or increased supervision until
the issue has been resolved and performance reaches the expected level. Hence, in our model,
the quality assurance activities are triggered by less than acceptable performance on identified
quality improvement indicators.
- Angela Wood
Chief Operations Officer
Washington, DC
Cultural Competence
An individual’s health beliefs and behaviors (including use of health care resources) are
influenced and informed by a range of factors, such as race, ethnicity, nationality, language,
gender identity, sexual orientation, age, occupation, religion, and economic background. The
term culture is often used interchangeably with ethnicity, nationality, or language. It is
important to recognize, however, that culture cannot be reduced to a single variable, such as
ethnicity. Multiple variables influence and inform how we think of, experience, and feel about
various aspects of our lives, including our health and health behaviors. Even within an ethnic
or social group, individuals may think about their health and health behaviors very differently
because of differences in age, gender, religious beliefs, life experiences, or even personality.
Definition
To help promote health equity in the context of HIV testing and linkage services, it is critical
that we provide culturally competent services. Cultural competence can be broadly defined
as the capacity of your staff and your organization to understand and integrate, into provision
of HIV testing services, the factors that influence and inform the ways in which your clients
understand and feel about HIV and HIV services, such as testing and care. The goal of

culturally competent services is to provide the highest quality care to every client that you
serve.
There are a number of strategies that you can adopt to ensure provision of culturally
competent HIV testing and linkage services. These are summarized in Exhibit 9.4, but also
appear throughout this guide.
Exhibit 9.4. Strategies for Providing Culturally Competent Services
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Engage members of the target population in the planning, implementation, and evaluation of program
services.
Convene a consumer advisory board to provide ongoing advice and guidance regarding your services.
Engage gatekeepers to help you build trust and credibility with the community, and also to facilitate
access to the target population.
Address cultural norms, values, and preferences in your formative evaluation. This will help to ensure that
you select recruitment, testing, and referral/linkage strategies that are appropriate to your target
population.
Provide interpreter services, preferably onsite, for clients with limited English proficiency.
Develop collaborative relationships with other community partners that can provide culturally
competent services to your clients, in accordance with their needs and priorities.
Present health information (whether presented in writing, video, in person or other means) at the
appropriate language and literacy level for clients. The developmental level and community norms of the
target population should be reflected in health information.
Provide training for staff and volunteers to increase awareness and understanding of the cultural norms
and values of the communities that you serve, along with the skills to provide culturally competent
services.
Engage staff and volunteers who represent your target population in delivering services.
Use community health workers (CHWs) to provide HIV testing and linkage services. CHWs typically reside
in the community where services are provided, and are often trusted peers of clients.
Provide training for staff and volunteers that will help them build the knowledge and skills necessary to
interact with clients in a sensitive manner and which will assist them in identifying service needs,
priorities, and barriers of individual clients.
In general, if you conduct a thoughtful and systematic planning process that is guided by a
well-executed formative evaluation, engage community representatives in planning and
implementation of your program, train your staff, and conduct ongoing monitoring and
quality assurance of your program activities, you are in all likelihood providing culturally
competent services. Even so, there is always room for improvement, and there are some good
resources to help you to assess and build your capacity for providing culturally competent
services. Please refer to Appendix B for additional resources related to provision of culturally
competent services.
If your target population speaks a primary language other than English, it is important for
staff providing HIV testing and linkage services to be proficient in that language. If you are
unable to provide translation services onsite, explore other arrangements to ensure provision
of services in the primary language of your clients. This may involve partnership with another
agency in your community. Some hospitals and health care systems also provide telephone
interpreting services. Contracting with translation services is another option. Some resources
for translation services are presented in Appendix B: Resources.

Use a professional translator. Unless a client insists on having a friend or family member act as an
interpreter, arrange for and provide translation services, and advise the client of the availability of these
services. Never use a minor as an interpreter.
Having peers provide HIV testing and linkage services is often a good way to ensure that the
services you provide are culturally competent. However, it is important to ensure that clients
find provision of services by peers acceptable. Explore this in your formative evaluation. For
example, a program serving young Latino men learned that their clients preferred testing
services provided by older women, and preferably women who were nurses. When the
program started using only public health nurses to provide testing services for this
community, their uptake of testing increased dramatically.
Tip
Peers are people in equal standing in a social group, especially based on HIV status, ethnicity, age, or
similar characteristics. “Peerness” is the extent to which a person may be considered a peer. In and of
itself, peerness is not adequate to ensure provision of culturally competent services. Individuals
providing HIV testing and linkage services must also have the knowledge and skills necessary to
provide these services and to interact with clients in a meaningful manner.
What Is Monitoring and Evaluation?
M&E activities are key components of any successful HIV testing and linkage program. M&E
helps you to look at the resources that go into the program (e.g., staff, funding), the services
provided (e.g., tests provided), and the results of the program (e.g., successful linkage to care,
yield of testing). M&E activities help to ensure the effectiveness of a program and that services
provided are responsive to client needs. Monitor and evaluate all HIV testing and linkage
activities to assess program performance, identify areas in need of improvement, and ensure
accountability to stakeholders. Applying M&E data to program planning and management
can help to refine and strengthen programming.
Definition
Program evaluation is the “systematic assessment of intervention planning, implementation,
and outcomes in order to determine the value and improve program.”1
1
Centers for Disease Control and Prevention. (1999). Framework for program evaluation in public health.
Morbidity and Mortality Weekly Report, 48(RR-11), 1–58.

Monitoring and Evaluation for Program Improvement
Program M&E is an iterative process, and conducting it will help you to have a strong
program. Prioritize M&E, ensure that you dedicate adequate resources to M&E activities, and
conduct it on a regular basis.
Before you begin providing services, evaluation ensures that your program activities are
properly focused and that the strategies that you select are responsive to the needs and
priorities of your target population. Using formative evaluation findings before you start
providing services helps you to select the strategies that will assist you in achieving your
program goals and objectives, and are within the capacity of your agency to implement.
Once you have begun providing services, M&E will help ensure the following:
Your program stays on track relative to achieving its goals and objectives
You provide the services that you planned to, and in the way that you intended
Your recruitment, testing, and linkage strategies are effective
You identify, in a timely manner, areas of your program that are in need of improvement
You identify strategies to improve your program
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In the text box below, Neena Smith-Bankhead describes the importance of regularly
evaluating your program—even ones that are well established.
Many times, the programs that we have cherished for years no longer meet the needs of the
community, the populations that we are serving, or the needs of the agency. Although these
programs are much loved and sometimes hard to consider getting rid of, shrinking resources
sometimes dictate that we reevaluate their effectiveness. Consider the following when
rethinking the much-loved program:
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Does the program still meet the need of the target population?
Have you done an assessment to see what they would like to see remain, and if their needs
and interests have changed?
Is this program still meeting the need that it was originally intended to meet? When was
the last time this program was evaluated?
Is this program in line with what your agency’s mission and goals (i.e., what you are best
at and are deeply passionate about)? Does this program either support or enhance the
agency mission and goals, or is it disconnected?
Are there other needs not being met in order to support this project?
Although hard to consider, sometimes it is important to reevaluate your agency’s activities to
ensure that the projects and services that you provide are the most beneficial for the resources
that you have, as well as meet the needs of the population served. If not, consider eliminating,
updating, or changing activities.
- Neena Smith-Bankhead
Director of Education and Volunteer Services
AIDS Atlanta
Atlanta, GA
The Evaluation Guide will provide you with detailed information and tools needed to develop
a comprehensive approach to monitoring and evaluating your HIV testing and linkage
program. This section focuses on M&E for program improvement. Tool 4, the Yield Analysis, is
designed to help you to monitoring your HIV testing and linkage program. Using it will assist
you to identify and describe practices or approaches that may benefit from refinement or
redirection, and identify strategies to improve your program.

Tools and Templates: The Yield Analysis
Tool 4 will help you to conduct a yield analysis and assist you in applying the results to program
improvement.
Tool 4. The Yield Analysis
About Tool 4: Tool 4 is divided into two parts. Yield Analysis Part I: Compilation of Data is a
tool for you to use in compiling and organizing the data you will need to conduct a yield
analysis. Yield Analysis Part II: Data Interpretation and Program Improvement can be used to
assist you in interpreting data, and may be used as a guide in to help to identify and describe
the factors that are impacting your program (both negative and positive), and to identify
strategies that could be used to improve your program. Part II requires that you have clear
program objectives in place. Please refer to the Evaluation Field Manual, Step 2: Describe the
Program for additional information about and guidelines for constructing program
objectives. Tool 4 addresses the key measures of success of an HIV testing and linkage
program operating in non-clinical venues: targeting; recruitment; identification of new HIV
positives; ensuring client knowledge of HIV status; and linkage to medical, prevention, and
other services. Tool 4 can be easily adjusted to include additional measures of success
relevant to your program, such as frequency of retesting.
Tool 4 was designed to be applied to a single target population. However, Tool 4 could easily
be adjusted to be used at various levels of program operations:
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Agency: The yield analysis would reflect all HIV testing and linkage services delivered by
the agency.
Program: The yield analysis would reflect a specific HIV testing and linkage program
operated by the agency. Multiple yield analyses could be conducted to compare how
well various programs are doing.
Grant/Funding Source: The yield analysis would reflect a specific source of funding.
Multiple yield analyses could be conducted by source of funding to compare services
across funding sources.
Site/Venue: The yield analysis would reflect HIV testing and linkage services delivered
at a single site or venue. Multiple yield analyses could be conducted to compare how
well each site is doing.
Individual: The yield analysis would reflect HIV testing and linkage services delivered by
a single staff member or volunteer. Multiple yield analysis could be conducted to
compare delivery of services across staff and could assist in QA by identifying potential
areas where individual staff could benefit from additional education, training, or
coaching.
To complete Part I, you will need your program service data for the time period that you wish
to review (e.g., the number of tests conducted, client demographics). Part II is designed to be
completed after Part I.

This tool, particularly Part II, should be completed in conjunction with staff/volunteers who
provide HIV testing and linkage services, as well as others, such as community advisory board
discussion, a deeper understanding of the issues that are affecting your program, as well as
better ideas and strategies to improve your program.
How New Programs Can Use This Tool: Monitoring should be an ongoing program activity
and evaluation is best done early and often. More often than not, new programs experience
“bumps in the road” during early implementation, as new strategies are being used and new
procedures are being learned. Staff and volunteers are getting comfortable with their roles,
and workflow may need to be adjusted as you gain more practical experience. New programs
can benefit from using this tool shortly after implementation (e.g., within the first 3 months),
because conducting a yield analysis very soon after you begin providing HIV testing and
linkage services can help you to identify areas of your program where refinements or
adjustments would be beneficial. During the first year of implementing a new program,
consider conducting a yield analysis frequently (e.g., monthly). This will help ensure that your
program gets off to a good start and that needed adjustments are made early, and before
practices which do not work well become too well established.
How Established Programs Can Use This Tool: If you have an established program, using
this tool will help you to monitor the performance of your program on an ongoing basis,
detect possible problems in a timely manner, and identify strategies that will improve your
program. Yield analysis can be conducted on a regular basis, and it is recommended that this
occur no less than quarterly for established programs. Consider conducting a yield analysis
more frequently in some circumstances, such as when your program appears to be struggling
or when you have made some changes to the program, such as adding a new venue,
adopting a new testing strategy, or introducing a new linkage procedure.
may find it helpful to use this tool in monitoring grantees or contractors. Staff with
responsibility for monitoring contracts or providing technical assistance to local providers can
use a yield analysis to help monitor program performance and identify potential technical
assistance needs. HDs or other funders may also wish to require grantees or contractors
complete a yield analysis on a regular basis as part of required reporting or in conjunction
with corrective action for programs that are struggling. HDs and other funders can adapt this
tool to reflect local expectations regarding performance or program requirements.

Instructions for Completing Tool 4. Yield Analysis, Part I: Compilation of Data
What is the purpose of this tool? Tool 4, Part I is to be used to compile and organize your program service data.
Who should complete this tool? Non-clinical program managers can complete this tool or others with responsibility for program
M&E.
When should this tool be completed? New programs can first complete this within the first 3 months of program
implementation and then regularly (e.g., monthly) thereafter. Established programs may complete this regularly (e.g., quarterly),
unless the program is experiencing difficulties or there has been some change in the program (e.g., adoption of new HIV testing
strategy).
How should this tool be completed? To complete Tool 4, Part I, you will need program service data for the time period that you
wish to review (e.g., the number of tests conducted, client demographics, test results, referrals made, and linkage completed).
In the top portion of Tool 4, Part I, record the following information in the designated cells:
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Agency/Program/Site: Record the name of your agency, the program, or the site/venue for which this tool is to be
completed.
Location: Record the location of the agency, program, or site/venue for which this tool is to be completed.
Reporting Period: Record the time period for which the yield analysis is to be conducted.
Funding Source: Record the source of funding for which the yield analysis is to be conducted, if applicable.
Funding Amount: Record the amount of funding associated with the agency, program, or site for which the yield analysis is
to be conducted, if applicable.
Other Information: Record any other information that may be of interest to you in conducting the yield analysis, such as the
number of staff providing services for this program or site, or the number of hours dedicated to HIV testing and linkage
services during the review period.
In the bottom portion of Tool 4, Part 1, record the specified data in each of the numbered cells and calculate the percentages
according to the instructions provided in the column labeled Instructions. Once you have finished compiling your data, you will
need to review and interpret it, and try to draw some conclusions from it about how to adjust your program practices (Part II).
Tool 4, Part I has been completed for you to illustrate how it may look when completed. The example reflects how you would
complete this tool if for an individual HIV testing site or venue.

