Coherence
Before the educational intervention, HIV testing was described as ad-hoc, opportunistic and informed by patient characteristics (e.g. high-risk groups such as men-who-have-sex-with-men, people who inject drugs and country of origin with high-HIV prevalence) and behaviours (e.g. unprotected sex), appointment type (e.g. sexual health screening and antenatal appointments) and consultation presentation with “obvious” indicator conditions (e.g. rash, chronic diarrhoea). Some HCPs felt that individual and practice level HIV testing was adequate while others reflected that more testing was needed. Several HCPs described offering HIV tests infrequently (i.e. 1–2 tests per year) while others tested routinely. Some nurses described only doing HIV tests requested by GPs.
It was very ad hoc and a bit chaotic, and it would be really just if we thought of it.
Practice 9, Female, Doctor, Interview 13
Pre-training, the acceptability of HIV testing among patients was perceived to vary and some HCPs were anxious about offering the test to some patients due to concern about appearing to judge and stigmatise.
If you’d have asked me that before the teaching I would’ve very much said the communication side, the getting across, and the worry that the patients would feel that I was judging them.
Practice 4, Female, Doctor, Interview 18
Most HCPs felt the training was necessary and relevant. However, two questioned the appropriateness of targeting their practices based on high-HIV prevalence because they perceived the incidence of new HIV cases as low.
I think it’s [educational intervention] extremely necessary, (…) for our practice population it’s extremely relevant.
Practice 7, Female, Doctor, Interview 4
I think we actually have a very low [HIV] incidence because the vast amount [of patients] were diagnosed sort of 10 years ago (…) actually the prevalence may seem great but whether we were really a target audience is not quite as clear to me.
Practice 9, Male, Doctor, Interview 20.
Some HCPs felt reasonably knowledgeable about HIV pre-training in part due to their practice population. While a few HCPs described lacking HIV knowledge (e.g. awareness of indicator conditions) and training.
I would have thought we’re reasonably clued-up on this kind of thing because of the population we work in.
Practice 4, Female, Doctor, Interview 14
Cognitive participation
HCPs approved of the training’s interactive and informal style, which encouraged practice level discussion and supported increased awareness of HIV testing practice of peers. The training length and location was acceptable, however, some practices experienced difficulties organising a convenient time for staff due to variable working patterns. Well attended sessions were held within pre-existing staff meetings. The content was seen as appropriate to primary care and pre-existing knowledge. The local and specialist knowledge of the GUM specialist registrar delivering the intervention was valued. The intervention deliverer and a minority of participants described the training as increasing knowledge of local specialist services for patient referral and reciprocal relationships between primary and specialist sexual health care.
I liked the way it was very informal, lots of opportunity to ask questions, that was really useful, but I loved the way she delivered these messages all the way through (…) she let people chat around the subjects and then she brought them to the conclusion.
Practice 4, Female, Nurse, Interview 23
It’s nice to know what service is available and there are specialists who would be able to help or give some advice.
Practice 3, Female, Nurse, Interview 10
Most HCPs described intentions to change their practice in relation to HIV testing and adopt some of the messages from the training. The training helped HCP address the barrier of remembering when to offer an HIV test by increasing consideration of HIV. Most HCPs described feeling more aware of the need to test for HIV, the importance of testing early to improve prognosis and increased knowledge of both indicator conditions and HIV prevalence of their practice population. The training addressed HCPs concern about patients wanting detailed HIV information, by equipping them with more knowledge and verbal strategies to use. Most HCP felt more confident in their HIV knowledge, ability to talk to patients about HIV and to offer tests. In contrast, a minority did not feel more confident as this was not a pre-training issue.
‘Think HIV’ so in a much wider set of conditions or symptoms, or situations, to actually be thinking about testing (…) I think it’s my thresholds and my internal alarm bells, probably have got a lower setting now than they did before.
Practice 1, Male, Doctor, Interview 16
I would probably now offer it more readily if needed rather than being panicky and scared about offering it.
