title: HIV testing implementation in two urban cities: practice, policy, and perceived barriers.
abstract: BACKGROUND
  Although funding has supported the scale up of routine, opt-out HIV testing in the US, variance in implementation mechanisms and barriers in high-burden jurisdictions remains unknown.
  
  
  METHODS
  We conducted a survey of health care organizations in Washington, DC and Houston/Harris County to determine number of HIV tests completed in 2011, policy and practices associated with HIV testing, funding mechanisms, and reported barriers to testing in each jurisdiction and to compare results between jurisdictions.
  
  
  RESULTS
  In 2012, 43 Houston and 35 DC HIV-testing organizations participated in the survey. Participants represented 85% of Department of Health-supported testers in DC and 90% of Department of Health-supported testers in Houston. The median number of tests per organization was 568 in DC and 1045 in Houston. Approximately 50% of organizations in both DC and Houston exclusively used opt-in consent and most conducted both pre- and post-test counseling with HIV testing (80% of organizations in DC, 70% in Houston). While the most frequent source of funding in DC was the Department of Health, Houston organizations primarily billed the patient or third-party payers. Barriers to testing most often reported were lack of funding, followed by patient discomfort/refusal with more barriers reported in DC.
  
  
  CONCLUSIONS
  Given unique policies, resources and programmatic contexts, DC and Houston have taken different approaches to support routine testing. Many organizations in both cities reported opt-in consent approaches and pre-test counseling, suggesting 2006 national HIV testing recommendations are not being followed consistently. Addressing the barriers to testing identified in each jurisdiction may improve expansion of testing.
authors.affiliation: Houston Department of Health and Human Services, Houston, Texas, United States of America.
authors.forename: Camden J
authors.initials: CJ
authors.lastname: Hallmark
authors.affiliation: Department of Epidemiology and Biostatistics, School of Public Health and Health Services, George Washington University, Washington, DC, United States of America.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Skillicorn
authors.affiliation: Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America; Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America.
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Giordano
authors.affiliation: Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America; Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America.
authors.forename: Jessica A
authors.initials: JA
authors.lastname: Davila
authors.affiliation: Houston Department of Health and Human Services, Houston, Texas, United States of America.
authors.forename: Marlene
authors.initials: M
authors.lastname: McNeese
authors.affiliation: HIV/AIDS, Hepatitis, STD, and TB Administration, District of Columbia Department of Health, Washington, DC, United States of America.
authors.forename: Nestor
authors.initials: N
authors.lastname: Rocha
authors.affiliation: HIV/AIDS, Hepatitis, STD, and TB Administration, District of Columbia Department of Health, Washington, DC, United States of America.
authors.forename: Avemaria
authors.initials: A
authors.lastname: Smith
authors.affiliation: HIV/AIDS, Hepatitis, STD, and TB Administration, District of Columbia Department of Health, Washington, DC, United States of America.
authors.forename: Stacey
authors.initials: S
authors.lastname: Cooper
authors.affiliation: Department of Epidemiology and Biostatistics, School of Public Health and Health Services, George Washington University, Washington, DC, United States of America.
authors.forename: Amanda D
authors.initials: AD
authors.lastname: Castel
mesh_terms: D002947:Cities; D004219:District of Columbia; D005378:Financial Support; D015658:HIV Infections / Q000175:diagnosis* / Q000191:economics; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel; D006284:Health Plan Implementation; D006291:Health Policy; D006295:Health Resources; D006801:Humans; D015995:Prevalence; D013781:Texas