Tool 4. Yield Analysis, Part I: Site Information
1. Agency/Program/Site: Club Adam 4. Location: North Center City (ZIP code 50201)
2. Reporting Period: April 1, 2012 to June 30, 2012 5. Funding Source: Center City Community Foundation
3. Target Population: African American MSM less than 24 years of age,
not previously tested
6. Funding Amount: $122,000
7. Other Information: Three staff provided HIV testing and linkage services at
Club Adam during the time period, and 15 HIV testing and linkage events
were provided at Club Adam during the time period (75 hours).
Yield Analysis, Part I: Compilation of Data
Instructions
8. Number of clients tested for HIV 150 Record the total number of clients tested for HIV during the reporting period.
9. Number of clients from the target
population tested for HIV
74
Record the total number of clients tested for HIV from the target population during the
reporting period (see #3, above).
10. Recruitment # % Instructions
10a. Clients representing the target
population
74 49% • In the column marked #, record the number of clients tested for HIV who were from
the target population (from #8, above).
• In the column marked %, record the percentage of clients tested for HIV who were
from the target population. To calculate the percentage, divide the number of
clients from the target population by the total number of clients tested (#10a/#9)
11. Testing History # % Instructions
11a. No previous test 15 10% • In the column marked #, record the number of clients who report having never
been tested for HIV.
• In the column marked %, record the percentage of clients who reporting having
never been tested for HIV. To calculate the percentage, divide the number of clients
who reported no previous HIV test by the total number of clients tested (#11a/#8)

Tool 4. Yield Analysis, Part I: Site Information (continued)
# % Instructions
11b. Tested previously negative/unknown
results
110 73% • In the column marked #, record the number of clients who report having a previous
test with a negative or unknown result.
• In the column marked %, record the percentage of clients who reported having
been tested previously and who had a negative or unknown result. To calculate the
percentage, divide the number of clients who reported being previously tested
with a negative or unknown result by the total number of clients tested (#11b/#8).
11c. Previously tested, HIV positive 15 10% • In the column marked #, record the number of clients who report having a previous
test with a positive results (i.e., previously diagnosed).
been tested previously and who had a positive result. To calculate the percentage,
divide the number of clients who reported being previously tested with a positive
result by the total number of clients tested (#11c/#8).
12. Number of clients with HIV-positive
test result
22 Record the total number of clients with an HIV-positive test (newly positive and
previously diagnosed) result during the reporting period.
13. Number of clients with HIV-negative
test result
128 Record the total number of clients with an HIV-negative test result during the reporting
period.
14. Seropositivity # % Instructions
14a. All clients with HIV-positive test result 22 15% • In the column marked #, record the number of clients with an HIV-positive test
result (from #12).
• In the column marked %, record the percentage of clients found to be HIV positive.
To calculate the percentage, divide the number of clients with an HIV-positive test
result by the total number of clients tested for HIV (#14a/#8).
14b. Clients with new HIV-positive test
result
7 5% • In the column marked #, record the number of clients with a new HIV-positive test
result.
• In the column marked %, record the percentage of clients with new HIV-positive
test result. To calculate the percentage, divide the number of clients with an HIV-
positive test result by the total number of clients tested for HIV (#14b/#8).

# % Instructions
14c. Clients with previous HIV-positive test
result
15 10% • In the column marked #, record the number of clients with an HIV-positive test
result who had previously had an HIV-positive test result.
• In the column marked %, record the percentage of clients with an HIV-positive test
result who had previously had an HIV-positive test result. To calculate the
percentage, divide the number of clients with an HIV-positive test result by the
total number of clients tested for HIV (#14c/#8).
15. Number of clients who received their
final HIV test result
135 Record the total number of clients who received their final HIV test result during the
reporting period.
16. Results receipt # % Instructions
16a. All clients who received their final test
results
133 90% • In the column marked #, record the number of clients who received their final HIV
test result (from #13).
• In the column marked %, record the percentage of clients who received their final
HIV test result. To calculate the percentage, divide the number of clients who
received their final test result by the number of clients tested for HIV (#16a/#8).
16b. HIV-negative clients who received
their final test results
128 100% • In the column marked #, record the number of HIV-negative clients who received
their final test results.
• In the column marked %, record the percentage of HIV-negative clients who
received their final test results. To calculate the percentage, divide the number of
HIV-negative clients who received their test results by the number of clients who
tested HIV-negative (#16b/#13).
16c. New 5HIV-positive clients who received
71% • In the column marked #, record the number of clients with a new HIV-positive test
result who received their final test results.
• In the column marked %, record the percentage of clients with a new HIV-positive
test result who received their final test result. To calculate the percentage, divide
the number of new HIV-positive clients who received their final test results by the
number of clients newly tested HIV-positive (#16c/#14b).
16d. Previously HIV-positive clients who
received their final test results
2 13% • In the column marked #, record the number of clients previously diagnosed HIV-
positive who received their final test results.
• In the column marked %, record the percentage of clients previously diagnosed
HIV-positive who received their final test result. To calculate the percentage, divide
the number of clients previously diagnosed who received their final test results by
the number of previously diagnosed clients (#16d/#14c).

17. HIV-positive linkage to care and
Partner Services
# % Instructions
17a. New 5HIV-positive with confirmed
linkage to HIV medical care
71% • In the column marked #, record the number of clients with a new HIV-positive test
result who were successfully linked to HIV medical care.
• In the column marked %, record the percentage of clients with a new HIV-positive
test result who were successfully linked to care. To calculate the percentage, divide
the number of new HIV-positive clients successfully linked to care by the number of
clients with a new HIV-positive test result (#17a/#14b).
17b. New 4HIV-positive with confirmed
linkage to HIV medical care within 90 days
of test
57% • In the column marked #, record the number of new HIV-positive clients who were
successfully linked to HIV medical care within 90 days of receiving an HIV test.
• In the column marked %, record the percentage of new HIV-positive clients who
were successfully linked to HIV medical care. To calculate the percentage, divide
the number of new HIV-positive clients with confirmed linkage to HIV medical care
by the number of HIV-positive clients (#17b/#14b).
17c. New 3HIV-positive with confirmed
linkage to HIV PS within 30 days of test
43% • In the column marked #, record the number of HIV-positive clients who were
successfully linked to HIV partner services.
• In the column marked %, record the percentage of HIV-positive clients who were
successfully linked to HIV Partner Services. To calculate the percentage, divide the
number of HIV-positive clients with confirmed linkage to PS by the number of HIV-
positive clients (#17c/#14b).
18. Previously diagnosed HIV-positive
out of HIV care at time of HIV test
11 Record the number of previously diagnosed HIV-positive clients who were not in HIV
medical care at the time of the HIV test.
18a. Previously diagnosed HIV-positive
reengaged in HIV medical care.
10 91% • In the column marked #, record the number of previously diagnosed clients
reengaged with HIV medical care.
• In the column marked %, record the percentage of previously diagnosed clients
reengaged with HIV medical care. To calculate the percentage, divide the number
of previously diagnosed clients reengaged with HIV medical care by the total
number of previously diagnosed clients who were out of HIV care at the time of HIV
testing (#18a/#18).
19. Number of HIV-negative clients at
high risk for HIV acquisition
44 Record the number of HIV-negative clients at high risk for HIV acquisition.

20. Linkage to risk-reduction services # % Instructions
20a. HIV-negative clients at high risk for HIV
acquisition with confirmed linkage to risk-
reduction services
20 45% • In the column marked #, record the number of high-risk HIV-negative clients who
were successfully linked to needed risk-reduction services.
• In the column marked %, record the percentage of HIV-negative clients who were
successfully linked to needed risk-reduction services. To calculate the percentage,
divide the number of HIV-negative clients successfully linked to risk-reduction
services by the number of HIV-negative clients in need of risk-reduction services
(#20a/#19).

Instructions for Completing Tool 4. Yield Analysis, Part II: Data Interpretation and Program Improvement
What is the purpose of this tool? Tool 4, Part II will help you understand how successful your recruitment, testing, and linkage
strategies are; the factors that might be associated with the effectiveness of these strategies; and strategies that might help you to
make program improvements. Tool 4, Part II will also help you to monitor progress toward achieving your program objectives.
Please refer to the Evaluation Guide, Step 2: Describe the Program for detained discussion about construction of program
objectives.
Who should complete this tool? Program managers, staff, or others with responsibility for program M&E should complete this
tool. Also consider inviting members of your community advisory board or other stakeholders to participate in these discussions.
Refer to the discussion questions presented in Exhibit 9.5 for additional information to help you complete this tool.
When should this tool be completed? New non-clinical HIV testing programs can first complete this within the first 3 months of
program implementation, and then regularly (e.g., monthly) thereafter. Established programs may complete this regularly (e.g.,
quarterly), unless the program is experiencing difficulties or there has been some change in the program (e.g., adoption of new
HIV testing strategy). Part II should be completed only after you have completed Part I.
How should this tool be completed? In the top portion of Tool 4, Part II, record the following information in the designated cells:
•
•
•
•
•
•
•
completed.
number of staff members providing HIV testing and linkage services for this program or site, or the number of hours
dedicated to HIV testing and linkage services during the review period.

In the bottom portion of Tool 4, Part II, key measures of success for your program are presented in the far left column. These
should correspond to the goals and objectives that you have established for your program (see the Evaluation Guide, Chapter 3,
Step 2: Describing Your HIV Testing and Linkage Program for additional information on writing program goals and objectives).
Record the following information in the designated cells:
• Objective: Record the objective that you have set for your program corresponding to the measure of success.
Summary of Yield Analysis: Record a brief summary of the data presented in Tool 4, Part I, relevant to the corresponding
measure of success.
Contributing Factors: Brainstorm with your group to identify the factors that may be affecting the success of your program.
Summarize these factors in the corresponding cells on the table.
Strategies: Brainstorm with your group to identify the strategies that could help you build on your success or could help
you to improve your program. Summarize these in the Strategies column.
•
•
•
Tool 4, Part II has been partially completed for you to illustrate how it may look when completed. The example reflects how you
would complete this tool for an individual HIV testing site or venue.

Tool 4. Yield Analysis, Part II
1. Agency/Program/Site: Club Adam 4. Location: North Center City (ZIP code 50201)
2. Reporting Period: April 1, 2012 to June 30, 2012 5. Funding Source: Center City Community Foundation
3. Target Population: African American MSM under 24 years of age, not
previously tested
6. Funding Amount: $122,000
7. Other Information: Three staff provided HIV testing and linkage
services at Club Adam during the time period, and 15 HIV testing and
linkage events were provided at Club Adam during the time period (75
hours).
Yield Analysis, Part II: Interpretation of Data and Strategies for Program Improvement
Measures of Success Objective Summary of Yield Analysis Contributing Factors Strategies
How successful were we in
engaging members of the
target population?
90% of all clients tested will
be of the target population
(see # 3, above).
• Only 49% of clients
tested at this site were
African American MSM
24 years of age or
younger. Almost 90% of
the clients tested were
MSM, but most were 25
years or older.
• Only 10% had never
previously tested.
• Club Adam has raised
its cover to $10, which
may be prohibitive for
younger MSM.
• Advisory board reports
opening of The Hoist, a
hot new club in Center
City.
• Citywide testing blitz
with large media
campaign conducted
by CCHD recently
completed and may
explain why many
patrons of Club Adam
tested previously.
• Consider reducing the
number of testing
events at Club Adam,
focusing on nights
where there is no cover
(evaluate whether this
attracts younger men).
• Evaluate feasibility and
appropriateness of
testing at The Hoist.

Tool 4. Yield Analysis, Part II (continued)
Measures of Success Objective
Summary of Yield
Analysis
Contributing Factors
Strategies
identifying new infection?
1% of clients tested will be newly
identified HIV positive.
• 5% of all clients
tested at Club
Adam were newly
diagnosed.
• 10% of all clients
tested at Club
Adam were
previously
diagnosed.
• Club Adam appears to
be a productive site for
identifying new HIV
positives.
• The relatively high
percentage of
previously diagnosed
could be attributable to
relatively older age of
Club Adam patrons.
• Consider continued
testing at Club Adam
due to yield of
positives.
• Review data more
closely to determine
the age range of
previously diagnosed
versus newly diagnosed
positives.
helping clients learn their
test results?
• 90% of all clients will receive
final HIV test results.
• 100% of newly identified
HIV-positive will receive final
HIV test results.
linking newly diagnosed
HIV-positive clients to HIV
medical care?
90% of newly identified HIV-
positive clients will be linked to
HIV medical care.
PS?
75% of newly identified HIV-
positive clients will be linked to
the CCHD PS.
reengaging previously
diagnosed HIV-positive
clients with HIV medical
care?
90% of previously diagnosed
HIV-positive will be reengaged
with HIV medical care.
linking high-risk HIV clients
80% of high-risk HIV clients will
be linked to risk-reduction
services.

Exhibit 9.5 provides you with discussion questions that you may use during the process of yield analysis for interpreting data and
identifying strategies for program improvement.
Exhibit 9.5. Discussion Questions for Yield Analysis
Level of Success Summary of Yield Analysis Contributing Factors Strategies
How well are we doing for each of
the indicators of success—is the
number and percentage above or
below where we want it?
•
•
What aspects of HIV testing
and linkage do we seem to
do well at this
venue/location?
Which aspects of HIV testing
and linkage services need
improvement?
•
•
•
•
•
•
•
•
What are the possible factors that
contribute to what we do well?
What are the possible factors that
are negatively impacting our
services?
Is the population still present in the
venue?
Has something about the venue
changed that makes it less likely
than before that the population can
be reached in this venue?
Are there other factors or
community issues that make it less
likely than before that the
population can be reached in this
venue?
Are staff members able to
successfully engage members of
the target population? If not, why
not?
Are there aspects of our workflow
that might make testing and
linkage easier or more appealing to
clients?
What factors or community issues
might be making it challenging for
clients to be successfully linked to:
▪ HIV medical care?
▪ PS?
▪ Risk-reduction services?
•
•
•
•
Should testing and linkage at
this venue be discontinued or
expanded?
Are there alternative venues
that should be considered?
What adjustments can be made
to current practice to improve
the program?
What additional information is
needed to make decisions to
improve the program?

Practice Example 9.1. Yield Analysis: Interpretation of Data and Strategies for Program
Improvement
In the example yield provided in Tool 4, recruitment efforts at Club Adam were not as successful as ACME staff
would have liked. Less than half of all individuals tested were from the target population. The target
population for Club Adam was African American MSM, under 24 years old, who had not previously tested for
HIV. While most of the clients tested were MSM, less than half were 24 years old or younger and relatively few
had never been tested. ACME did not meet their program objective of 90% of all clients tested being from the
target population.
The testing and linkage program supervisor presented data from the Part I yield analysis to HIV testing and
linkage staff and volunteers and to the agency’s community advisory board. The group discussed the
contributing factors. It was learned that the CCHD had recently completed a testing blitz and that Club Adam
was included in that blitz. The community advisory board also told staff about a new club in the area, The
Hoist, that is attracting a younger crowd. Staff that conducted testing at Club Adam reported that new
management at the club had doubled the cover charge on Thursday and Friday nights, which historically
have been the most productive nights for testing.
The group brainstormed and discussed possible strategies for program improvement. They decided to
approach the management of The Hoist about implementing HIV testing services, in an effort to better reach
their target population. The HIV testing and linkage coordinator, along with one of the community advisory
board members, agreed to approach the owner of The Hoist to explore the feasibility of offering HIV testing
services.
The group also recognized that testing at Club Adam has been productive from the perspective of identifying
new HIV positives, ACME established an objective of 1% seropositivity for testing at this venue, and the data
show a 5% rate of seropositivity.
A closer look at the data, however, showed that all but one of the clients newly diagnosed was over the age of
24 years, suggesting that there may be an unmet need for HIV testing in this population. The group agreed to
discuss whether they can and should expand testing for MSM over age 24 in the future. The HIV testing and
linkage coordinator and HIV prevention manager will present these data to the ACME board of directors at its
next meeting.
Because testing at Club Adam has helped them to identify new positives, the group agreed that they should
maintain some minimum level of effort at Club Adam, at least for the short term. At the same time, because
efforts at Club Adam have not been totally successful in reaching the target population, the group agreed
that it is important that program effort be redirected to venues/settings where they can more successfully
reach the target population.

