Targeted Testing Initiative

Introduction

“We can prevent the late diagnosis of HIV/AIDS.”

One of the key markers of success for the Vancouver STOP Project is the expansion of opportunities for HIV testing and early diagnosis for all people in Vancouver. To reach specific populations disproportionately affected by HIV, including gay men, people who use injection drugs, sex workers, refugees, immigrants and Aboriginal people, the Vancouver STOP Project expanded the number of settings that now routinely offer HIV testing to clients – either with standard blood- draw tests or rapid, point-of-care tests. In many of these sites, HIV testing was not previously available or testing rates were low. Access to testing has been expanded in primary healthcare centres, mental health and addictions services, supportive housing, in the justice system and in other settings.

The small Targeted Testing Team identified, collaborated with, trained and supported 88 sites to introduce the routine offer of HIV testing as part of their complement of services. In some settings, such as primary healthcare centres where clinicians were already accustomed to ordering blood work and delivering difficult diagnoses, the change has been relatively smooth. In other venues, such as dental clinics and mental health and addictions services where HIV testing has traditionally not been offered, in part due to significant structural barriers, it’s been more challenging.

Across all sites, ongoing and responsive support has been critical to the success of this project. Nurse educators from the Targeted Testing Team return to sites every few months to offer additional support and to help reduce barriers to embedding testing in health services. Importantly, they also provide updates on each site’s testing trends, which demonstrates to the staff how many tests they have done, the number of new diagnoses and possibly, what impact the initiative is having in Vancouver.

According to Misty Bath, a former nurse educator on the team, the team works hard to ensure that clinicians know there is support for them when one of their patients is diagnosed with HIV. When a person tests positive for HIV, clinicians can draw on the expertise of the STOP Outreach Team or Vancouver Coastal Health Communicable Disease Control to offer specialized diagnosis and linkage to care services.

In addition to supporting others to offer expanded testing opportunities, the Targeted Testing Team hosts HIV testing events at universities, and staffs micro-clinics in bathhouses and a mobile outreach van that travels to outdoor sex venues frequented by gay men and other men who have sex with men.

The team has made significant inroads in normalizing HIV testing both among clinicians and among the people for whom they provide care. According to Bath, “There’s still a lot that we can do to sustain improvements in testing.” As part of this drive, the team is currently working closely with First Nation communities located within Vancouver Coastal Health to increase the availability of testing for Aboriginal people closer to home.

What is the Program?

The targeted testing initiative is a new project developed and led by the Vancouver STOP Project. It aims to ensure that people who are at high risk for HIV have easy access to testing and, for those who test HIV-positive, that they are diagnosed early and linked to appropriate care and support. It accomplishes this through the implementation of the routine offer of HIV testing at sites that have never offered testing and at sites that had not been optimally offering testing, but that are frequented by people who are at high risk for HIV. Some sites offer standard blood-draw test while others offer a blended standard and rapid test, both with pre-and post-test counselling.

In the last two years, through this initiative, access to testing has been expanded in 88 sites, including primary healthcare centres, abortion and youth clinics, mental health and addictions services, the justice system, supportive housing, First Nation communities within Vancouver Coastal Health’s region, and in bathhouses and at outdoor sex venues frequented by gay men. For many of these sites, the implementation of HIV testing was a significant change to their practice. Managing and supporting this change was, therefore, an important component of successful implementation. 

This initiative is led by a group of nurse educators and a program manager known as the Targeted Testing Team. This group is a smaller part of the STOP Outreach Team, an interdisciplinary clinical team responsible for improving engagement and linkage to care for people with some of the most complex barriers to care. For more information on this, please see the Programming Connection case study on the STOP Outreach Team.

The team successfully expanded access to HIV testing and diagnosis in in three ways. The team:

1. provides training and support to clinicians and service providers whose clientele is drawn from high prevalence populations
2. offers regular workshops on rapid testing and the introduction of routine testing for clinicians wanting to build their skills
3. provides HIV testing clinics in non-traditional outreach settings such as bathhouses and outdoor sex venues

Why Was the Program Developed?

One of the goals of the overall STOP HIV/AIDS Project was to increase opportunities for HIV testing and diagnosis. The Vancouver STOP Project explored and implemented several different strategies to expand testing opportunities for everyone in Vancouver, including the integration of a routine offer of HIV testing in family practice and acute care.

