What is the activity?
Clinical interventions have been undertaken in community settings almost as long as the NHS has existed - for example, blood donation sessions in the workplace. However, since the publication of the National Strategy for Sexual Health and HIV (Department of Health 2001) they have become much more common as a tool for diagnosis of HIV and other sexually transmitted infections (STIs).
Many charitable organisations now host clinical sexual health interventions, including chlamydia screening, hepatitis B vaccination, HIV testing and other screening for STIs. Others provide fast-tracked referrals into HIV testing services, or even chaperone their clients into standard NHS environments and provide informal support and / or interpretation.
Of particular interest here, are HIV testing services coordinated by community or charitable organisations. The actual counselling and testing in these interventions is often provided by staff from local genito-urinary medicine (GUM) or sexual health services, with the charitable organisation provide the venue, the reception staff and promote the intervention to potential users. Im many circumstances, clinical governance remains with the organisation providing the nursing and health advising staff, and they also provide the bridge back into mainstream HIV services, which is especially important when someone receives a positive HIV diagnosis.
Testing and counselling should be undertaken by fully qualiﬁed staff in rooms appropriately equipped and adequate supervision, clinical governance and insurance should be in place. While it is feasible for charitable organisations to directly employ staff qualiﬁed to provide HIV testing and other clinical interventions, there will rarely be sufﬁcient demand for the services to make such appointments worthwhile.
Community-based HIV testing services frequently use rapid testing technologies, also commonly know as point-of-care testing (or PoCT). Testing kits usually require a ﬁnger-prick of blood applied directly to a small disposable diagnostic device. These kits are also used in clinical environments where rapid testing is the goal and are considered sufﬁciently sensitive and speciﬁc for a preliminary HIV diagnosis. The kits themselves are relatively inexpensive (usually less than £10), and give a result in less than ten minutes. Where HIV infection is indicated by the rapid test kit, a full blood test is required to provide conﬁrmation.
Strengths and limitations
People who are wary of interacting with standard NHS services - such as GP surgeries, or hospitals - may feel more comfortable in a community setting where there is a pre-existing relationship of trust.
Making HIV testing - or any other clinical intervention - easily accessible in community venues increases their acceptability to many users. Evaluation data (Weatherburn et al. 2006, Weatherburn et al. 2006) suggests users particularly welcome services that are accessible outside core hospital hours (9am-5pm) and where no appointment is necessary. Clinical sessions can be used as a means of referring individuals to other services, as providing information and advice and distributing HIV prevention resources (such as leaﬂets and condoms). Further evaluation of expanded opportunities for testing in eight pilot cities has been undertaken by the Health Protection Agency. Their interim report, Time to test for HIV (HPA 2010), suggests that testing carried out in the community may carry a higher positivity rate (more HIV positive diagnoses per test undertaken) than HIV tests performed in clinics.
Because of the relatively high cost of stafﬁng, sessions tend to be short (typically 2-3 hours during which 8-10 people might be tested) and may only occur once a week. However, substantial effort might be needed to ensure service uptake, so service promotion will be required.
Many clinical interventions in the community test for one speciﬁc infection only. People attending standard genito-urinary medicine (GUM) services might expect to receive a battery of screening tests that could identify a larger range of infections.
Some agencies believe it is unethical to test for HIV in certain settings (such as gay saunas) and / or at certain times (such as a weekend evening) and, as such, HIV tests might not be offered.
Where does it happen?
Clinical interventions can occur in public, private and commercial spaces where MSM socialise or use other services, including clubs or pubs, sex venues such as saunas, colleges / universities, businesses and community centres. In reality, clinical interventions in the community often occur in the ofﬁces of the host charities themselves, because of the speciﬁc demands of clinical interventions.
The host charity must provide a waiting or reception area; at least one private room and ideally two, each with comfortable seating for up to 3 people; a sink (for hand-washing); a hard ﬂoor (in case of sample spillage); and sharps boxes for the disposal of clinical waste. There should be a secure area for keeping conﬁdential records, and rooms should be equipped with a panic button system to be used if there is a physical danger.
Centre-based interventions lack the immediacy and coverage of outreach interventions. The self-referral demanded by such services means that individuals have identiﬁed a need (knowledge), decided to act to get it met, found out where to go, planned a time to attend, and had the capacity to act on it. People using such services demonstrate motivation (will) and the capacity to seek services to meet their needs (power).
Frequently delivered alongside ...
- 1-to-1 information and advice
- 1-to-1 therapeutic change
- Interactive distribution
- Static distribution
Issues to consider
Providers should be familiar with a range of sexual health issues such as the transmission, prevention and treatment of STIS and HIV. Beyond this, they also require familiarity with services to which they can make appropriate referrals. Workers providing information and advice should have proven listening and communication skills.