Appendix A ● Page 1 of 7
Appendix A: Glossary
Algorithm: The combination and sequence of specific tests used to diagnose HIV.
Acute: Acute HIV infection is the highly infectious phase of HIV disease. It can last
approximately 2 months. It is characterized by a variety of flu-like symptoms such as fever,
fatigue, rash, headache, sore throat, swollen tonsils, nausea, vomiting, diarrhea, and joint and
muscle aches.
Anonymous HIV testing: HIV testing in which client identifying information is not linked to
testing information, including the request for tests or test results.
Antiretroviral therapy (ART): Treatment with drugs that inhibit the ability of HIV or other
types of retroviruses from replicating in the body.
Blood: Blood is a body fluid composed of red and white blood cells suspended in a liquid
called blood plasma. Blood carries nutrients and oxygen to cells in the body and carries away
waste.
Capacity building: Activities that strengthen the core competencies of an organization and
contribute to its ability to develop and implement an effective HIV prevention intervention
and sustain the infrastructure and resource base necessary to support and maintain the
intervention.
Medical case management: A service generally provided through an ongoing relationship
with a client that includes comprehensive assessment of medical and psychosocial support
needs, development of a formal plan to address needs, provision of assistance in accessing
services, and monitoring of service delivery.
Centers for Disease Control and Prevention (CDC): The lead Federal agency for protecting
the health and safety of U.S. citizens providing credible information to enhance health
decisions, and promoting health through strong partnerships. Based in Atlanta, Georgia, this
agency of the U.S. Department of Health and Human Services serves as the national focus for
developing and applying disease prevention and control, environmental health, and health
promotion and education activities designed to improve the health of the people of the
United States.
Client: Any person served by a health department or other health or social services provider.
Clinical setting: A setting in which both medical diagnostic and treatment services are provided.

Cluster interview: An interview with a non-infected partner (or social contact or associate),
conducted to elicit information about persons within the social network (e.g., associates) who
might benefit from counseling, examination, or testing for HIV and other STDs. Such persons
might include persons with symptoms suggestive of disease, partners of other persons known to
be infected, or others who might benefit from examination.
Comprehensive Risk Counseling and Services (CRCS): An intensive, individualized, client-
centered counseling for adopting and maintaining HIV risk-reduction behaviors.
Confidentiality: Ensuring that information is accessible only to those authorized to have
access.
Cultural competence: Cultural competence can be broadly defined as the capacity of your
staff and your organization to understand and integrate, into provision services, the factors
that influence and inform the ways in which your clients understand and feel about HIV and
HIV services, such as testing and care.
Data security: The protection of public health data and information systems in order to
prevent unauthorized access or release of identifying information and accidental data loss or
damage to the systems. Security measures include measures to detect, document, and
counter threats to data confidentiality or the integrity of data systems.
Disease intervention specialist (DIS): A health department staff member who is specially
trained to interview persons infected with HIV or another STD (i.e., index patients); elicit
information about their partners and associates; notify the partners of their possible
exposure; ensure that the partners are offered appropriate services, including examination,
treatment and referrals; and provide prevention counseling to index patients, partners, social
contacts and associates. Evaluation: The systematic collection of information about the
activities, characteristics, and outcomes of programs to make judgments about the program,
improve program effectiveness, and inform decisions about future programming.
External referral: Clients are referred by external agencies to the testing program.
High risk: Clients who report any of the following may be at high risk for HIV transmission or
acquisition:
• Recent unprotected anal and/or vaginal sex with an HIV-positive partner or partner of
unknown HIV status
Recent sharing of drug injection equipment with an HIV-positive partner or partner of
unknown HIV status
Current or recent past diagnosis of and/or treatment of a sexually transmitted infection
in self or partner
Symptoms of viral illness
•
•
•

Human Immunodeficiency Virus (HIV): A virus that disables the immune system composed
either of two strains of a retrovirus, HIV-1 or HIV-2, and destroys the immune system’s helper T
cells, the loss of which causes AIDS.
Incentive: Compensation for a person’s time and participation in a particular activity, (e.g.,
voucher for transportation, food, money, or other small reward).
Incidence: The number of new cases in a defined population within a certain time period
(often a year). It is important to understand the difference between HIV incidence, which
refers to new HIV infections, and new HIV diagnoses. New HIV diagnoses represent persons
newly identified as HIV infected, usually through HIV testing. These persons may have been
infected recently or at some time in the past.
Index patient: The person in whom an index case occurs and who prompts the initiation of
an investigation to identify other possibly related cases. Index patients also are sometimes
referred to as “original patients” (i.e., the original patient identified in an investigation, not
necessarily the original patient in a chain of transmission).
Informed consent: An individual receives and understands information sufficient to obtain
his/her consent to undergo HIV testing.
Internal referral: Accessing clients through other services that are provided within the
agency where the testing program resides (e.g., syringe exchange programs, substance abuse
programs, mental health services, crisis care).
Intervention: A specific activity (or set of related activities) intended to reduce the risk of HIV
transmission or acquisition. Interventions may be either biomedical or behavioral and have
distinct process and outcome objectives and procedures outlining the steps for
implementation.
Laboratory testing: Refers to HIV or other testing performed in a public health or clinical
laboratory. Sometimes referred to as “conventional” testing.
Linkage to medical care: A person is seen by a health-care provider (e.g., physician,
physician assistant, nurse practitioner) to receive medical care for his/her HIV infection,
usually within a specified time. Linkage to medical care is the outcome of the referral. Linkage
can be verified by following up with the provider. This requires a valid release of information
form signed by the client in advance of the referral.
Men who have sex with men (MSM): Men who report sexual contact with other men and
men who report sexual contact with both men and women, whether or not they identify as
gay.

Monitoring: The regular observation, tracking, and recording of activities taking place in a
program or project. It includes the process of systematically observing and routinely
gathering information on all aspects of the program. Monitoring also involves providing
feedback about the progress of the program to the stakeholders and implementers to be
used in making decisions for improving program performance.
Monitoring and evaluation (M&E) plan: A comprehensive planning document for all M&E
activities. An M&E plan documents the key M&E questions to be addressed, including what
indicators are collected; how, how often, from where, and why they will be collected; what
baselines, targets, and assumptions will be included; how the indicators are going to be
analyzed or interpreted; and how or how often reports will be developed and distributed on
these indicators.
nPEP: Non-occupational post exposure prophylaxis (n-PEP) refers to the provision of
antiretroviral drugs to prevent HIV infection after unanticipated sexual or injection-drug–use
exposure.
Non-clinical setting: A setting which does not provide medical diagnostic and treatment
services.
Partner: For persons with HIV infection, partner refers to sex and drug-injection partners (i.e.,
persons with whom an index client has had sex or shared drug-injection equipment at least
once, not just regular or main partners).
Partner elicitation: The process of obtaining the names, descriptions and locating
information of person who are sex or drug-injection partners.
Partner Services (PS): A systematic approach to notifying sex and needle-sharing partners of
HIV-infected persons of their possible exposure to HIV so they can be offered HIV testing and
learn their status, and, if already infected, services to help them prevent transmission to
others.
Plasma: Plasma is the straw-colored liquid component of blood that holds the red and white
blood cells in suspension.
Positive predictive value PPV): The percentage of true positive results among all positive
results, (i.e., the number of true positives divided by the number of true positive results added
to the number of false positive results). A low positive predictive value (e.g., 50%) indicates
that many of the positive test results are false positives. A high PPV (e.g., 98%) indicates that
most of the positive test results are true positives.
Prevalence: The total number of cases of a disease in a given population at a particular point
in time. HIV/AIDS prevalence refers to persons living with HIV, regardless of time of infection
or diagnosis date. Prevalence does not give an indication of how long a person has had a
disease and cannot be used to calculate rates of disease. It can provide an estimate of risk that
an individual will have a disease at a point in time.

Privacy: The right of an individual to keep his or her identity and information concealed or
hidden from the unauthorized access and view of others.
Program: Collection of services or activities within an agency or jurisdiction designated to
meet a social or health services need in a community.
Program activities: Specific actions directly related to program objectives that occur,
including provision of information, testing, and referral and linkage services.
Program evaluation: Program evaluation is the “systematic assessment of intervention
planning, implementation and outcomes in order to determine the value and improve
program.”
Program planning: The process of defining goals, objectives, and activities relevant for
specific target populations.
Process evaluation: Evaluation that assesses planned versus actual program performance
over a period of time for the purpose of program improvement and future planning.
Qualitative data: Detailed descriptions of situations, events, people, interactions, and
observed behaviors; direct quotations from people about their experiences, attitudes, beliefs,
and thoughts; or excerpts or passages from documents, correspondence, records, and case
histories. Qualitative data come from open-ended interviews, focus groups, observations,
document review, and questionnaires without predetermined, standardized categories.
Quantitative data: Numeric information representing predetermined categories that can be
treated as ordinal or interval data and subjected to statistical analysis. Quantitative data come
from structured questionnaires, tests, standardized observation instruments, and program
records.
Quality assurance: Quality assurance is a planned and systematic set of activities designed to
ensure that clear expectations for program operations are established, policies and
procedures are adhered to, and work products fulfill expectations.
Recruitment: The process by which individuals are identified and invited to become
participants in HIV testing and linkage to care programs.
Referral: Referral is the process by which a client’s immediate needs for medical care or risk-
reduction services are assessed and prioritized, and the client is provided with information
and/or assistance in accessing referral services. A referral may be either passive or active.
Linkage takes a further step by verifying that the referral was successfully completed.
• Passive referral: In a passive referral, a client is provided with information, such as
agency name and location, about one or more referral services. It is then up to the client
to make decisions about whether and which services to access.

• Active referral: An active referral begins with assessment and prioritization of a client’s
immediate needs for medical and/or risk-reduction services. In an active referral, a client
is provided with assistance in accessing referral services, such as setting up an
appointment or being given transportation.
Linkage: Linkage means that a referral has been verified as having been successfully
completed. If a client keeps his or her first appointment or receives the referral service (if
the referral requires keeping only a single appointment) the referral can be considered
as having been successfully completed. Optimally, it might be valuable to include
feedback on a client’s satisfaction with referral services as part of the linkage process.
Risk reduction: Risk reduction refers to a range of interventions designed to reduce or
eliminate the risk for transmission or acquisition of HIV infection.
Sensitivity: Sensitivity is the ability of a test to correctly identify clients with HIV infection (i.e.,
“true positives”). A highly sensitive test is unlikely to give a false negative result.
Serum: Serum is the component of blood from which all red and white blood cells and
clotting factors have been removed. Serum contains antibodies and antigens.
Sexually transmitted diseases (STDs): STDs are illnesses that are most often transmitted
between people by means of sexual contact, including vaginal intercourse, oral sex, and anal
sex. STDs are also referred to as sexually transmitted infections (STIs).
Social networking: A peer-driven approach of identifying HIV-positive or HIV-negative high-
risk persons from the community who are able to recruit individuals at high risk from their
social, sexual, or drug-using networks; partner referral is a type of social networking which
involves members referring their sexual partners to a testing program.
Specificity: Specificity is the ability of a test to correctly identify clients without HIV infection
(i.e., “true negatives”). A highly specific test is unlikely to give a false positive result.
Stakeholders: People or organizations that are invested in the program, are interested in the
results of the evaluation, and/or have a stake in what will be done with the results of the
evaluation.
Targeting: Use of data or information to direct HIV testing, linkage and HIV risk-reduction
services to high-risk populations, and settings in which high-risk persons can be accessed,
with the purpose of ensuring that services are available and accessible by persons who need
them.
Target populations: The primary groups of people that the program will serve. Target
populations are defined by both their risk(s) for HIV infection or transmission as well as their
demographic characteristics and the characteristics of the epidemic within this population.
Testing strategy: Activities and processes associated with employing specific testing
technologies to conduct HIV testing with clients.
•

Testing technology: Type of test used to perform HIV testing on an individual or specimen.
Whole blood: Whole blood is liquid plasma in which red and white blood cells are
suspended.
Window period: A window period is the time period between when a person is infected and
when a test can detect HIV infection.

Appendix B ● Page 1 of 8
Appendix B: Resources
Chapter 3: Targeting and Recruitment
Social Networks Testing (http://www.cdc.gov/hiv/resources/guidelines/snt/)
CDC has produced interim guidance on HIV testing using the social networking strategy.
Additional information is available at the link above.
Social Media
(http://www.cdc.gov/socialmedia/Tools/guidelines/pdf/SocialMediaToolkit_BM.pdf)
CDC has produced a guide for using social media for health communications. The guide is
available for download at the link above.
Chapter 4: Risk Reduction
Behavioral Interventions
Effective Interventions (http://www.effectiveninterventions.org)
Additional information about brief behavioral interventions for a variety of populations,
including training resources, is available at this Web site.
Compendium of HIV Prevention Interventions With Evidence of Effectiveness
(http://www.cdc.gov/hiv/topics/prev_prog/rep/resources/initiatives/compendium.htm)
CDC maintains a compendium of behavioral interventions effective for different populations,
including injecting drug users, adolescents, and other populations at this Web site.
Selecting Evidence-Based Interventions (http://depts.washington.edu/nnptc/index.html)
Resources and training to assist providers in selecting and adapting interventions is available
through the National Network of HIV/STD Prevention Training Centers. Information is
available at this Web site.

Other Risk-Reduction Interventions
Non-Occupational Post-Exposure Prophylaxis
(http://www.cdc.gov/mmwr/PDF/rr/rr5402.pdf)
CDC recommendations regarding nPEP, published in the Morbidity and Mortality Weekly
Report are available for download at the link above.
AIDS Education and Training Centers National Resource Network
(http://www.aidsetc.org/aidsetc?page=home-00-00)
The AIDS Education and Training Centers conduct targeted, multidisciplinary education and
training programs for health care providers treating persons living with HIV/AIDS. They have
many resources on nPEP that can help you work with clinical providers to provide this service
to your clients.
National Network of STD/HIV Prevention Training Centers (http://www.nnptc.org/)
The National Network of STD/HIV Prevention Training Centers is a CDC-funded group of
regional centers created in partnership with health departments and universities. The PTCs
provide education and training to health professionals in the areas of STD diagnosis and
treatment, behavioral interventions, and PS.
Chapter 5: HIV Testing Methods in Non-Clinical Settings
HIV Tests
Overview of Available Tests (http://hivinsite.ucsf.edu/insite?page=basics-01-01)
HIV InSite, sponsored by the University of California, San Francisco, provides an overview and
explanation of the HIV screening tests currently available in the United States available at this
Web site.
Rapid Test Considerations (http://www.cdc.gov/hiv/topics/testing/rapid/)
CDC maintains a rapid testing toolkit that includes a comparison of rapid tests and laboratory
considerations available at the link above.
Acute Infection
Acute Infection Signs
(http://aids.gov/hiv-aids-basics/hiv-aids-101/overview/signs-and-symptoms/)
Information about the signs and symptoms associated with acute infection are available at
this link.