In order to expand testing opportunities for key populations disproportionately affected by HIV, the Vancouver STOP Project developed a targeted settings strategy to increase the capacity of services and programs that primarily serve clientele from high prevalence populations to offer HIV testing routinely.

How Does the Program Work?

The successful implementation and roll-out of the routine offer of HIV testing at sites where staff are  unaccustomed to offering HIV testing requires a number of resources and activities. These include: the development of a solid clinical and public health rationale for expanded HIV testing; the engagement and buy-in from leaders in the clinics and organizations implementing HIV testing; and extensive (and intensive) training and support for the staff at the various sites.

This initiative requires the leadership of a highly skilled team – the Targeted Testing Team – made up of nurse educators experienced in HIV testing, diagnosis, and linkage to care and a project manager skilled at developing a change management framework to guide the change in practice that the implementation of the routine offer of HIV testing requires. While the nurse educators train and support sites to integrate HIV testing into their services, the project manager guides implementation plans for each site.

Background: Policies and recommendations in place to facilitate implementation

Recommendation on testing frequency

Clinicians and service providers offering HIV testing are typically guided by recommendations and guidelines and Vancouver is no different. In British Columbia, HIV testing among high prevalence populations is guided by a provincial recommendation from the BC Centre for Disease Control (BCCDC) that stipulates that, depending on risk, in high prevalence populations, people should test at least once and up to four times annually. The complete recommendation can be found in the Program materials section of this case study.

This recommendation, which is followed by many Vancouver clinicians, is important to ensuring that clinicians support people at ongoing high risk for HIV infection to get tested often and be diagnosed as early as possible. Early detection and treatment are key to optimal health outcomes for people living with HIV.

Recommendations for pre-test counselling

Since September 2011, the BC Centre for Disease Control’s new HIV Test Pre and Post Test Guidelines do not require an in-depth pre-test counselling session prior to getting informed consent from a person and ordering an HIV test. Under the new guidelines, written information provided to clients is sufficient to receive verbal informed consent from people being offered and accepting an HIV test.

However, in settings now offering HIV testing routinely to people at high risk for HIV infection, clinicians are still encouraged to have an in-depth pre-test discussion with clients. That said, for people who test regularly—every three or six months—in-depth pre-test counselling may not be required. The new pre-test guidelines allow clinicians to streamline discussions with these clients.

Engaging, training, and supporting sites to routinely offer HIV testing

As of February 2013, staff at 88 sites have been trained to expand or introduce HIV testing services through this initiative. This was accomplished through engagement and training activities guided by the Targeted Testing Team. This team collaborates with a variety of programs that have competing clinical priorities along with their own strengths and challenges.  As a result, there has not been one standard process used to introduce the routine offer of HIV testing.

The goal of the project is to routinize the offer of HIV testing, and each site is free to determine how to do this with whatever tools and through whatever means are appropriate for their setting. Most settings implement the offer of a routine standard laboratory test, with results available in one or two weeks. Some offer a blended approach, with rapid testing offered to clients when it seems clinically appropriate (i.e. a client may have been exposed to HIV and is unlikely to return for a positive result).

The process described below is based on the process used to initiate the routine offer of HIV testing in primary healthcare centres. Where the process differs significantly for other settings that have integrated the routine offer of testing, mention is made of that. 

Identifying which services should implement the routine offer of HIV testing

The team uses a priority scale to identify services where it would be most appropriate to integrate the routine offer of an HIV test. The scale includes whether the service’s clients may be likely to be at high risk for HIV, based on the known risk factors of the population, the presence of supportive clinical and operational champions to promote testing, the potential reach of the service, and the presence of other competing clinical priorities. The priority scale is available in the Program Materials section of this case study.

Given these criteria, the team identified inner city primary healthcare centres, mental health and addictions services and youth clinics as primary settings in which HIV testing could be expanded. Expanded HIV testing has also been initiated in abortion clinics, supportive housing, First Nation communities within Vancouver Coastal Health (whose region extends up the B.C. Coast and includes 15 First Nation communities), and in the justice system.

