Universal for All, Frequent for Some: HIV Testing in School-Based Health Centers

Principal Investigator(s): 

Theo Sandfort, PhD

Neal Hoffman, MD


Funding Agency:

National Institute on Drug Abuse (NIDA)

Collaborating Institution: 

Albert Einstein College of Medicine

Study Location:

The Bronx, New York, USA


The CDC requires offering an HIV test in health care settings to adolescents aged >13; unfortunately only a small proportion of youth are tested. Compared to adults, larger proportions of youth drop out at all steps of the HIV treatment cascade. Thus, although HIV incidence nationally is relatively stable, the rate of new HIV infections among young persons is increasing. We propose to adapt, implement, and evaluate a multi-level, multi-component intervention to increase the uptake of routine annual HIV testing and to provide more frequent testing to high-risk youth. The target population is adolescents in 2 middle and 28 high schools in the Bronx, New York, and the county with among the highest HIV prevalence in the state. The intervention will be implemented in school-based health centers (SBHCs) of the Montefiore School Health Program, which already offer HIV testing in schools. Consistent with national data, analysis of Montefiore's electronic medical record data confirms that uptake of HIV testing is low. Although we need effective strategies to increase universal HIV testing, our data suggests that approximately 40% of Bronx youth are at high risk of HIV acquisition. We also propose to offer bi-annual HIV testing for these youth, and to formalize counseling to reduce high risk behavior.

The specific aims are:

  1. Develop a replicable effective model of universal HIV testing in SBHCs;
  2. Identify youth in SBHC at high risk for HIV acquisition through screening at annual and emergent visits and engage them in twice-yearly testing and safer sex and substance use counseling;
  3. Implement the HIV universal and frequent interventions with youth not currently served by doubling the number of youth that utilize the SBHCs from 36% to 72% of the student population.

The proposed intervention includes (1) system-level initiatives (an Implementation Coach, screening for high risk, practice work flows for HIV testing, system reminders for repeat HIV tests); (2) provider-level initiatives (training to successfully offer an HIV test, training in motivational interviewing for HIV testing and to reduce HIV risk); (3) adolescent-level initiatives (individualized provider counseling, a 4-session motivational interviewing program for high risk youth to promote safer sex and to prevent substance abuse); and (4) implementation initiatives to expand coverage to more youth (peer outreach; school-based messaging about SBHCs; in-class education sessions about SBHCs, informational sessions for school personnel). Interventions will be implemented in three phases (Universal Testing, Targeted Prevention, and Scale Up). Three randomly selected SBHC will implement the program first, followed by three "delayed control" centers. The 6 SBHC now serve over 9,000 youth. All proposed interventions will be sustainable when the project ends.

The interventions will be evaluated in terms of reach, adoption, implementation/fidelity, effectiveness, maintenance, and sustainability by collecting data from multiple sources, including, school-wide assessments of randomly sampled classes of students, exit interviews with students using the SBHC, provider interviews, and electronic medical records which include HIV test results. The proposed project aims to understand how routine HIV testing in middle and high school students can be promoted through sustainable interventions at school-based health centers. Specifically for youth, HIV testing is a critical first step in the HI treatment cascade. Routine testing will help with early detection of new infections and facilitate access to timely care.