Clinical Laboratory Improvement Amendments (CLIA) of 1988
CLIA Forms (http://www.cms.hhs.gov/CLIA)
Information about CLIA, enrollment forms, and fee explanations are available for download
from the Centers for Medicaid and Medicare Services at this Web site.
Rapid Testing Toolkit (http://www.cdc.gov/hiv/topics/testing/rapid/)
CDC maintains a rapid testing toolkit that includes links to CLIA information. It is available at
the link above.
Universal Precautions and Exposure Control
Universal Precautions and Exposure Control Plans (http://www.osha.gov)
OSHA has produced a series of fact sheets on universal precautions and exposure controls
and workplace posters in downloadable format. Additional detail and discussion of universal
precautions and exposure control plans are available from OSHA at these links:
Training resources and materials:
(http://www.osha.gov/SLTC/bloodbornepathogens/index.html)
A sample exposure control plan: (http://www.osha.gov/Publications/osha3186.pdf)
Model Performance Proficiency Program
External Proficiency Program (http://wwwn.cdc.gov/mpep/enrollment.aspx)
CDC runs an external proficiency program that is available free of charge to HIV testing and
linkage providers operating in non-clinical settings. Annually, a blinded set of specimens (i.e.,
a panel) will be sent to each participating agency. Each testing program staff will perform
testing on each of the samples and interpret the test result. The results will be scored and
provided to participating agencies. This is one way to ensure that staff members conducting
testing maintain the necessary proficiency to accurately conduct and interpret test results.
Enrollment forms are available at this Web site.
Chapter 6: Implementing HIV Testing
Rapid HIV Testing Quality Assurance
Quality Assurance Templates
(http://www.cdc.gov/hiv/topics/testing/resources/guidelines/qa_guide.htm)
CDC has produced Quality Assurance Guidelines for Testing Using Rapid HIV Antibody Tests
Waived Under the Clinical Laboratory Improvement Amendments of 1988. This document
provides guidance on quality assurance practices for sites using or planning to use rapid test
•
•

kits to detect antibodies to the human immunodeficiency virus (HIV) waived under the CLIA
regulations.
The San Francisco Department of Health has developed templates for rapid HIV testing
quality control (e.g., sample collection procedures, temperature logs, external control logs) for
use by HIV testing and linkage providers. These templates are available for download at
http://www.sfhiv.org/testing_coordinator_resources.php
The Michigan Department of Community Health has developed a comprehensive laboratory
quality assurance manual for rapid HIV testing. Templates include sample collection and
testing procedures, control logs, and tools for proficiency assessment. Templates are available
for download at http://www.michigan.gov/mdch/0,4612,7-132-2945_5103_7168-15018--
,00.htm
The Virginia Department of Health has developed a comprehensive quality assurance manual
for community-based providers of rapid HIV testing services. Detailed procedures and
template tools (e.g., temperature logs, external control logs) can be adapted for local use. The
manual is available for download at
http://www.vdh.virginia.gov/epidemiology/diseaseprevention/programs/HIVPrevention/doc
uments/Rapid%20HIV%20Testing%20Quality%20Assurance%20Manual%202010.pdf
The HIV Early Intervention Services Program of the Division of Addictive Diseases, Georgian
Department of Behavioral Health and Developmental Disabilities has a variety of templates
available, including sample quality assurance procedures and sample forms (e.g., temperature
log, consent forms) for rapid HIV testing. These are available for download at
http://www.hiveis.com/hiv-eis-forms.html
Results Disclosure Procedures
Results Disclosure Procedure: The New York Department of Health has developed a
procedure for results disclosure in the context of rapid HIV testing. It can be adapted and is
available for download at http://www.health.ny.gov/diseases/aids/testing/rapit/protocol.htm
Chapter 7: Referral and Linkage to Health and Prevention
Services
Linkage Case Management
ARTAS Manual: Additional information on ARTAS, including an implementation manual and
training resources, is available at http://www.effectiveinterventions.org.

System Navigation
Patient Navigator Programs: This resource describes a variety of patient navigator
programs for people living with cancer and other chronic diseases:
http://bhpr.hrsa.gov/grants/patientnavigator/outreachandprevention.html.
Peer Navigator Program: The Peer Education and Evaluation Resource Center (Boston) has
produced a toolkit, Building Blocks to Peer Success, to support the training of HIV-positive
peers to engage and retain individuals living with HIV into medical care. This site also contains
a link to a Health Resources and Services Administration (HRSA)-sponsored Webcast, which
provides an overview of the toolkit. The toolkit is available at
http://peer.hdwg.org/training_toolkit
Health System Navigation: The Fenway Institute has developed and evaluated health
system navigation (HSN). Useful resources are available from the Fenway Institute, include a
learning module on health systems evaluation and overview presentations of the HSN model.
Information is available at http://www.fenwayhealth.org. Click Research and scroll down to
Health System Navigation.
Outreach and Peer Support
Peer Support Services: The Massachusetts Department of Public Health has produced
Guidelines for Peer Support Services. This document provides a clear definition of peer
support services, describes various methods of delivering peer support, identifies the core
competencies of peer leaders, and provides guidance on quality assurance and evaluation of
peer outreach and support programs. The guidelines are available at
http://www.mass.gov/eohhs/docs/dph/aids/peer-support-guidelines.pdf
Peer Support Tools: The Los Angeles County Commission on AIDS has produced Standards
of Care: Peer Support. This document describes the components of peer support services and
competencies for peers, and provides sample tools for use in conjunction with peer outreach
and support services. It is available at http://hivcommission-la.info/cms1_034031.pdf
Comprehensive Risk Counseling and Services
CRCS Implementation Manual: CDC has developed an array of resources and tools to
support implementation of CRCS, including an implementation manual, which can be found
at http://www.cdc.gov/hiv/topics/prev_prog/CRCS/index.htm
Medical Case Management
Case Management Recommendations: Recommendations for Case Management
Collaboration and Coordination in Federally Funded HIV/AIDS Programs were developed
jointly by CDC and HRSA to help promote collaboration and coordination across various case
management systems. The core components of medical case management are identified, and

the basic process of medical case management is described. The recommendations can be
found at http://www.cdcnpin.org/scripts/features/CaseManagement.pdf
General Linkage
Best Practices: Project Inform has prepared a summary of best practices from the HPTN 065
study, TLC+: Best Practices to Implement Enhanced HIV Test, Link-to-Care, Plus Treat (TLC-
Plus) Strategies in Four U.S. Cities. Various linkage strategies currently being evaluated are
described, and the summary is available at http://www.projectinform.org/pdf/testing and
linkage_implementation.pdf.
Adapting Interventions
Evidence-Based Behavioral Interventions: Training and resources for adapting evidence-
based behavioral interventions is available through the HIV and STD prevention training
centers. For additional information, go to the National Network of STD and HIV Prevention
Training Center’s Web site at: http://depts.washtington.edu/nnptc/index.htm
Chapter 9: Quality Assurance and Monitoring and
Evaluation
Procedures and Quality Assurance
HIV Testing Quality Assurance Tools and Templates: The San Francisco Department of
Health has developed templates for rapid HIV testing quality control (e.g., sample collection
procedures, testing procedures, temperature logs, external control logs) for use by HIV testing
and linkage providers. These templates are available for download at
The Michigan Department of Community Health has developed a comprehensive laboratory
quality assurance manual for rapid HIV testing. Templates include sample collection and
testing procedures, control logs, and tools for proficiency assessment, and are available for
download at http://www.michigan.gov/mdch/0,4612,7-132-2945_5103_7168-15018--,00.htm
The Wisconsin AIDS/HIV Program, Division of Public Health, Wisconsin Department of Health
and Family Services has published a standardized set of quality assurance procedures for HIV
rapid testing used by providers in that State. Tools and templates include temperature logs,
proficiency checklists, and external control logs. The procedures can be adapted for use
elsewhere. They are available for download at
http://wihiv.wisc.edu/trainingsystem/libraryDownload.asp?docid=432.

The Virginia Department of Health has developed a Rapid Test Site Evaluation Checklist that is
used in conjunction with quality assurance of rapid testing. The tool can be adapted for local
use and is available for download at
http://www.vdh.virginia.gov/epidemiology/diseaseprevention/programs/HIVPrevention/doc
uments/RapidTestQASiteVisitForm.docx
Linkage to Care
Referral and Linkage Procedures: The San Francisco Department of Health has developed
sample procedures for referral and linkage of clients with a positive HIV test for use by HIV
testing and linkage providers. These samples are available for download at
Cultural Competence
Culturally and Linguistically Appropriate Services Standards: In 2001, the Office of
Minority Health in the Department of Health and Human Services published national
standards for delivering services that reflect a group’s culture and language. This is referred to
as culturally and linguistically appropriate services. More information is available at
http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15.
Translation Services: The American Translator Association (ATA) maintains an online
searchable directories of translation and interpreting services. ATA has also produced a guide
titled How Do You Choose the Best Translator for Your Job? that can provide you with
information about selecting the right translation services for your organization. Information is
available at http://www.atanet.org/
The New Jersey Hospital Association (NJHA) has produced a state-by-state guide of
translation services for health care providers available for download at
http://www.njha.com/publications/pdf/Model_Local_Programs_by_State.pdf.
There are many types of organizations that provide telephone interpreting services, including
for-profit companies, governmental organizations, and nonprofit groups. Many commercial
telephone companies provide interpreting services and can provide interpreting services
anytime of the day, sometime on demand. Language Line Services is the largest provider of
telephone interpreting services in the United States. More information is available at
http://www.languageline.com/.
Tools and Other Resources for Culturally Competent Services: The National Center for
Cultural Competence (NCCC) has a mission to increase the capacity of health care and mental
health care programs to design, implement, and evaluate culturally and linguistically
competent service delivery systems to address growing diversity, persistent disparities, and to
promote health and mental health equity. NCCC has produced a number of training curricula
and assessment tools that can assist you with developing your agency’s capacity for
providing culturally competent services. Additional information is available at
http://nccc.georgetown.edu/index.html.

The Gay, Lesbian, Bisexual and Transgender Health Access Project produced Community
Standards of Practice for Provision of Quality Health Care Services for Gay, Lesbian, Bisexual
and Transgendered Clients. The community standards of practices address both agency
administrative practices, as well as delivery of services. The standards include recommended
practices (e.g., intake assessment, planning services, recruitment, confidentiality) for ensuring
culturally competent services for LGBT The standards are available for download at
http://www.glbthealth.org/CommunityStandardsofPractice.htm
The Seattle-King County Health Department has produced Culturally Competent Care for
GLBT People: Recommendations for Health Care Providers. The recommendations can be
adapted for use with HIV testing and linkage programs and are available for download at
http://www.kingcounty.gov/healthservices/health/personal/glbt/CulturalCompetency.aspx

Appendix C ● Page 1 of 36
Appendix C. Toolkit
The following appendix includes all the tools discussed in the Implementation Guide. Prior to
each tool, we provide information on the purpose of the tool, how new and established
programs can use the tool, how health departments or funders can use the tool, as well as
detailed instructions on who can complete the tool, the timing of completion, and how to
complete it.

Tool 1. HIV Testing and Linkage Program Planning and Capacity Assessment
About Tool 1: Tool 1 is divided into two parts. Part I: HIV Testing and Linkage Program Planning serves as a guide for and tool to
document your program planning process. Part II: HIV Testing and Linkage Capacity Assessment assists you in assessing your
capacity for implementing an HIV testing and linkage program. The “Domains of Readiness” presented in Part II correspond to the
major implementation activities that need to be completed to prepare you to implement HIV testing and linkage services. The
greater the number of domains of readiness completed, the greater your capacity to fully implement HIV testing and linkage
services.
Part II is designed to be completed after Part I. If you are planning a new program, it is recommended that you do not begin
providing services to clients until you have full capacity to implement HIV testing and linkage services (i.e., all of the boxes on Part
II are checked as complete). However, established programs may wish to begin with Part II to identify those domains where
program improvement efforts can be concentrated.
This tool should be completed in conjunction with discussion with staff members who provide HIV testing and linkage services, as
well as others, such as consumer advisory board members or members of your board of directors. Multiple perspectives will result
in richer discussion, a deeper understanding of program planning issues and program operations, as well as better ideas and
strategies to ensure a successful program.
Tool 1 presents HIV testing and linkage program planning activities as though they occur in a sequential fashion. It is important to
note, however, that some activities may occur at the same time. For example, you may be simultaneously working on developing
your recruitment protocol and developing client educational materials. Some activities may reoccur at multiple points in time,
such building new partnerships, establishing a new memorandum of agreement (MOA), or hiring new staff members who must
be trained.
How New Programs Can Use This Tool: This tool is designed to assist you in planning your HIV testing and linkage program. This
tool will take you through the key steps of program implementation, including formative evaluation, planning for delivery of HIV
testing and linkage services, as well as monitoring, providing QA, and evaluating your program. This tool will help you to assess
your capacity and readiness to implement your HIV testing and linkage program. It will help you to identify any gaps in your
knowledge or resources that will need to be addressed to ensure that your program will meet the needs of your target population
and that you have the knowledge, tools, and resources needed to deliver high-quality services.

How Established Programs Can Use This Tool: If you have already implemented an HIV testing and linkage program, you can
use this tool to help you to assess whether your program is still meeting the needs of your target population, and if you need to
make any changes to strengthen your program. It is good practice to periodically reassess your program to ensure it is still
meeting community needs and that you are using the tools and strategies that help you deliver effective and high-quality HIV
testing and linkage services.
Many agencies reassess their programs on an annual basis, as part of a regular program planning and improvement process.
Some funders require work plans on a regular (e.g., annual) basis. It is always a good idea to reassess program practices when
substantial changes occur in your agency (e.g., staffing changes) or community (e.g., changes in health and social services in the
community). It is also a good idea to reassess program practices in light of new technologies (e.g., availability of new HIV tests) or
advent of new strategies and tools.
Established programs may find it helpful to use this tool as to take inventory of a program and its capacity. In this case, you could
complete the entire tool and update it periodically (e.g., during your annual planning process) or as changes warrant (e.g., when
policies and procedures are updated). Alternately, established programs may not need to complete the entire tool, but only
sections which are most relevant. For example, if you are considering adopting a new test technology, you may only need to
complete the section on testing capacity and QA.
How Health Departments and Other Funders Can Use This Tool: Health departments and other funders may find this tool
helpful for use with grantees or contractors. You could use this tool in providing technical assistance to agencies that are just
beginning a new program, or for agencies that seem to be struggling with program implementation. Some HDs or other funders
may wish to have grantees or contractors complete this tool at the beginning of a project (e.g., as a component of a funding
proposal) or on a regular basis (e.g., at the beginning of each contract cycle) as a means to assess and monitor capacity to provide
HIV testing and linkage services. HDs and other funders can adapt this tool to suit local needs by adding or adjusting the activity
fields to reflect local policies, regulations, or requirements, such as specific training or certification requirements for staff
providing HIV testing and linkage services.