Agencies will need to have procedural and boundary guidelines for workers, and will need to ensure that these are built into staff inductions and are regularly revisited. These should aim to maximise the physical safety and comfort of workers while also ensuring a standardised service. The providers’ credibility is paramount to the success of these interventions, therefore workers will need training about personal, professional and social boundaries during work (and about contact with clients outside of work). The Sigma Research evaluation of Terrence Higgins Trust’s fasTest pilots of HIV testing in the community (Weatherburn et al. 2006, Weatherburn et al. 2006) concluded that the success of the fasTest interventions was a function of: their promotion; a need to establish HIV status in the local population; and pre-existing service provision in the locality of the site (ie. the availability and accessibility of comparable HIV testing services). This same evaluation demonstrated:
- More than half of all service users reported that their main reason for choosing fasTest over other options for HIV testing was because the test result was available at the same visit.
- Another third stated that it was more convenient because of the after hours nature of the service and the absence of a need for an appointment.
- None of the clinics ran at full capacity for the entire pilot period but managing (over)demand was problematic at times in all sites. Overall, on average one HIV test was delivered for every 41-53 minutes of clinical staff time.
- Promotion of the service affected uptake but more expensive methods of promotion (including outreach) did not have a large impact on uptake.
Aims and outcomes
Community testing interventions are primarily a means of increasing HIV (and STI) diagnoses. They seek to address Population Target #1 of this framework, that is to reduce the average length of time between HIV infection and HIV diagnosis in men who become infected.
- The existence of community testing sites aims to increase the uptake of HIV testing (and STI screening) - see associated choice and potential aims associated with HIV testing knowledge; STI knowledge; and the testing opportunities and skills required.
A variety of claims are made about the utility of clinical interventions in community settings - most common among these are the assertion that the population of people testing in community settings is different from those that test at GUM clinics, GP surgeries or elsewhere in the NHS. Most commonly it is claimed that the population using community testing sites will be younger, more recent migrants and / or more recently infected with HIV. None of these claims are proven but none are necessary to justify the intervention since HIV testing in community environments expands HIV testing capacity in a locality and improves patient choice.
Monitoring and evaluation
Clinical interventions in community settings are generally subject to monitoring and access evaluation exercises which collate information about service users’ basic demographics' (age, ethnicity, gender, geographical location etc.) and their expected and actual test results. These details will enable some assessment of whether the intervention is reaching the desired target populations. Evaluation of the outcomes of community testing and immunisation interventions will require speciﬁc funding and research expertise.
Useful evaluation models for community testing are outlined in the evaluation reports for the eight pilot community testing sites funded by the Department of Health and drawn together by the Health Protection Agency in Time to test for HIV (HPA 2010).
Page last updated: 17 June 2013
Community testing clinics
The Lesbian & Gay Foundation (LGF) runs two clinics in partnership with Manchester Public Health Development Service and the Manchester Centre for Sexual Health. One is a full sexual health screening service running weekly from two City Centre saunas, and LGF’s Community Resource Centre. The other offers point of care HIV testing. Clients are greeted by LGF staff who explain the tests available. Tests are performed by nurses who perform pre and post-test discussions.The testing services are publicised through LGF’s safer sex packs that promote their HIV testing campaign. LGF feel that clinics in saunas offer an opportunity to target men who might not access mainstream sexual health services.
Testing @ Leicester Pride
Trade Sexual Health partnered with Leicester GUM Clinic to present a Health and Well-being Marquee offering HIV and STI screens to men attending Leicester Pride 2011. With development funding from the national CHAPS programme, the marquee offered a range of STI tests. A decision was made not to provide rapid HIV tests, overcoming ethical concerns about giving results to men when they might not be in an environment to receive them. Instead, results are provided via the GUM clinic. Over 100 men chose to use the service and an exit survey highly rated the acceptability of the intervention. Trade are now producing a tool-kit that highlights their learning from running clinical testing services at community events.
Yorkshire MESMAC's Testing Times aims to increase access to rapid HIV testing and STI testing by providing services in MSM community settings in Leeds. Rapid HIV tests, and pee-in-a-pot screening for gonorrhoea and Chlamydia, are provided by MESMAC. Nurses can give hepatitis B vaccination in the same settings. Removing barriers to accessing services is seen as important - especially if men have concerns about confidentiality in traditional sexual health clinics. This service allows men to access STI services in familiar settings. The element of peer support and having services provided by other MSM is also important. Workers also provide information on PEP, STI and HIV prevention and refer on to other services.