Practice 1, Female, Nurse, Interview 11
I think it was just really ways (…) incorporate it into the consultation (…) if somebody was disclosing…you know if a man was disclosing to you that they’d you know had sex with another man or drug user etc., then how you can actually move that consultation on to say why we want to test and you know little scenarios of how you could ask you know, ask that and inform the patient – I thought that was really good.
Practice 5, Female, Nurse, Interview 9
Collective action
When to test
Following the training, HCPs were more likely to view HIV as a normal, routine test. Some HCPs described targeting testing toward patients with indicator conditions rather than focusing on those considered to be at increased risk. This reflected consideration of HIV testing for a “wider spectrum of people” and a “lower threshold” for offering the test, which in part was attributed to an increased awareness of indicator conditions. This led to it being viewed as a test to offer alongside other tests. Indeed, some GPs acknowledged that it can be difficult to ascertain whether patients are at high-risk of HIV which could prevent them from offering tests appropriately. However, some HCPs still felt the need to use patient characteristics and explicit or assumed risk factors to justify HIV testing and two GPs commented that it remained easier to offer an HIV test to high-risk patients.
I think [the key take home message from the training is] don’t be afraid to ask the question or offer the test, because we always assume there are certain high-risk groups so we should just be focusing on them and in fact it’s out there, anybody could be affected, its perhaps where you least expect it.
Practice 11, Female, Doctor, Interview 25
I mean obviously for high-risk groups it’s different, I think about HIV a lot more, you know, if I see a homosexual man or an intravenous drug user, or a sex worker or something. Then I think about it, but in the general population I think about it far less.
Practice 9, Female, Doctor, Interview 15
The training was experienced as increasing the likelihood of considering HIV as a diagnostic test for atypical, unexplained and persistent infections. In contrast, some HCPs queried the practicality of testing those with common indicator conditions (e.g. chronic tiredness).
… Immune things or you know recurrent viral illnesses, recurrent bacterial infections, things that normally in my mind I’d jump straight to ‘oh we need to check they’re not diabetic’ are now also kind of jumping in to my mind ‘oh we need to check for HIV status as well’ which again is a change.
Practice 4, Female, Doctor, Interview 18
The training reassured HCPs that patients are likely to find HIV testing acceptable and concerns about offending patients were reduced by highlighting that testing should be routine rather than targeted at high-risk groups. This helped address concerns about offering an HIV test as “insinuating anything about their [patient] lifestyle”. HCPs also felt more confident about allaying patient anxiety.
They’ve taken it better than I originally maybe thought they had and maybe that’s why I have become more relaxed about it myself. … my own worry I think as I said at the beginning would be that they would feel that I was judging their behaviours and, but actually you know…maybe it’s the way that I’m now quite confident in putting it.
Practice 4, Female, Doctor, Interview 18
I think the training was quite good about encouraging us to normalise it [HIV testing] and you know opening it up to be a more frequent test that we do … and I think with that would follow that people expect it more and don’t consider it to be a judgmental or negative thing to be doing like it perhaps was in the past.
Practice 12, Female, Doctor, Interview 8
The training led to nurses and healthcare assistants (HCAs) feeling more empowered and confident to offer HIV tests without referring patients to or asking a GP’s permission. Some HCPs perceived themselves and others to be offering more HIV tests, while others felt the training had limited impact on testing practice and they had not yet had the opportunity to test for HIV.
Now I can make a decision of who I need to do it on and I don’t have to run to the GP and ask him all the time.
Practice 1, Female, Nurse, Interview 11
I’ve requested two patients have HIV tests since the training which is probably about the same as I’ve done in the year prior to that, so in other words I’ve increased my frequency of testing.
Practice 9, Female, Doctor, Interview 21
I would be keen to try and increase my screening but as, yet I haven’t sort of felt ‘oh this is a case where that’s relevant’.
Practice 9, Male, Doctor, Interview 20
How testing is offered
Following the training, consultation communication about HIV testing was described as more “forthright”, “matter of fact”, “informal” and, “less in-depth”. Some HCPs felt that the time needed to offer an HIV test had reduced since the training because it highlighted that the test can be offered without lengthy counselling. For some, this represented a change in practice, which made offering a test easier and more efficient and enabled HIV tests to be offered in routine consultations for other conditions. In contrast, more experienced HCPs reflected that their own “patter” around HIV testing had not changed, while a minority argued that offering an HIV test could not be done quickly as informed consent had to be sought to ensure patients understand the test’s implications.