Tool 1. HIV Testing and Linkage Program Planning and Capacity Assessment
What is the purpose of this tool? Tool 1, Part I is used to guide and document your program planning efforts.
Who should complete this tool? HIV testing and linkage program managers, in collaboration with staff, consumer advisory
board members, and others involved in planning, implementation, and evaluation of the program.
When should this tool be completed? Before you implement HIV testing and linkage services or as part of periodic program
assessment of established programs.
How should this tool be completed? In the top portion of Tool 1, Part I, record the following information in the designated cells:
Target Population: Record the target population
The left column presents the key activities involved in planning for and implementation of an HIV testing and linkage program.
HDs and other funders, in particular, may wish to add, delete, or modify these activities to suit local needs and requirements. For
each activity listed, record the following information in the designated column:
Last Update: Enter the date that corresponds to when the activity was completed or last updated.
Responsible Individual/Position: Enter the name of the individual (or title of the position) that has taken responsibility for
the activity.
Timeline for Completion: Enter the date by which the activity must be completed.
Challenges: Summarize challenges, if any, which may delay completion of the activity.
Strategies: Summarize strategies that you will use to address the identified challenges in completing the activity.
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•
•
•
•
•
•
•

Tool 1. Part I: HIV Testing and Linkage Program Planning
Agency/Program: Participants:
Target Population:
Date Completed:
Activity
Last
Update*
Responsible
Individual/Position
Timeline for
Completion
Challenges
Implementation Planning – General
Conduct community readiness
assessment
Conduct agency readiness
assessment
Review applicable State and
local laws, regulations, and
policies governing HIV testing
and linkage
Identify partner agencies that
may refer clients to the testing
program or provide medical
and social services to tested
clients
Implementation Planning (continued)
Obtain input from
representatives of the target
population in development of
plans for implementing HIV
testing and linkage services
Develop staffing and
supervision plan
Hire staff in accordance with
staffing and supervision plan
Develop agency policies for
HIV testing and linkage
services
*Existing programs may note the date that the activity was completed or last updated. New programs should leave this column blank.

Activity
Last
Update*
Responsible
Individual/Position
Timeline for
Completion
Challenges
Client Targeting and Recruitment
Conduct formative
evaluation**
• Define the target
population and select a
targeting strategy
• Select a recruitment
strategy
Identify recruitment venues
Execute MOA with recruitment
partners
Obtain incentives
Testing
Select HIV tests that will be
offered
• Identify providers of risk
reduction and medical
and social services of
value to clients with
positive tests.
• Decide if will provide
these onsite or through
external agencies, and if
the later, by linkage,
referral, or both
Execute MOA with health
departments for partner
services
**Refer to the section titled Formative Evaluation and Implementation Planning (including Tool 2) in Chapter 2 for additional information on formative
evaluation activities.

Activity
Last
Update*
Responsible
Individual/Position
Timeline for
Completion
Challenges
Develop a tool to classify
clients with negative tests as
having elevated risk that can
be used to triage these clients
to more intensive risk-
reduction services
Decide whether risk reduction
interventions will be provided
onsite or through linkage or
referral
Training
Develop written targeting,
services for HIV-positive clients
and services for HIV-negative
clients procedures
Develop (or identify and
obtain) marketing materials
Train staff on targeting,
services after testing
strategies (e.g., SNS)
Orient/train staff on targeting,
recruitment, testing, services
for HIV positives and services
for HIV-negative client
procedures
Train/certify staff as required
by statute, regulation, or policy

Instructions for Completing Tool 1. Part II: HIV Testing and Linkage Capacity Assessment
What is the purpose of this tool? Tool 1, Part II can be used to assess your capacity to implement an HIV testing and linkage
program.
Who should complete this tool? Program managers can complete this tool, in collaboration with HIV testing and linkage staff,
consumer advisory board members, and others involved in planning, implementation, and evaluation of your program.
When should this tool be completed? This tool should be completed before you implement services. It can also be used to assist
and document ongoing program assessment and to plan for program enhancements if you have already implemented services.
How should this tool be completed? The left column presents the domains of readiness associated with implementing HIV
testing and linkage programs. For each of the major program areas included in Part II (e.g., recruitment, testing), there is some
overlap in the kinds of activities that must be completed (e.g., development of implementation procedures). These activities are
grouped together in Part II and are often developed at the same time.
For each domain of readiness listed, record the following information in the designated column:
Complete: Check the corresponding box if the activities associated with this domain have been completed (or have been
updated, if completed by an established program). Leave this box blank if the activities associated with the domain have not
been completed or updated.
Timeline for Completion: If the activities have not been completed or updated, enter the date by which the activities
associated with the domain must be completed.
Strategies to Address Gaps in Capacity: Summarize the strategies that you will use to address identified gaps. If you are
planning a new HIV testing and linkage program, it is recommended that you do not begin providing services to clients until
you have full capacity to implement HIV testing and linkage services (i.e., all of the boxes on Part II are checked as complete,
and all identified gaps in capacity have been addressed).
•
•
•

Tool 1. Part II: HIV Testing and Linkage Capacity Assessment
Target Population:
Date Completed:
Timeline for
Completion
Community readiness assessment
Agency readiness assessment
Formative evaluation
Agency policies
Staffing plans
Recruitment/hiring of staff
Implementation strategies selected:
low/medium risk
clients
k. Risk reduction interventions for highest-risk clients

Timeline for
Completion
MOA established with partners for the following:
l. Population targeting
m. Client recruitment
n. Testing (field—initial test)
o. Testing (laboratory for any supplemental testing)
p. Linkage to care for HIV-positive clients
q. Basic needs assessment for HIV-positive clients
r. Partner services for HIV-positive clients
s. Triaging HIV-negative clients into highest risk and
low/medium risk
t. Condoms and basic prevention information for low-risk
clients
u. Prevention needs assessment for highest-risk clients
v. Risk-reduction interventions for highest-risk clients
Written policies and procedures developed for the following:
w. Population targeting
x. Client recruitment
y. Testing (field—initial test)
z. Testing (laboratory for any supplemental testing)
aa. Linkage to care for HIV-positive clients
bb. Basic needs assessment for HIV-positive clients
cc. Partner services for HIV-positive clients
dd. Triage process to classify clients with negative clients into
those with and without elevated risk of HIV acquisition
ee. Condoms and basic prevention information for low-risk
clients

ff.
gg.
Domains of Readiness
Prevention needs assessment for highest risk clients
Risk reduction interventions for highest risk clients
Complete
Timeline for
Completion
Written quality assurance plan developed
Monitoring and evaluation plans developed
hh. Population targeting
ii. Client recruitment
jj.
kk. Testing
Testing (field—initial test)
ll.
mm.
nn.
(laboratory for any supplemental testing)
Linkage to care for HIV-positive clients
Basic needs assessment for HIV-positive clients
Partner services for HIV-positive clients
oo.
pp.
clients
Triaging HIV-negative
low/medium risk
Condoms and basic prevention information for low-risk
clients into highest risk and
qq.
rr.
ss.
Prevention needs assessment for highest-risk clients
Risk reduction interventions for highest-risk clients
Quality assurance plans and activities
tt. M&E plans and activities
uu. Other training/certifications required by State or local
Risk-reduction materials secured
statute, regulation, or policy
Client educational materials secured

Tool 2. Formative Evaluation and Implementation Planning
About Tool 2: Complete Tool 2 for each of your target population(s). Tool 2 is divided into two parts. Part I: Organizing Your
Formative Evaluation Data is intended to provide a guide for the kinds of questions that your formative evaluation efforts should
try to answer. It is not intended as a guide on the types of methods you should use or the specific questions that you should
include in focus group scripts, interview guides, or survey questionnaires. Before you begin to use this tool, you will need to
gather all of the data that you intend to use to plan your program. Part I is also a tool for you to use in compiling and summarizing
your data.
Part II: Interpreting and Applying Findings of Your Formative Evaluation is intended to help you and your staff to interpret the
data you have compiled for your formative evaluation and apply it to your program plan, including selection of strategies for
recruitment, testing, and linkage. It will also help you to identify gaps in your knowledge about the target population and
community resources to serve this population. Part II is designed to be completed after Part I. Compile and summarize your data
before you begin to process it and decide how to apply it to program planning.
This tool may be completed in conjunction with discussion with staff members who provide HIV testing and linkage services, as
well as others, such as community advisory board members or members of your board of directors. Multiple perspectives will
result in richer discussion, a deeper understanding of program planning issues and program operations, as well as better ideas
and strategies to ensure a successful program. For more information on working with key stakeholders, please refer to Chapter 3,
Step 1 in the Evaluation Guide.
How New Programs Can Use This Tool: This tool is designed to assist you in planning your HIV testing and linkage program by
providing you with guidance on the kinds of information that you may find useful to collect through your formative evaluation. It
will also help you to organize and interpret your data. Working through this tool will help you to plan a program that uses
strategies, messages, and tools that are best suited to meet the needs of your target population(s) and which will successfully
engage members of the target population services.
How Established Programs Can Use This Tool: If you have already implemented an HIV testing and linkage program, you can
use this tool to help you plan for modifications or enhancements to existing services. Conduct formative evaluation if program
M&E efforts (see Chapter 2, Tool 1 for additional information about program M&E) suggest that the strategies, messages, or tools
you are currently using may not be as successful or well-suited to the target population as they were previously. In addition,
before implementing specific changes, such as introducing a new HIV testing technology or adopting a new linkage strategy, you

need to understand the extent to which the proposed modification or enhancement is responsive to the needs of your target
population(s). Established programs may wish to complete only those sections of the tool relevant to the part of the program for
which adjustment or enhancement is being considered, such as where services should be provided.
How Health Departments and Other Funders Can Use This Tool: HDs and other funders may find this tool helpful for use with
local grantees or contractors. You could use this tool in providing technical assistance to agencies that are just beginning a new
program, or agencies that seem to be struggling with program implementation. Some HDs or other funders may wish to have
grantees or contractors complete this tool at the beginning of a project (e.g., as a component of a funding proposal) or when they
are proposing expanding services to a new target population or adopting new strategies or technologies. HDs or other funders
may also wish to adapt this tool for use with other interventions or services.

Instructions for Completing Tool 2. Part I: Organizing Your Formative Evaluation Data
What is the purpose of this tool? Tool 2, Part I is a tool for you to use in framing your formative evaluation and in compiling and
summarizing data.
Who should complete this tool? HIV testing and linkage program managers can complete this tool, in collaboration with staff
and/or volunteers, consumer advisory board members, and others involved in planning, implementation, and evaluation of your
testing and linkage program.
When should this tool be completed? Before you implement services. It can also be used prior to implementing adjustments or
enhancements to established programs.
How should this tool be completed? Conduct formative evaluation for each target population you intend to or are serving. You
may also want or need to complete formative evaluation for individual programs or funding sources. In the top portion of Tool 2,
Part I, record the following information in the designated cells:
The left column presents evaluation questions related to the kinds of information that you will need to gather in order to plan
your HIV testing and linkage program and to help you identify the best strategies for recruitment, testing, and linkage. It is best to
use multiple sources of data, including anecdotal sources, to fully answer these questions.
For each evaluation question listed, record the following information in the designated column:
Answer to Evaluation Question: Record a brief summary of available data corresponding to the evaluation question.
Information Source and Date of Collection/Publication: Record the source of the data. This will help you to refer back to
the source if more information is needed. Record the date of collection/publication associated with each data source. This
will help you to know whether the data is current.
•
•
•
•
•
•

Tool 2. Part I: Organizing Your Formative Evaluation Data
Target Population:
Date Completed:
live?
socialize?
meet sex partners?
use/share drugs?
health and dental care?
health and dental information?
Who/what does the target population
trust for its health information? Why?
What issues or factors are barriers to
HIV testing for the target population?
Why?

What other kinds of health or
preventive services interest the target
population?
factors are barriers to linkage to care?
factors are barriers to linkage to PS?
For the target population, what issues
or factors are barriers to linkage to
risk-reduction services?

Instructions for Completing Tool 2. Part II: Interpreting and Applying Findings of Your Formative Evaluation
What is the purpose of this tool? Tool 2, Part II is designed as a guide and tool to help you to apply the findings of your
formative evaluation in order to select the most appropriate strategies, messages, and tools for your HIV testing and linkage
program.
Who should complete this tool? Program managers can complete this tool, in collaboration with testing and linkage staff
and/or volunteers, consumer advisory board members, and others involved in planning, implementation, and evaluation of your
program.
When should this tool be completed? This tool may be completed before you implement HIV testing and linkage services
and/or prior to implementing adjustments or enhancements to established programs.
Discussion questions are presented in the left column and are segmented by program component: recruitment, testing, and
linkage. For each of the discussion questions, record the following information in the designated column:
Summary of Formative Evaluation Questions: Record a summary of the findings of your formative evaluation (as recorded
in the Answer column in Part 1. This will help you to draw conclusions about which strategies are appropriate for the target
population.
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•

Tool 2. Part II: Interpreting and Applying Findings of Your Formative Evaluation
Target Population:
Date Completed:
Implementation
Findings
Targeting
• What data sources might be useful to
identify areas of high prevalence?
• Which risk groups should be targeted
for testing?
• Within jurisdictions, where do high risk
groups congregate?
• How can you determine membership in
a target population with a few
questions?
Recruitment
• Where should we recruit and offer
testing and linkage?
• How should we recruit for HIV testing?
• What recruitment messages will be
persuasive?
• Who should do the recruiting?
positives are recruited for retesting?
positives that may be encountered
during testing efforts have fallen out of
care?

Implementation
Findings
Testing
• Which HIV testing strategy should
we use?
• Where should HIV testing be
provided?
• What kinds of things might motivate
or interest our target population in
HIV testing?
• Who will provide supplemental
testing, if the program only offers
rapid testing?
• Will the testing program provide
blood-based or oral tests?
• Does the testing program able to
train staff to ask about recent HIV
exposure?
• Does the staff have capacity to
evaluate recent infection?
needed?

Services
Discussion Questions for Program Summary of
Implementation
for HIV-positive
Formative Evaluation
Findings
Clients
•
•
•
•
•
•
What strategies and resources are
required to link HIV-positive
individuals in our target population
to care?
What potential barriers are faced by
HIV-positive individuals for linkage
to care?
What kinds of practices or things
might help HIV-positive individuals
in our target population link partner
services (PS)?
Can basic needs assessment be
provided onsite following testing?
needed?

Services
Discussion Questions for Program Summary of
Implementation
for HIV-Negative
Formative Evaluation
Findings
Clients
•
•
•
•
•
What strategies can be used to
triage the highest-risk persons to
prevention services?
What kinds of practices or tools are
available to conduct a prevention
needs assessment for the highest
risk clients?
Are there prevention messages or
tools available for low-risk clients?
needed?