Using a change management framework to guide change

The team uses a change management framework to guide each site to change their practice to incorporate or expand HIV testing. This process involves four phases:

1. Initial engagement (why change?): In this phase, the medical health officer or a physician-leader and a nurse educator introduce the rationale for the routine offer of HIV testing and present the proposed change in practice to upper management at each site. Baseline testing numbers in their program area (if they are doing any testing) are shared. The goal of this phase is to get buy-in from leadership and identify site champions and a coordinator for implementation.
2. Site preparation (how will we implement the change?): In this phase, the nurse educators and the project manager work directly with the frontline staff at a site to understand the unique nature of the site, existing work flows, and determine the best way to integrate change into existing practice. They also identify any challenges and support tools required.
3. Go live (when do we start?): In this phase, nurse educators provide shoulder-to-shoulder support (where needed) on the date the team chooses to start the practice change.
4. Site monitoring and check-in (how are we doing?): In this phase, nurse educators connect back with each team and provide a progress report showing the number of tests administered and number of positive diagnoses made as compared to baseline testing data (if any). The site check-ins are also used to identify and attempt to resolve any further barriers that prevent the integration of the routine offer of HIV testing. During check-in, the nurse educators also share best practices from other programs that have achieved implementation success.

Initial engagement

It was crucial to secure senior medical and operational leadership to support change in each program, before engaging each site in the implementation of the routine offer of HIV testing. The clinical practice leader and medical health officer request to present the STOP Project’s goals and objectives, outline the rationale for the routine offer of HIV testing, review the testing initiative and timelines, and secure the support for the initiative of the clinical and operational leadership.

Communicating this support from site leaders to site staff is key to integrating the routine offer of HIV testing in certain settings. For example, after encountering some resistance at the site level in primary care in Vancouver Coastal Health sites, it was determined that a high-level policy directive was needed to reach all clinicians, some of whom were resistant to the change.  The Vancouver Coastal Health primary care operational and medical directors then sent a supportive memo to all clinicians, briefly outlining the rationale for the routine offer of testing and indicating their endorsement of the initiative. This reduced resistance.

Site preparation

When the leadership is engaged and the Targeted Testing Team has addressed any concerns, the team will deliver a minimum of one educational workshop to the whole staff. During this presentation, the medical health officer and nurse educator provide an update on improvements in HIV testing, treatment, prognosis and community supports for people living with HIV. The medical health officer then presents the rationale for the routine offer of HIV testing and how routine testing has been implemented in some areas of the United States and in the United Kingdom. Using local data, the nurse educator demonstrates how some diagnoses are being missed in Vancouver. During this meeting, the nurse educator also provides a trends analysis of the site’s testing data between 2009 and the time of the initial meeting (if any testing has been done).

Finally, the nurse educator presents the sample tools and supports available to help sites implement a routine offer of HIV testing. Please see the Program materials section for more information about these tools. During the meeting, staff are encouraged to identify a reminder system that would work best for the site. Frequently selected tools that are used as reminders include a green sticker or a stamp on lab requisitions, two sets of lab requisitions, both pre-ticked and blank, changes to electronic medical records systems to include blood orders for HIV tests, and a change to existing intake packages or standing orders.

The nurse educator always follows up with the clinical leadership and reviews the decisions made during the staff meeting. This includes the types of resources needed from the Targeted Testing Team such as posters or patient information pamphlets and the implementation date the site has chosen. This reminds the clinical leaders that the nurse educator is available for any added support. The nurse educator follows up again during the first week of implementation and offers any additional support.

Site monitoring and check in

Three months after the roll-out of HIV testing (discussed below), the nurse educator returns to the site and reviews how testing trends have changed. They also encourage discussion of the barriers that remain to integrating a routine offer of HIV testing at the site and what facilitators have made integration easier.

Best practices from other sites are also shared at these meetings. These have included clerical staff handing out the patient FAQ on HIV testing to all patients seeking care, and brightly coloured reminders on charts that ask “Have you offered your client an HIV test today?” Admissions forms at one addictions clinic include a question about a patient’s last HIV test. Clinics with labs onsite involve laboratory technicians and licensed practical nurses as a secondary safety net. These professionals check lab requisitions to make sure an HIV test has been offered and if one has been offered, make sure that the client does not have any additional questions.

Using resources to facilitate implementation

The Targeted Testing Team developed new resources and adapted others for clinicians to facilitate the routine offer of an HIV test. This includes a matrix that covers the recommended frequency of HIV testing in high prevalence populations, examples of laboratory requisition form reminders, a FAQ for primary care providers on routine HIV testing and a patient FAQ on HIV and HIV testing. These, and other materials, can be found in the Program Materials section of the case study. Clinicians were also offered materials from the It’s Different Now campaign. For more information on the It’s Different Now campaign, please see the It’s Different Now case study.