In the past, one of the things you know if I did think of it, then it would be ‘how am I going to get this into the discussion? What other discussions are gonna be raised? We’re already 10-15 minutes into a 10-minute appointment … ’ whereas now I can say ‘well we need to check some bloods, as part of those blood tests I want to check your kidneys, your liver, and if it’s ok with you I’m also gonna add on an HIV test because that can also have quite a big impact on your physical health’ (…) it may well be negative but it’s better to check for it.’
Practice 4, Female, Doctor, Interview 18
I don’t think we’d have a leg to stand on if we did an HIV test on somebody without them knowing and it came back positive (…) so that I didn’t agree with her [intervention deliverer] (…) and because there’s stigma attached to HIV testing it’s particularly important that consent is documented.
Practice 9, Female, Doctor, Interview 19
Reflexive monitoring
Several barriers to HIV testing persisted after the training. Relatives and interpreters present in consultations or patients presenting with multiple issues made discussing HIV challenging. Similarly, although smear tests were viewed as a good HIV testing opportunity it was difficult to do both tests in the same consultation due to time constraints. Patients seeing multiple HCPs was another challenge for detecting relevant signs and symptoms reported previously. Some GPs felt it was unlikely that they would take bloods themselves in the consultation, instead some practices had a phlebotomy service and others asked patients to book in with a nurse. A couple of nurses described doing blood tests within the consultation rather than asking patients to make another appointment as they may not return. A few HCPs raised having continued concerns of introducing the topic of HIV when this was not the original reason for consulting. Managing patient expectations and the patient agenda was challenging in this situation. A minority of HCPs felt HIV testing was not part of their role either because they did not see ‘appropriate’ patient groups or believed GPs were responsible for these tests rather than nurses.
You’ve got ten minutes, and the HIV testing is not top of your list. And so what I would normally do in that situation is tell them to come back and see the nurse or make another appointment for a sexual health screen, which I appreciate isn’t ideal, because you should seize the moment, but there’s only so many moments in a consultation and you’ve often run out by that point.
Practice 4, Female, Doctor, Interview 14
Approximately half the interviewed HCPs had no suggestions for improving the training. A minority suggested role-play exercises or observing consultations in which HIV tests are offered and two suggested that more case examples would be valuable. A couple of HCPs wanted more guidance on dealing with positive test results and a few HCPs suggested a longer session.
Some HCPs commented that they struggled to remember the training content, beyond the key messages. “Regular”/ “intermittent” follow-up sessions were recommended by several HCPs to help them remember the content, consolidate learning and optimise the training’s impact.
HCPs suggested email reminders of the training content, computer system (e.g. pop-ups) and laboratory prompts as well as universal screening for all new registrants could support/increase HIV testing. Although computer prompts were seen as a good idea, one nurse queried how such a system would determine which patients to include a pop-up for or whether a universal pop-up system would be more appropriate. Too many or indiscriminate prompts may become ineffective. A minority of HCPs noted that the option to test for HIV was not easily visible on the computer system. Testing encouragement and feedback from the laboratory was expected to support HIV testing. One practice described how the laboratory had praised a HCP for testing for HIV and this had been shared within the practice as a good learning point. Automatically adding HIV tests for related blood tests were suggested. However, these measures were expected to have workload and financial implications. A more efficient system for giving results whereby receptionists phone patients with negative results was proposed. While, in some practices, all HIV test results were given by GPs which may limit the potential to increase HIV testing due to the workload implications.
There were some practices who when they have negative results all the results are given out by reception (…). There were other practices that had a policy where HIV tests specifically were given out only by GPs, whether they were positive or negative, so then the thought of increasing the amount of HIV tests that they were going to have to manage was just insurmountable, so in a couple of those practices (…) I spent quite a long time talking about results management (…) giving them an opportunity to reflect on why they have that policy for an HIV test and not for other tests and whether that was really appropriate.
Intervention deliverer