Tool 3. Outreach HIV Testing Planning Tool
About Tool 3: The Discussion Questions for Program Planning and Implementation correspond to key factors and issues that you
need to address in planning to undertake HIV testing in an outreach setting or venue. It is recommended that you do not begin
providing outreach HIV testing services until you have completed planning.
This tool should be completed in conjunction with discussion with staff members who provide HIV testing and linkage, as well as
others, such as consumer advisory board members or members of your board of directors. Multiple perspectives will result in
richer discussion, a deeper understanding of program planning issues and program operations, as well as better ideas and
strategies to ensure a successful program.
How New Programs Can Use This Tool: This tool is designed to assist you in planning outreach HIV testing and linkage activities.
This tool will help you to assess community support and identify key partnerships, assess the feasibility of providing services, and
plan for how those services will be delivered. It will help you to identify any gaps in your knowledge or resources that will need to
be addressed to ensure the success of your outreach testing program.
How Established Programs Can Use This Tool: If you have already implemented HIV testing, or even if you have already
implemented outreach-based testing, you can use this tool to help you to plan implementation in new settings or venues or for
new target populations.
How Health Departments and Other Funders Can Use This Tool: HDs and other funders may find this tool helpful for use with
local grantees or contractors. You could use tool in providing technical assistance to agencies that are just beginning to
implement HIV testing in outreach settings or for agencies that seem to be struggling with implementing these services. Some
HDs or other funders may wish to have grantees or contractors complete this tool at the beginning of a project (e.g. as a
component of a funding proposal) or when they add new sites or venues.

Instructions for Completing Tool 3. Outreach HIV Testing Planning Tool
What is the purpose of this tool? Tool 3 guides and documents your planning efforts as they relate to testing in outreach
settings.
Who should complete this tool? Managers or coordinators of HIV testing programs can complete this tool, in collaboration with
staff and/or volunteers, consumer advisory board members, and others involved in planning, implementation, and evaluation of
your program.
When should this tool be completed? Before you implement services in outreach settings or before you begin testing in new
venues or with new target populations.
How should this tool be completed? In the top portion of Tool 3, record the following information in the designated cells:
Discussion questions relevant to planning and implementation of HIV testing and linkage in outreach settings are presented in
the left column:
Answers to Discussion Questions: Record a summary of your discussion about each of the corresponding questions in the
left column.
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Tool 3. Outreach Testing Planning Tool
Target Population:
Date Completed:
Planning and Implementation
Partnerships and Community Support
Who are the gatekeepers to the setting
or venue?
From whom or what do we need to
obtain permission to provide HIV testing
at the setting or venue?
How are we perceived by potential
partners? By the surrounding
community?
What are the concerns or fears about HIV
testing among potential partners? In the
Site/Event Assessment
Will the venue or setting attract
individuals other than your target
population?
What kind of traffic (e.g., how many
people) can you expect in the venue or
setting and in what timeframe?
Is alcohol or drug use a consideration?
Will other service providers be working
at the setting or venue? At the same
time?

Client
Planning and Implementation
adequate confidentiality?
adequate and appropriate space for
testing?
Are there any restrictions or conditions
that impact the kind of samples you can
collect or the kind of tests you can run?
Will we need any special supplies and
equipment?
What adjustments will we need to make
to our written procedures and quality
assurance practices?
Conducting Testing
How will we manage client flow?
How will clients get test results?
How will clients be linked to HIV medical
care?

Tool 4. Yield Analysis for Program Improvement
About Tool 4: Tool 4 is divided into two parts. Yield Analysis Part I: Compilation of Data is a tool for you to use in compiling and
organizing the data you will need to conduct a yield analysis. Yield Analysis Part II: Data Interpretation and Program Improvement
can be used to assist you in interpreting data, and may be used as a guide in to help to identify and describe the factors that are
impacting your program (both negative and positive), and to identify strategies that could be used to improve your program. Part
II requires that you have clear program objectives in place. Please refer to the Evaluation Field Manual, Step 2: Describe the
Program for additional information about and guidelines for constructing program objectives. Tool 4 addresses the key measures
of success of an HIV testing and linkage program operating in non-clinical venues: targeting; recruitment; identification of new
HIV positives; ensuring client knowledge of HIV status; and linkage to medical, prevention, and other services. Tool 4 can be easily
adjusted to include additional measures of success relevant to your program, such as frequency of retesting.
Tool 4 was designed to be applied to a single target population. However, Tool 4 could easily be adjusted to be used at various
levels of program operations:
Agency: The yield analysis would reflect all HIV testing and linkage services delivered by the agency.
Program: The yield analysis would reflect a specific HIV testing and linkage program operated by the agency. Multiple yield
analyses could be conducted to compare how well various programs are doing.
Grant/Funding Source: The yield analysis would reflect a specific source of funding. Multiple yield analyses could be
conducted by source of funding to compare services across funding sources.
Site/Venue: The yield analysis would reflect HIV testing and linkage services delivered at a single site or venue. Multiple
yield analyses could be conducted to compare how well each site is doing.
Individual: The yield analysis would reflect HIV testing and linkage services delivered by a single staff member or volunteer.
Multiple yield analysis could be conducted to compare delivery of services across staff and could assist in QA by identifying
potential areas where individual staff could benefit from additional education, training, or coaching.
To complete Part I, you will need your program service data for the time period that you wish to review (e.g., the number of tests
conducted, client demographics). Part II is designed to be completed after Part I.
This tool, particularly Part II, should be completed in conjunction with staff/volunteers who provide HIV testing and linkage
services, as well as others, such as community advisory board members or members of your board of directors. Multiple
perspectives will result in richer discussion, a deeper understanding of the issues that are affecting your program, as well as better
ideas and strategies to improve your program.
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•

How New Programs Can Use This Tool: Monitoring should be an ongoing program activity and evaluation is best done early
and often. More often than not, new programs experience “bumps in the road” during early implementation, as new strategies are
being used and new procedures are being learned. Staff and volunteers are getting comfortable with their roles, and workflow
may need to be adjusted as you gain more practical experience. New programs can benefit from using this tool shortly after
implementation (e.g., within the first 3 months), because conducting a yield analysis very soon after you begin providing HIV
testing and linkage services can help you to identify areas of your program where refinements or adjustments would be
beneficial. During the first year of implementing a new program, consider conducting a yield analysis frequently (e.g., monthly).
This will help ensure that your program gets off to a good start and that needed adjustments are made early, and before practices
which do not work well become too well established.
How Established Programs Can Use This Tool: If you have an established program, using this tool will help you to monitor the
performance of your program on an ongoing basis, detect possible problems in a timely manner, and identify strategies that will
improve your program. Yield analysis can be conducted on a regular basis, and it is recommended that this occur no less than
quarterly for established programs. Consider conducting a yield analysis more frequently in some circumstances, such as when
your program appears to be struggling or when you have made some changes to the program, such as adding a new venue,
adopting a new testing strategy, or introducing a new linkage procedure.
How Health Departments and Other Funders Can Use This Tool: HDs and other funders may find it helpful to use this tool in
monitoring grantees or contractors. Staff with responsibility for monitoring contracts or providing technical assistance to local
providers can use a yield analysis to help monitor program performance and identify potential technical assistance needs. HDs or
other funders may also wish to require grantees or contractors complete a yield analysis on a regular basis as part of required
reporting or in conjunction with corrective action for programs that are struggling. HDs and other funders can adapt this tool to
reflect local expectations regarding performance or program requirements.

Instructions for Completing Tool 4. Yield Analysis Part I: Compilation of Data
What is the purpose of this tool? Tool 4, Part I is to be used to compile and organize your program service data.
Who should complete this tool? Non-clinical program managers can complete this tool or others with responsibility for program
M&E.
When should this tool be completed? New programs may first complete this within the first 3 months of program
implementation and then regularly (e.g., monthly) thereafter. Established programs may complete this regularly (e.g., quarterly),
unless the program is experiencing difficulties or there has been some change in the program (e.g., adoption of new HIV testing
strategy).
How should this tool be completed? To complete Tool 4, Part I, you will need program service data for the time period that you
wish to review (e.g., the number of tests conducted, client demographics, test results, referrals made, and linkage completed).
In the top portion of Tool 4, Part I, record the following information in the designated cells:
completed.
number of staff providing services for this program or site, or the number of hours dedicated to HIV testing and linkage
services during the review period.
In the bottom portion of Tool 4, Part 1, record the specified data in each of the numbered cells and calculate the percentages
according to the instructions provided in the column labeled Instructions. Once you have finished compiling your data, you will
need to review and interpret it, and try to draw some conclusions from it about how to adjust your program practices (Part II).
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•
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•

Tool 4. Yield Analysis Part I: Site Information
1. Agency/Program/Site: 4. Location:
2. Reporting Period: 5. Funding Source:
3. Target Population: 6. Funding Amount:
7. Other Information:
Yield Analysis Part I: Compilation of Data
Instructions
8. Number of clients tested for HIV Record the total number of clients tested for HIV during the reporting period.
9. Number of clients from the target
population tested for HIV
Record the total number of clients tested for HIV from the target population during
the reporting period (see #3, above).
10. Recruitment # %
10a. Clients representing the target
population
• In the column marked #, record the number of clients tested for HIV who were
from the target population (from #8, above).
• In the column marked %, record the percentage of clients tested for HIV who
were from the target population. To calculate the percentage, divide the number
of clients from the target population by the total number of clients tested
(#10a/#9).
11. Testing history # %
11a. No previous test • In the column marked #, record the number of clients who report having never
been tested for HIV.
never been tested for HIV. To calculate the percentage, divide the number of
clients who reported no previous HIV test by the total number of clients tested
(#11a/#8).
11b. Tested previously negative/unknown
results
• In the column marked #, record the number of clients who report having a
previous test with a negative or unknown result.
• In the column marked %, record the percentage of clients who reported having
been tested previously and who had a negative or unknown result. To calculate
the percentage, divide the number of clients who reported being previously
tested with a negative or unknown result by the total number of clients tested
(#11b/#8).

Tool 4. Yield Analysis Part I: Site Information (continued)
# % Instructions
11c. Previously tested, HIV positive • In the column marked #, record the number of clients who report having a
previous test with a positive results (i.e., previously diagnosed).
been tested previously and who had a positive result. To calculate the
percentage, divide the number of clients who reported being previously tested
with a positive result by the total number of clients tested (#11c/#8).
12. Number of clients with HIV-positive
test result
Record the total number of clients with an HIV-positive test (newly positive and
previously diagnosed) result during the reporting period.
13. Number of clients with HIV-negative
test result
Record the total number of clients with an HIV-negative test result during the
reporting period.
14. Seropositivity # %
14a. All clients with HIV-positive test result • In the column marked #, record the number of clients with an HIV-positive test
result (from #12).
• In the column marked %, record the percentage of clients found to be HIV
positive. To calculate the percentage, divide the number of clients with an HIV-
positive test result by the total number of clients tested for HIV (#14a/#8).
14b. Clients with new HIV-positive test
result
• In the column marked #, record the number of clients with a new HIV-positive
test result.
• In the column marked %, record the percentage of clients with new HIV-positive
test result. To calculate the percentage, divide the number of clients with an HIV-
positive test result by the total number of clients tested for HIV (#14b/#8).
14c. Clients with previous HIV-positive test
result
• In the column marked #, record the number of clients with an HIV-positive test
result who had previously had an HIV-positive test result.
• In the column marked %, record the percentage of clients with an HIV-positive
test result who had previously had an HIV-positive test result. To calculate the
percentage, divide the number of clients with an HIV-positive test result by the
total number of clients tested for HIV (#14c/#8).
15. Number of clients who received their
final HIV test result
Record the total number of clients who received their final HIV test result during the
reporting period.

Instructions
16. Results receipt # %
16a. All clients who received their final test
results
• In the column marked #, record the number of clients who received their final HIV
test result (from #13)
• In the column marked %, record the percentage of clients who received their
final HIV test result. To calculate the percentage, divide the number of clients
who received their final test result by the number of clients tested for HIV
(#16a/#8).
16b. HIV-negative clients who received
• In the column marked “#,” record the number of HIV-negative clients who
received their final test results.
• In the column marked %, record the percentage of HIV-negative clients who
received their final test results. To calculate the percentage, divide the number of
HIV-negative clients who received their test results by the number of clients who
tested HIV-negative (#16b/#13).
16c. New HIV-positive clients who received
test result who received their final test results.
• In the column marked %, record the percentage of clients with a new HIV-
positive test result who received their final test result. To calculate the
percentage, divide the number of new HIV-positive clients who received their
final test results by the number of clients newly tested HIV-positive (#16c/#14b).
16d. Previously HIV-positive clients who
received their final test results
• In the column marked #, record the number of clients previously diagnosed HIV-
positive who received their final test results.
• In the column marked %, record the percentage of clients previously diagnosed
HIV-positive result who received their final test result. To calculate the
percentage, divide the number of clients with a positive HIV test who received
their final test results by the number of clients previously tested HIV-positive
(#16d/#14c).

# % Instructions
17. HIV-positive linkage to care and
partner services
# %
17a. New HIV-positive with confirmed
linkage to HIV medical care
test result who were successfully linked to HIV medical care.
• In the column marked %, record the percentage of clients with a new HIV-
positive test result who were successfully linked to care. To calculate the
percentage, divide the number of new HIV-positive clients successfully linked to
care by the number of clients with a new HIV-positive test result (#17a/#14b).
17b. New HIV-positive with confirmed
linkage to HIV medical care within 90 days
of test
• In the column marked #, record the number of new HIV-positive clients who were
successfully linked to HIV medical care within 90 days of receiving an HIV test.
• In the column marked %, record the percentage of new HIV-positive clients who
were successfully linked to HIV medical care. To calculate the percentage, divide
the number of new HIV-positive clients with confirmed linkage to HIV medical
care by the number of HIV-positive clients (#17b/#14b).
17c. New HIV-positive with confirmed
linkage to HIV PS within 30 days of test
• In the column marked #, record the number of HIV-positive clients who were
successfully linked to HIV PS.
• In the column marked %, record the percentage of HIV-positive clients who were
successfully linked to HIV PS. To calculate the percentage, divide the number of
HIV-positive with confirmed linkage to PS by the number of HIV-positive clients
(#17c/#14b).
18. Previously diagnosed HIV-positive
out of HIV care at time of HIV test
Record the number of previously diagnosed HIV-positive clients who were not in HIV
medical care at the time of the HIV test.
18a. Previously diagnosed HIV-positive
reengaged in HIV medical care
• In the column marked #, record the number of previously diagnosed clients
reengaged in HIV medical care.
• In the column marked %, record the percentage of previously diagnosed clients
reengaged in HIV medical care. To calculate the percentage, divide the number
of previously diagnosed clients reengaged in HIV medical care by the total
number of previously diagnosed clients who were out of HIV care at the time of
HIV testing (#18a/#18).
19. Number of HIV-negative clients at
high risk for HIV acquisition
Record the number of HIV-negative clients at high risk for HIV acquisition.

# % Instructions
20. Linkage to risk-reduction services # %
20a. HIV-negative clients at high risk for HIV • In the column marked #, record the number of high-risk HIV-negative clients who
acquisition with confirmed linkage to risk- were successfully linked to needed risk-reduction services.
reduction services • In the column marked %, record the percentage of HIV-negative clients who
were successfully linked to needed risk-reduction services. To calculate the
percentage, divide the number of HIV-negative clients successfully linked to risk-
reduction services by the number of HIV-negative clients in need of risk-
reduction services (#20a/#19).