HIV testing workshops and training

The Targeted Testing Team hosts regular workshops on HIV testing for all clinicians working in the Vancouver Coastal Health region to increase their capacity to offer HIV testing. During these workshops, they go over HIV basics, the rationale for the routine offer of HIV testing, and provide training on how to use the point-of-care HIV test. They also review pre- and post-test counselling guidelines and provide information on how to link newly diagnosed people to care and support.  Workshops from one hour to two days in length are given depending on clinicians’ previous experience and learning goals.

Onsite rollout of HIV testing (go live)

Offering an HIV test

The offer of an HIV test is made routinely during provider-patient interactions, at any time during the appointment when the provider feels the offer is appropriate. A nurse, nurse practitioner or physician makes the offer. However, this does not preclude the ongoing importance of patient-initiated HIV testing or risk-based HIV testing, which continues to be a part of healthcare in Vancouver.

Clinicians at many sites also have the option to provide point-of-care testing when it is clinically appropriate.

Sites where the offer of an HIV test differed from the typical procedure

Abortion Clinics

In abortion clinics, the counsellor rather than a nurse or a physician offers the HIV test. This decision was made because women typically do not meet with their providers before the procedure. The offer of an HIV test during the pre-procedure counselling was deemed the best fit in this setting.

Addictions services

Some addictions teams opted to have the HIV test offered at intake as the client is filling out other assessment materials. This allows the intake worker to provide an in-depth pre-test discussion, using the patient FAQ on HIV testing as a guide.

In all cases when a test is positive, a registered nurse, nurse practitioner or physician provides post-test counselling.

Diagnosis and linkage to care

The sites that have introduced the routine offer of HIV testing do not all have the same experience offering post-test counselling and public health follow-up, or the same knowledge about existing HIV services in Vancouver. This limits the capacity of some service providers to offer comprehensive diagnosis, follow-up and linkage to care services.

The STOP Outreach Team and the Vancouver Coastal Health Communicable Disease Control team are two available resources whose staff have the appropriate skills to support and facilitate diagnosis and linkage to care for clinicians and patients.

Primary care, onsite clinics in housing projects and youth clinics

Clinicians working in primary healthcare centres often have significant experience diagnosing HIV and linking patients to care. Many primary care clinics also have physicians on staff who have experience caring for people living with HIV. For patients diagnosed in these settings, this means that a seamless transition to HIV care can be accomplished, with their testing, diagnosis and treatment all handled in the same space. Clinicians who need coaching or in-person support can access that through the STOP Outreach Team, whose nurses offer advice over the phone and are available to come to the clinic and help with diagnosis.

Mental health and addictions services

In mental health and addictions services where clinicians may have limited experience with HIV diagnosis or care, follow-up services can be delegated to the STOP Outreach Team. A nurse from the team will meet with the clinician when a test is positive, discuss the client and their needs and determine a referral site for primary care.

Typically, the testing clinician and the nurse offer the diagnosis. After the diagnosis, however, the STOP Outreach Team takes on the responsibility for public health follow-up, contact tracing, and primary care until a strong linkage to an HIV primary care provider is developed. Once a plan for the client’s healthcare is determined, the testing clinician is informed, with the consent of the client, of the plan.

Abortion Clinics

In abortion clinics, diagnosis and follow-up support are offered through the BC Centre for Disease Control (BCCDC). Patients do not tend to have an ongoing relationship with their abortion providers, so the BCCDC, which has a pre-existing relationship with abortion clinics in Vancouver for chlamydia and gonorrhea follow-up, offers public health follow-up and contact tracing as well as linkage-to-care services.

Testing events in First Nation communities

As part of the targeted testing initiative, the team has engaged with several First Nations communities within the Vancouver Coastal Health region to build the capacity of nurses to offer point-of-care testing and standard laboratory testing.  They have also worked with urban Aboriginal organizations such as the Vancouver Native Health Society and the Aboriginal Wellness Program to expand access to testing for off-reserve Aboriginal clients.

Engagement

Typically, members of the Targeted Testing Team facilitate the introduction of HIV testing in First Nation communities by participating in wellness days or health fairs. These usually serve as kick-off events to the introduction of the routine offer of HIV testing in a pre-existing youth clinic or health centre. Embedding HIV testing in a wellness model can increase confidentiality and decrease stigma for community members by normalizing testing as an important part of healthcare. 

