title: The role of evidence and context for implementing a multimodal intervention to increase HIV testing.
abstract: BACKGROUND
  Increasing the use of routine preventive care such as HIV testing is important, yet implementation of such evidence-based clinical care is complex. The Promoting Action on Research Implementation in Health Services (PARiHS) model for implementation posits that implementation will be most successful when the evidence, context, and facilitation strategies are strong for the clinical practice. We evaluated the relative importance of perceived evidence, context, and facilitation of HIV testing during the implementation of a multimodal intervention in US Department of Veterans Affairs primary care clinics.
  
  
  METHODS
  A multimodal intervention including clinical reminders (CRs), academic detailing--providing education sessions for providers--and social marketing to improve HIV testing was implemented in 15 VA primary care clinics in three regions. We conducted qualitative formative and process evaluations using semi-structured interviews with HIV lead clinicians, primary care lead clinicians, nurse managers, and social workers. Interviews were analyzed thematically to identify barriers and facilitators to implementation of HIV testing and how these were addressed by the intervention. Sites were then rated high, medium, or low on the dimensions of perceived evidence and the context for testing. We then assessed the relationship of these ratings to improvements in HIV testing rates found in earlier quantitative analyses.
  
  
  RESULTS
  Sites that showed greatest improvements in HIV testing rates also rated high on evidence and context. Conversely, sites that demonstrated the poorest improvements in testing rates rated low on both dimensions. Perceptions of evidence and several contextual aspects resulted in both barriers and facilitators to implementing testing. Evidence barriers included provider perceptions of evidence for routine testing as irrelevant to their population. Contextual barriers included clinical reminder overload, insufficient resources, onerous consent processes, stigma, provider discomfort, and concerns about linking individuals who test positive to HIV treatment. While most barriers were ameliorated by the intervention, HIV stigma in particular regions and concerns about linkage to care persisted.
  
  
  CONCLUSIONS
  Interventions to implement evidence-based practices such as HIV testing can be successful when utilizing proven quality improvement techniques. However, it is critical to address providers' perceptions of evidence and consider aspects of the local context in order to fully implement new routine clinical practices such as HIV testing.
authors.affiliation: Quality Enhancement Research Initiative for HIV and Hepatitis C, US Department of Veterans Affairs, Bedford, MA, USA. Barbara.Bokhour@va.gov.|Center for Healthcare Organization and Implementation Research, Bedford, MA, 01742, USA. Barbara.Bokhour@va.gov.|Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA. Barbara.Bokhour@va.gov.
authors.forename: Barbara G
authors.initials: BG
authors.lastname: Bokhour
authors.affiliation: Quality Enhancement Research Initiative for HIV and Hepatitis C, US Department of Veterans Affairs, Bedford, MA, USA. Hemen.Saifu@va.gov.|VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. Hemen.Saifu@va.gov.
authors.forename: Hemen
authors.initials: H
authors.lastname: Saifu
authors.affiliation: Quality Enhancement Research Initiative for HIV and Hepatitis C, US Department of Veterans Affairs, Bedford, MA, USA. Matthew.Goetz@va.gov.|VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. Matthew.Goetz@va.gov.|David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. Matthew.Goetz@va.gov.
authors.forename: Matthew Bidwell
authors.initials: MB
authors.lastname: Goetz
authors.affiliation: Quality Enhancement Research Initiative for HIV and Hepatitis C, US Department of Veterans Affairs, Bedford, MA, USA. Gemmae.Fix@va.gov.|Center for Healthcare Organization and Implementation Research, Bedford, MA, 01742, USA. Gemmae.Fix@va.gov.|Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA. Gemmae.Fix@va.gov.
authors.forename: Gemmae M
authors.initials: GM
authors.lastname: Fix
authors.affiliation: Quality Enhancement Research Initiative for HIV and Hepatitis C, US Department of Veterans Affairs, Bedford, MA, USA. jburgess@sonnet.ucla.edu.|UCLA School of Nursing, Los Angeles, CA, USA. jburgess@sonnet.ucla.edu.
authors.forename: Jane
authors.initials: J
authors.lastname: Burgess
authors.affiliation: Quality Enhancement Research Initiative for HIV and Hepatitis C, US Department of Veterans Affairs, Bedford, MA, USA. Michael.Fletcher@va.gov.|Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA. Michael.Fletcher@va.gov.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Fletcher
authors.affiliation: VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. Herschel.Knapp@va.gov.
authors.forename: Herschel
authors.initials: H
authors.lastname: Knapp
authors.affiliation: Quality Enhancement Research Initiative for HIV and Hepatitis C, US Department of Veterans Affairs, Bedford, MA, USA. Steven.Asch@va.gov.|VA Palo Alto Health Care System, Menlo Park, CA, USA. Steven.Asch@va.gov.|Division of General Medical Disciplines, Stanford University Medical School, Palo Alto, CA, USA. Steven.Asch@va.gov.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Asch
mesh_terms: D015492:AIDS Serodiagnosis / Q000379:methods*; D057286:Electronic Health Records; D055317:Evidence-Based Practice; D015658:HIV Infections / Q000175:diagnosis*; D006787:Hospitals, Veterans / Q000458:organization & administration; D006801:Humans; D007407:Interviews as Topic; D016730:Program Development; D017010:Reminder Systems