Instructions for Completing Tool 4. Yield Analysis, Part II: Data Interpretation and Program Improvement
What is the purpose of this tool? Tool 4, Part II will help you understand how successful your recruitment, testing, and linkage
strategies are; the factors that might be associated with the effectiveness of these strategies; and strategies that might help you to
make program improvements. Tool 4, Part II will also help you to monitor progress toward achieving your program objectives.
Please refer to the Evaluation Guide, Step 2: Describe the Program for detained discussion about construction of program
objectives.
Who should complete this tool? Program managers, staff, or others with responsibility for program M&E can complete this tool.
Also consider inviting members of your community advisory board or other stakeholders to participate in these discussions. Refer
to the discussion questions presented in Exhibit 9.5 for additional information to help you complete this tool.
When should this tool be completed? New non-clinical HIV testing programs may first complete this within the first 3 months of
program implementation, and then regularly (e.g., monthly) thereafter. Established programs may complete this regularly (e.g.,
quarterly), unless the program is experiencing difficulties or there has been some change in the program (e.g., adoption of new
HIV testing strategy). Part II may be completed only after you have completed Part I.
completed.
number of staff members providing HIV testing and linkage services for this program or site, or the number of hours
dedicated to HIV testing and linkage services during the review period.
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In the bottom portion of Tool 4, Part II, key measures of success for your program are presented in the far left column. These may
correspond to the goals and objectives that you have established for your program (see the Evaluation Guide, Chapter 3, Step 2:
Describing Your HIV Testing and Linkage Program for additional information on writing program goals and objectives). Record
the following information in the designated cells:
Objective: Record the objective that you have set for your program corresponding to the measure of success.
Summary of Yield Analysis: Record a brief summary of the data presented in Tool 4, Part I, relevant to the corresponding
measure of success.
Contributing Factors: Brainstorm with your group to identify the factors that may be affecting the success of your program.
Summarize these factors in the corresponding cells on the table.
Strategies: Brainstorm with your group to identify the strategies that could help you build on your success or could help
you to improve your program. Summarize these in the Strategies column.
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Tool 4. Yield Analysis, Part II: Site Information
1. Agency/Program/Site: 4. Location:
2. Reporting Period: 5. Funding Source:
3. Target Population: 6. Funding Amount:
7. Other Information:
Measures of Success Objective Summary of Yield Analysis Contributing Factors Strategies
engaging members of the
target population?
identifying new infection?
helping clients learn their
test results?
medical care?
PS?
reengaging previously
diagnosed HIV-positive
clients with HIV medical
care?
linking high-risk HIV-
negative clients to risk-
reduction services?

Appendix D ● Page 1 of 19
Template 1. Procedures for Use of Incentives and Client
Incentive Distribution Log
You can use the example below as a template for your own procedures and distribution log.
Adjust the language to align with your organizations policies and procedures regarding the
distribution of incentives.
ACME PREVENTION SERVICES
PROCEDURES FOR USE OF INCENTIVES
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Purchase of incentives must be preapproved, in writing, by ACME’s finance manager.
The finance manager will issue a check made out to the vendor in the appropriate
amount. The ACME credit card is not to be used to purchase incentives. Staff who
purchase incentives with personal funds will not be reimbursed.
Original receipts must be submitted to the finance manager.
Incentives will be stored in a locked filing cabinet in the finance manager’s office.
The program coordinator will sign out incentives prior to each outreach event.
The total number and amount (dollar value) of incentives will be recorded on the
inventory log. The inventory log will be initialed by the program coordinator.
Unused incentives will be returned to the finance manager at the conclusion of each
outreach event, and the unused number and amount will be recorded on the inventory
log. The inventory log will be initialed by the program coordinator.
The following procedures will be observed in distributing incentives to clients:
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•
•
The program coordinator will complete the upper portion of the distribution log, with
the date and location of the event, along with the number of attendees.
Clients must initial the distribution log to indicate receipt of incentives. If gift cards are
used, the program coordinator must also record the code on the gift card.
At the conclusion of the event, the program coordinator must record the total number
of incentives distributed and initial the distribution log.
The completed distribution log is to be returned, along with unused incentives, to the
finance manager.
Procedures updated May 30, 2012.
Appendix D. Templates

ACME PREVENTION SERVICES
INCENTIVE DISTRIBUTION LOG
Event Location: Event Date: Attendees:
Client Initial Inventory #
Incentives Distributed: Incentives Remaining: Total Incentives:
Program Coordinator:

Template 2. Sample Results Letter
You can use the example below as a template for your own letter. It is recommended that you
copy this onto your agency letterhead. Adjust the language to comply with State laws and
regulations regarding release of protected health information and your agency’s policies
regarding release of HIV test results.
Agency Name
Agency Address
______________________________________________________________________________
Neatly print or type client’s name
was tested for HIV on _____________________. The results of that test are NEGATIVE as of this
date. A negative test results means that the test did not detect HIV antibodies.
While this test is highly reliable, this result does not guarantee that you are not infected with
HIV. Most people who are infected will produce detectable antibodies within about 1 month
of infection. However, if you have been recently exposed to HIV, it may be too early to tell if
you are infected. This result also does not mean that you will continue to be HIV-negative in
the future. You should continue to take steps avoid becoming infected.
______________________________________________________________________________
Signature and typed name of authorized agency representative Date

Template 3. Sample Authorization for Release of
Information
You can use this sample as a template for your own client authorization for release of
information. Adjust the language to comply with State laws and regulations regarding release
of protected health information and/or your institutional policies.
Agency Name
Agency Address
Authorization for Release of Information
Client Name: __________________________________________________________________
Client Date of Birth:
I hereby authorize [insert the name of your agency] to release medical and confidential
information, including HIV/AIDS status, alcohol or drug use information, and mental health
status, to the individual or agency listed below:
The purpose of this disclosure: ____________________________________________________
I understand that my records are protected under Federal and State law and cannot be
disclosed without my written consent, unless otherwise provided by law.
This authorization is valid for 1 year from today’s date. I understand that I have the right to
revoke this consent at any time, but my consent must be revoked in writing.
I hereby release [insert the name of your agency], its employees, staff, and agents, from all
legal responsibility or liability that may arise from the disclosure of the information set forth
above, related to my files.
____________________________________________________________
Client and/or authorized signature Date
____________________________________________________________
Witness Date

Template 4. Sample Memorandum of Agreement
You can use the sample below as a template for your own memoranda of agreement. Adjust
the language to reflect the specific terms of your agreement with partner agencies. Please
refer to the section titled Community Partnerships and Referral Resources in Chapter 7 for
additional detail about constructing memoranda of agreement.
Memorandum of Agreement
Between
ACME Prevention Services
and
Center City Community Health Clinic
Effective January 1, 2012, through December 31, 2012, ACME Prevention Services (APS) and
the Center City Community Health Clinic (C3HC) agree to collaborate and coordinate in the
provision of services to prevent HIV transmission in the tricounty area and to ensure that
individuals identified with HIV infection receive expedited linkage to HIV medical care.
Under terms of this agreement, C3HC agrees to the following:
Provide expedited access to HIV medical care for clients referred by APS. Clients referred
by APS will meet with a C3HC patient navigator and will receive testing to evaluate HIV
status (i.e., CD4 and viral load) and STD screening on the same or next business day.
Provide supplemental testing for clients referred by APS suspected of having acute HIV
infection. Clients suspected of having acute HIV infection will be provided with
supplemental testing on the same or next business day.
Provide APS with verification that referred clients have received medical services.
Provide APS with information regarding clients lost to care to facilitate follow-up on
these clients.
Meet with APS on a quarterly basis to review the collaboration.
Provide APS with aggregated data on all clients referred by APS regarding retention in
care, health status (e.g., viral load), and ARV adherence.
Under terms of this agreement, ACME agrees to the following:
Refer clients with reactive rapid test result to C3HC for evaluation and treatment of HIV
disease.
Follow up with clients not in care, including those who have dropped out.
Meet with C3HC on a quarterly basis to review the collaboration.
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Under the terms of this agreement, BOTH agencies agree to the following:
Abide by the terms of the reciprocal data sharing agreement.
Retain copies of client authorizations for release of information.
Provide client-level data necessary to monitor the success of program efforts.
This agreement does not require financial obligations from either party at this time.
Responsibility for coordination of this agreement shall be the parties signed below or their
designees. This agreement will terminate December 31, 2012, and may be renewed for an
additional 12 months upon mutual agreement. Either party may make earlier termination of
this agreement with a 30-day written notice.
Jamal Jones Date
Executive Director
ACME Prevention Services
____________________________________________________________
Abigale Smith Date
Medical Director
Center City Community Health Clinic
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Template 5. Sample Client Referral Form
You can use the sample below as a template for your own referral form. It is recommended
that you copy this sample onto your own letterhead. Adjust the language to comply with
your agency’s policies and procedures on referral.
Agency Name
Agency Address
Client Referral Form
Today’s Date: ________________________
Client Name: __________________________________________________________________
Referred to:
Agency Name:
Address:
Contact Name: _____________________Telephone:
Services Requested/Reason for Referral:
Referred By: ____ Telephone: ___________________________
Neatly print or type your name
Services Received:
Services Provided:
Staff Providing Services: Date Provided:
Comments:
Our client has requested services provided by your agency. Once referral services are rendered, please
complete this section of the form and return it to us at [INSERT ADDRESS and CONTACT NAME].

Template 6. HIV Testing and Linkage Policies and
Procedure
You can use the sample below as a template for your own policies and procedures. Adjust the
language to comply with the policies of your agency and the procedures that you will be
using to implement HIV testing and linkage.
[Insert Your Agency or Site Name Here]
HIV Testing and Linkage Policies and Procedures
[Insert agency name] provides HIV Testing and Linkage services to [insert target population
and or service area, as applicable] HIV Testing and Linkage services provided by [insert agency
name] at [insert venue or location (e.g., health fairs or bars, as applicable)] are conducted in
accordance with these policies and procedures.
I. POLICIES (add, delete, or modify to reflect the policies of your agency)
HIV testing and linkage services provided by [insert agency name here] are:
A. Confidential: Confidential testing refers to HIV antibody testing services in which
personal identifiers are known to persons providing the services, and positive results
are reported to the [insert health department name] in accordance with State
reporting requirements.
[Insert information regarding your agency- or site-specific policy and procedure related to
anonymous testing (e.g., “Agency provides anonymous testing, at clients request,” or “Agency
refers to health department all clients requesting anonymous testing).]
B. Voluntary: Client acceptance of HIV testing and linkage services offered by [Agency]
are voluntary and clients have the right to decline services.
[Insert information regarding your agency- or site-specific policy and procedure related to the
voluntary nature of participation in HIV testing and linkage services (e.g., “Agency reserves
the right to refuse testing to clients who are unable to provide consent or who are being
coerced to accept services).]
C. Cultural Competence: HIV testing and linkage services provided by [Agency] are
culturally competent with respect to the race, ethnicity, gender, sexual orientation,
age, language, development level, literacy, and other relevant factors.
[Insert information regarding your agency- or site-specific procedures related to provision of
culturally competent services (e.g., translation services, referral of clients, provision of services
to clients with low levels of literacy)]