Rather than nurse educators from the Targeted Testing Team leading the initiative and engaging First Nation leadership and healthcare professionals, nurses from the First Nations and Inuit Health  Branch (FNIH) (now the First Nations Health Authority) and the Aboriginal Engagement Office at Vancouver Coastal Health often lead discussions about introducing expanded testing opportunities. The team never travels to reserves without an invitation and without consulting First Nation leadership in the community.

Before the team travels to these communities, it consults with the Chee Mamuk Aboriginal Program, a program of the BCCDC, for their guidance and leadership around community readiness.  Where possible, the team collaborates on the implementation of HIV testing in First Nation communities with Chee Mamuk, BCCDC and FNIH. Before implementing HIV testing, the team ensures some preliminary education and stigma reduction are done. 

Once the groundwork is laid, the clinical leader, a nurse educator, nurses from FNIH and often from Chee Mamuk travel to the community. Prior to the event, the team is present to provide mentorship to the on-reserve nurses on how to offer HIV testing and how to perform a point-of-care and a traditional blood test.  During health fairs, either standard laboratory testing or point-of-care testing is offered to community members, depending on which seems most appropriate based on community input.

Expanding HIV testing at other sites

In addition to implementing HIV testing in health and social service settings, the Targeted Testing Team has implemented testing in other venues. Bathhouses and outdoor sex venues were selected to help expand testing options for gay men and other men who have sex with men. Specific events to help connect with university students and the healthcare providers who serve them have also been held.

For more information on these initiatives, please see the Mobile and bathhouse testing project program element.

Next Steps

The routine offer of HIV testing in these and other settings is now standard practice in Vancouver. The Targeted Testing Team is working closely with services and clinics that have implemented testing to embed testing more fully in their regular services and to integrate testing at new sites.

Required Resources

Human resources

1. Nurse educators: 1.5 FTE. Provide training, education, and follow-up support to clinicians and services implementing change. Staff testing clinics.
2. Clinical practice leader: 0.5 FTE. Provides clinical oversight, policy direction, senior leadership engagement and project management of the team’s activities.
3. Project manager: 0.5 FTE. Assists with workflows for each site, provides project management structure, assists with evaluation and scorecards, lab processes and system redesign
4. Administrative support: 1.0 FTE.  Schedules meetings for medical health officer, physician leaders and educators.  Follows up after meetings with FAQs and resources that need to be mailed to sites.  Orders supplies and arranges logistics for education sessions.
5. Medical health officer and physician leadership:  0.1 FTE.  Provide clinical rationale for initial engagement sessions, help with resistant sites, approve documents and provide clinical directions.
6. Engaged clinical and operational leadership at each site.

Other

1. Strong, reliable and responsive public health follow-up and linkage-to-care system that reacts effectively to requests from clinicians for support in diagnosis and linkage to care.
2. Strong HIV treatment, care and support infrastructure.

Challenges

• Clinician time. The routine offer of an HIV test strains the time of clinicians who are already busy. The Targeted Testing Team works diligently with its partners to reduce the amount of time needed for testing, but this continues to be a barrier.
• New clinical initiatives. In primary care, new clinical initiatives are rolled out every few months. This makes it difficult to keep momentum going on a single initiative such as routine HIV testing.

Evaluation

Site evaluation

Each site that integrates the routine offer of testing is evaluated on the following metrics: number of tests performed; number of positives; percent positivity; and percentage change in testing volumes since implementation. All sites also receive a quarterly report card indicating their progress. This report card, available in the Program Materials section, lists the number of laboratory tests performed, the number of rapid tests performed, and the number of HIV-positive results. These reports also include the overall number of new HIV diagnoses that have occurred in the Vancouver Coastal Health region since July 2010. This allows sites that have not had any positive diagnoses to see that expanded access to testing is having an impact on the number of new diagnoses.

As of February 2013, there has been a 57 percent increase in HIV testing across all sites. The overall positivity rate is 0.4 percent, well above the cost-effectiveness threshold¹ for a routine HIV testing initiative. Primary healthcare clinics have the highest percent positivity at 0.5 percent.