D. Minors: Minors or clients under the age of [insert age at which individuals may
consent for HIV testing and/or medical procedures, as defined by statute or other
applicable policy] may consent to HIV testing and linkage services.
[Insert information regarding your agency- or site-specific policy for provision of services to
minors (e.g., “Agency will not provided HIV testing services to minors contacted through
outreach activities conducted by Agency in bars”) as applicable.]
E. Ethical Behavior: [Agency] staff and volunteers will conduct themselves ethically in
the provision of HIV testing and linkage services. Consumption of alcohol or drugs
during provision of HIV testing and linkage services is prohibited. Sexual or other
inappropriate contact with clients is prohibited.
Written Test Results: [Agency] provides written copies of HIV test results only for
confidentially tested clients and only to clients for whom testing was conducted.
II. TRAINING
HIV testing and linkage services is to be provided only by individuals who have successfully
completed the following training and education requirements: [Insert the training and
educational requirements applicable to all staff and volunteers providing HIV testing and
linkage service].
HIV tests will be performed only by individuals who have successfully completed the
following training and education requirements: [Insert the training and educational
requirements applicable to staff and volunteers performing HIV tests, as applicable]
Individuals performing recruitment, linkage, or other aspects of HIV testing and linkage
services will complete training and education requirements commensurate with their
responsibilities and as required by [insert requirements (e.g., Social Network Training if SNS is
used as a recruitment strategy; phlebotomy)].
III. SITE PREPARATION
[For fixed sites, insert description of set-up and preparation for testing, including the
following:
Supplies, materials, and paperwork required
Where supplies, materials, and paperwork are stored
Who is responsible to prepare and/or package supplies, materials, and paperwork
Location where samples are to be obtained and prepared
Who is responsible for obtaining and preparing samples
Where testing is performed, as applicable
Who is responsible for performing testing
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Include step-by-step instruction when appropriate (e.g., “Client educational packets are
prepared each Monday, by unit administrative assistant).]
[For outreach sites, include step-by-step instructions for site set-up and preparation, including
the following:
Supplies, materials, and paperwork required, including the following:
Equipment and supplies to perform acquire samples
Equipment and supplies to perform testing (e.g., sharps, thermometers, lamps)
Promotional materials (e.g., banners, agency brochures, business cards)
Equipment and supplies needed to ensure confidential space to perform testing
(e.g., white noise machine, curtains, signs)
Other equipment and supplies (e.g., display table, chairs)
Who (title) is responsible for transporting rapid HIV tests (reagents/controls) to and from
the outreach site and how will they ensure temperature control, as applicable
Who (title) is responsible for preparing and packaging supplies, materials, and
paperwork and when preparation is to be completed
Method for securely transporting supplies, materials, and paperwork to and from
outreach site
Set-up and ensuring client privacy:
Where clients will receive services (e.g., the VIP room at the back of the club;
curtained-off area at northwest corner of convention center)
How will privacy be ensured (e.g., a “private” sign will be hung on the door; white
noise machine will be used; window shades pulled down)
Procedures for packing up and returning to your agency, including the following:
Who (title) is responsible for packing up materials, equipment and supplies
Use of inventory checklist, if applicable
Who (title) is responsible for and how will you securely transport confidential
paperwork back to the agency (e.g., all client files placed in a locked box that site
supervisor returns to agency at close of outreach event)
Who (title) is responsible for transporting rapid HIV tests (reagents/controls) to and
from the outreach site and how will he or she will ensure temperature control, as
applicable
Who (title) is responsible for clean-up and what clean-up entails
Who (title) is responsible for transporting sharps and biohazardous waste and
procedures for transport]
IV. CLIENT ENGAGEMENT
[For fixed sites, describe here how you will obtain clients for HIV testing and linkage service.
Include the following in your description, as applicable:
Procedures for client appointments, including who is responsible, times/days of the
week when appointments are taken
Prioritization of internal and/or external referrals to HIV testing and linkage
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Educational and risk-reduction supplies and materials
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Handling of drop-in clients (e.g., are there certain days of the week or hours of the day
when services are provided on a drop-in basis?)
Intake procedures, including who will conduct intake and how intake will be conducted
(e.g., pen and paper form or interview with receptionist; which forms are to be used;
what information will be provided to clients at intake, whether consent will be
addressed with clients at intake)]
[For outreach sites, describe how client recruitment and engagement will be conducted.
Include step-by-step instructions, as applicable:
Promotion of services (e.g., canvassing the neighborhood; approaching individuals or
small groups)
Engaging clients, including when clients should not be approached (e.g., approaching
sex workers when they are trying to work)
Management of client flow (e.g., who will escort clients to the area where testing is
conducted, who will manage access to the area where tests are conducted)]
Intake procedures, including who will conduct intake and how intake will be conducted
(e.g., pen and paper form; client self-administered survey on tablet personal computer
which forms are to be used; what information will be provided to clients at intake,
whether consent will be addressed with clients at intake)]
V. TESTING
A. Information and Consent
Provide Information
Prior to HIV testing, provide clients with information about HIV testing. Each of the following
are to be addressed:
Overview of HIV testing
Procedure for testing
Procedure and timeline for obtaining results
Next steps and procedure associated with HIV-positive results
Next steps and procedure associated with HIV-negative results
Benefits and drawbacks of testing
HIV basics (e.g., transmission, prevention)
Meaning of test results, especially the window period (relative to last exposure and test
strategy used)
Applicable laws (e.g., disease reporting laws)
[Insert description, including step-by-step instructions on how information about HIV testing
will be provided to clients. In your description, address the method (e.g., brochure, by testing
staff that will be used to provide information, who has responsibility for collection of this
information, and how it will be documented in the client chart.]
Provide clients with the opportunity to ask questions.
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What is being tested (e.g., antibodies)
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Explain Confidential Versus Anonymous Testing (as applicable)
A confidential test requires that a client’s name appear on all laboratory slips and be
documented in the client chart. The result is not released without the client’s written
authorization, except for [insert applicable statutes or regulations]. Test results are
reported, in accordance with statute for [insert State].
In an anonymous test, the only identification used on laboratory slips, client charts, and
reports to the State is [insert code you will use].
Explain Test Strategy (and options for testing, as applicable)
Rapid HIV test: The test that we use require [insert sample type and describe method for
collection]. The result of the test will be available in [insert time to result available to
client]. If that test is reactive, another test will need to be performed to definitively
determine whether or not you have HIV. [Insert description of supplemental testing
and/or referrals, as applicable].
Laboratory HIV test: This test requires that we obtain [insert sample type and describe
method for collection]. The result of the test will be available [insert time to result
available to client. Describe process for client obtaining obtain results.]
Assess Client Sobriety and Ability to Consent
[Describe the process that you will use to assess client sobriety and ability to consent to HIV
testing, for clients who appear to be under the influence of drugs or alcohol. Provide a
detailed list of the criteria that testing staff should use to determine whether a client is able to
provide consent. Describe what testing staff should do if a client does not appear to be able
to consent to HIV testing.]
Obtain Consent
All clients tested for HIV must voluntarily consent to HIV testing prior to having a test
performed. [Insert description of process for obtaining and documenting consent (e.g., a
client must read and sign consent form, or a client reads information sheet, verbally consents,
and consent is documented in chart).]
[Describe other circumstances (e.g., a client becomes aggressive or violent) under which
testing should not be provided or should be discontinued for a client. Describe what testing
staff should do in the event that such a situation arises.]
Universal Precautions [(adjust this to reflect your test strategy and site-specific procedures]
Universal Precautions will be followed at all times during specimen collection and performing
HIV tests.
All samples and materials containing sample (e.g., rapid tests cassettes) must be
handled as if they are capable of transmitting an infectious organism. This includes
control vials and all rapid test kits.
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Staff collecting samples or performing tests must use protective equipment, including
gloves and lab coats.
Staff collecting samples or performing tests must follow procedures for biohazard safety
such as hand washing, use of gloves, sharps and biohazardous waste disposal, and spill
containment and disinfections.
Hand washing is a vital component of biohazard control and good laboratory practices. All
staff collecting samples or performing tests will do the following:
Wash hands before and after every client contact; before and after meals, breaks, and
using the toilet; and before going home.
Remove jewelry before washing hands and forearms or using hand sanitizer. Water
should be a warm gentle stream and hands and wrists should be made wet.
Lather hands and wrists using plenty of soap. Hands must be kept lower than elbows so
that the water runs from the least contaminated area (forearms) to the most
contaminated area (fingers).
Wash hands, wrists, and between fingers for 15 seconds using friction and rinsing
thoroughly.
Dry hands and wrist with paper towels.
Turn off the faucet with a paper towel, avoiding direct contact with the contaminated
faucet.
Sample Collection and Preparation
Rapid HIV Tests: [Insert step-by-step procedure for sample collection. Include in the
description what type of sample will be collected (e.g., oral or fingerstick whole blood); where
the sample will be collected; and by whom (title) (e.g., by the testing program staff in the
room with the client; by a technician in the laboratory area).] Note: Step-by-step instructions
for sample collection are provided by the manufacturers of each rapid HIV test. These are
included in the package inserts for rapid HIV tests. These can be copied into this procedure.
Supplemental Specimen Collection (if applicable): [Describe how specimens will be collected
following a reactive rapid test. Include in your description the test strategy that will be used
(e.g., laboratory or second rapid), as well as the type of sample (e.g., venous blood or oral
fluid); who (title) will obtain the specimen, and where the specimen is to be obtained (e.g., is
the client brought back to the lab or does a phlebotomist come to the area where the client is
seated?). You can refer back to other parts of the procedures (e.g., sample collection for
laboratory HIV tests, as applicable).]
Laboratory HIV Tests: [Insert step-by-step procedure for oral or venous sample collection and
preparation. Include in your description who collects the specimen (title) and how you
arrange for phlebotomy, if applicable. Include in your description where the specimen
collection is to occur.] Note: Step by-step instructions for oral fluid collection are included
with test collection kits and are available from the manufacturer. Step-by-step instructions for
preparing, packaging, and submitting oral fluid specimens are specific to individual
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laboratories. Obtain these from the laboratory that will be processing your samples and insert
them into this procedure.
Sample step-by-step instructions for collection and preparation of venous samples are
available in the Resources section of the toolkit. The laboratory processing your samples may
have specific requirements for preparation. Obtain these from the laboratory and insert them
here.
Testing Procedure (Rapid HIV Tests)
[Insert step-by-step procedure for performing rapid HIV test. Include in your description who
(title) will perform tests and where test will be performed (e.g., outreach staff will perform the
test in the VIP room of the club or testing program staff will perform tests in the lab area of
agency). Indicate whether test is run in presence of client and procedures, as applicable, to
block client view of test. Indicate who (title) will read the test for results and who (title) will
document test results.] Note: Step-by-step instructions for performing rapid tests are
provided by the manufacturers of each rapid HIV test. These are included in the package
inserts for rapid HIV tests. These can be copied into this procedure.
Results Delivery (address as applicable to the HIV testing strategy you use)
[Describe who (title) will be responsible for results delivery and where results delivery will
occur.]
Rapid HIV Tests (Reactive Result)
Deliver the result to the client.
Explain the meaning of the result to the client: the test has detected HIV, but
supplemental testing will be required to confirm HIV diagnosis.
Explain supplemental testing [Insert description of method used for supplemental
testing (e.g., second rapid, laboratory based with blood sample). Insert step-by-step
instruction for supplemental testing (e.g., referral to medical provider, sample obtained
onsite) including how the client will receive the test result. Address where the client will
go and what he or she will do (e.g., receive risk-reduction counseling) while waiting for a
second rapid HIV test result]
Provide risk-reduction information and messages
Document results in client chart
Rapid HIV Test (Negative Result)
Explain the meaning of the result to the client: the test has not detected HIV. Interpret
result relative to recent exposure and window period for test used.
Provide recommendation for retesting, including testing for acute HIV infection, as
applicable.
Provide risk-reduction information and messages.
Document results in client chart.
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Laboratory HIV Tests: [Insert agency name] provides clients with results of laboratory tests
only after the final written results are returned to [insert agency name] by the laboratory.
[Describe procedure for obtaining results from laboratory, e.g., the supervisor retrieves results
from secured fax every morning and records them in the client charts]
Clients may receive results [describe methods that clients may use to obtain results, e.g.,
phone]. Clients must provide [insert description of identification required] to receive test
results. In delivering the results to the client, do the following:
Explain the meaning of the result to the client.
Positive result means that the test has detected HIV.
Negative result means that the test has not detected HIV. Interpret result relative to
recent exposure and window period for test used.
Provide recommendation for retesting (if negative).
Provide risk-reduction information and messages.
Document results in client chart.
VI. REFERRAL AND LINKAGE
[Insert agency name] provides a variety of prevention and support services for individuals at
risk for or living with HIV. If [insert agency name] is unable to provide services that match the
clients needs, clients will receive referrals to other agencies.
[Describe who (title) will be responsible for conducting assessment of referral needs, and for
planning and managing referrals.]
HIV-Negative Clients: HIV-negative clients at high risk for HIV infection will be provided with
risk-reduction services that match their needs. The [insert title of individual(s) providing
referral services] will do the following:
Review risk information provided by client at intake.
Assess risk-reduction needs and identify barriers to accepting risk-reduction services
[insert description of the method that you will use to assess risk-reduction needs (e.g.,
survey completed by client) and when assessment will be conducted (e.g., while client is
waiting for test results].
[Insert description of risk-reduction services provided by your agency, as applicable;
provide step-by-step instructions of how clients will be offered risk-reduction services
(e.g., testing program staff will provide high-risk clients the opportunity to receive
Personal Cognitive Counseling). Testing program staff will provide PCC at the time of
results disclosure.]
Make referrals, as applicable [insert description of your process for making referrals,
including who is responsible for making the referral and the type of assistance provided
to clients in accessing the referral].
Document risk-reduction services and/or referrals in client chart.
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Clients with a Positive HIV Test Result: Clients with a positive HIV test result will be linked to
HIV medical care.
[Insert description of the method that you will use to link clients to medical care and
who (title) will be responsible for providing assistance in linkage.]
Assess barriers to care [insert description of method you will use to assess barriers (e.g.,
referral specialist will administer service assessment to client)].
Make referral [insert description of your process for making referral, including who is
responsible for making the referral and the type of assistance that will be provided to
client].
Document referral and assistance provided (as applicable) in client chart.
VII. SAFETY (address as applicable to your setting)
The safety of [insert agency name] staff members and volunteers is the highest importance.
To ensure safety, the following should be observed:
Fixed Sites:
Two staff are to be onsite at all times when HIV testing services are offered.
A supervisor is onsite at all times when HIV testing is provided.
If testing is provided after hours, a supervisor is to be on call. The schedule for on-call
supervisors is posted [insert location] every [insert when schedule posted].
If testing is provided after hours, all doors are to be locked at all times.
If testing is provided after hours, staff will contact the on-call supervisor at the
conclusion of testing.
The supervisor is to be notified of difficult situations (e.g., aggressive clients)
immediately.
Staff are not to provide their personal contact information (e.g., cell phone number) to
clients.
Staff are not to provide to clients with rides in their cars.
[Insert additional safety precautions and procedures]
Outreach Sites (as applicable):
A minimum of [insert number] of staff are to be onsite at all times when HIV testing
services are provided.
One staff member will be designated as the lead staff.
Outreach testing is to be provided only at scheduled times and as approved by the
program supervisor.
A supervisor is available at all times via phone during outreach testing events.
Staff will contact the on-call supervisor at the conclusion of testing.
Staff are not to provide their personal contact information (e.g., cell phone number) to
clients.
Staff are not to provide to clients with rides in their cars.
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Outreach Events:
Staff must display ID badges at all times.
Staff should remain in view of each other at all times.
Staff may not enter a private residence during outreach events.
Staff may not carry weapons.
Staff may not buy, receive, or use drugs or alcohol.
Staff may not buy or receive sexual favors from clients.
Staff may not participate in illegal activities.
Staff may not eat or smoke.
[Insert additional safety precautions and procedures]
VIII. Record Keeping
All client records are kept confidential.
HIV testing records are [insert whether testing records are kept separate from other
client records, if applicable].
Records of anonymous tests are kept separate from other client records (if applicable).
Client charts are kept in [insert where client charts are kept, describe who (title) is
authorized to access them, and when].
Client charts are returned to [insert who (title) or where client charts will be kept] when
not immediately needed (e.g., for results delivery, or documenting completed referrals).
Client charts are never to be left out on desks or stored anywhere other than [insert
where charts are to be kept].
For outreach testing: Client charts and other confidential information are to be
transported securely [insert method you will use to transport confidential information]
to and from outreach sites. Client information is to be returned to the [insert where
client charts are kept], immediately [insert other timeframe, as applicable] after the end
of outreach events. Confidential information is not to be taken to or stored in staff
homes or cars.
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Template 7. Outreach Testing Supplies and Materials
Checklist
This is a sample Outreach Supplies and Materials Checklist. Adjust this checklist to reflect the
supplies and materials that you will need for your outreach HIV testing event. Complete this
checklist before and after your outreach event to make sure that you do not leave anything
behind. Also revise this checklist periodically to reflect any changes needed (e.g., different
testing supplies, new brochures).
Event/Location:
Date: Site Supervisor:
Promotional Materials and General Supplies
Agency brochures
Agency business cards
Pens or markers
Stapler (with staples)
Tape
Scissors
Agency banner
Folding table
Folding chairs
Umbrella/tent
Tablecloth
Drapes/drop cloth
Education and Risk-Reduction Supplies
Testing information brochures
Educational/risk-reduction pamphlets
Incentives Number:
Condoms (male) Number:
Condoms (female) Number: _________
Lubricant
Records
Consent forms
Referral forms
Release of information forms
Laboratory requisition forms
Lock box
Client test log
External control log
Temperature log
Incentive distribution log
Testing and referral data collection forms
Testing Supplies
Vacuutainers
Tourniquet
Sample collection tubes
Blue absorbent disposable pads
Personal protection gown/lab coat
Latex gloves
Hand sanitizer
Antiseptic wipes
Sterile gauze pads/cotton balls
Sterile lancets
Adhesive bandages
Digital timer or stopwatch
Digital thermometer
Lamp or flashlight
Level
White noise machine
Cooler or insulated bag for storing tests, controls,
and/or samples
Red biohazard bags
Sharps containers
Uni-Gold Clearview Complete OraQuick ADVANCE
Rapid test kits
Number of kits:
External controls
Subject information booklets
Wash solution
Collection/transfer pipettes
Rapid test kits
Number of kits:
External controls
Running buffer
Test stands
Rapid test kits
Number of kits:
External controls
Test stands
Specimen collection loops

ICF Macro an ICF International Company
Corporate Headquarters
9300 Lee Highway
Fairfax, Virginia 22031
Phone: 703-934-3740
Fax: 703-943-3740
Atlanta Office

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