Data on the stage of disease at diagnosis, the socio-demographics of people newly diagnosed with HIV and data on how long it took to link a person to care are also collected. These data are gathered to determine the overall success of the Vancouver STOP Project in diagnosing people early and linking them to care effectively, both of which were goals of the overall STOP HIV/AIDS Project.

Team evaluation

The effectiveness of the Targeted Testing Team’s services is measured through surveys completed by testing sites.  The surveys are used to evaluate the tools the team uses as well as the support the team offers.

The team also holds focus groups that ask staff who have integrated the routine offer of HIV testing to reflect on how the routine offer of HIV testing is received by patients and perceived by staff. Sites are also asked to reflect on how prepared they feel to offer HIV testing, the challenges and benefits of point-of-care testing, ongoing barriers to implementing HIV testing, and recommendations to other sites implementing HIV testing.

1. Walensky RP et al. Routine human immunodeficiency virus testing: An economic evaluation of current guidelines. American Journal of Medicine. 2005; 18:  292–300. Available from: http://www.avpivnik.ru/works/aids/aids_pdf_202.pdf

Lessons Learned

1. Engage the leadership. Engaging the leadership at each site is critical to implementing routine testing. The leadership provides a channel through which to deliver the message about HIV testing to all staff. Encouraging the leaders to provide this message allows the clinic or program to own the change. 
2. Provide a clear directive. In primary healthcare centres, a clear directive to implement HIV testing was sent to all staff, which included an implementation date (July 15, 2012). It also included a clear indication of what leadership expected the primary care centres to accomplish (i.e. that all patients would be tested within 18 months of implementation). This likely improved uptake of the initiative. In mental health and addictions services, where no clear directive was given, uptake of routine testing has been slower.
3. Offer a strong rationale. Presentations by the medical health officer and nurse educators to staff on the rationale for routine HIV testing are key to promoting the introduction of routine testing in many of the services.
4. Provide skilled support to clinicians at every stage of the process.  Nurse educators put the emphasis on the fact that the responsibility for HIV testing, diagnosis, and linkage to care is shared. The STOP Outreach Team is available throughout the implementation process and when new positives are found, a strong, reliable and responsive system exists for both providers and patients to facilitate the transition from diagnosis to care.
5. Prepare for challenging sites. At sites where testing is not the norm before the introduction of routine testing, implementation of testing is more challenging than in primary care and uptake of routine testing is slow.

Program Materials

• HIV testing triangle model
• Recommendations for HIV testing in members of populations of British Columbia with a high prevalence of HIV infection
• Priority scale
• Implementation checklist for HIV testing in community and primary care settings
• Sample laboratory requisition forms
• Routine testing in primary care: FAQ
• HIV testing: Physician tracking sheet
• Testing report card
• Evaluation survey: Targeted testing sites

Contact Information

For more information, please contact

Meaghan Thumath
Clinical Practice Initiatives Lead HIV/AIDS
Vancouver Coastal Health
604-314-8906

What is the STOP HIV AIDS Project?

Seek and Treat for Optimal Prevention of HIV/AIDS (STOP) was a $48 million, four-year (2010-2013) pilot project funded by the government of British Columbia. This project aimed to increase the quality of life of people living with HIV and reduce the number of new HIV infections by taking a proactive public health approach to finding people living with HIV, linking them to HIV care and treatment programs, and supporting them to stay in care. STOP aimed to improve the experience of people living with HIV or AIDS in every health and social service interaction and significantly improve linkage and engagement across the full continuum of services in HIV prevention, testing and diagnosis, treatment, and care and support.

STOP was rolled out in Vancouver and Prince George. It was made up of numerous interconnected and discrete clinic-based, hospital-based, community-based and policy-focused programs implemented through the collaboration of a significant number of stakeholders. In Vancouver, Vancouver Coastal Health and Providence Health Care partnered to form the Vancouver Project. Through this partnership, these two organizations shared governance, funding and reporting for most of the initiatives that took place in Vancouver between 2011 and 2013.

As part of its commitment to expanding access to HIV testing and diagnosis, the Vancouver STOP Project initiated expanded rapid and routine testing in clinical services used by clients who might be at higher risk for HIV infection than the general population. These services include primary healthcare centres, mental health and addictions services, youth and abortion clinics, supportive housing, First Nation communities and in the justice system. They accomplished this through training and ongoing support to clinicians implementing the change from a lengthy pre-test counselling/risk-based model to a risk-based and routine testing model.