This is the first national study of CHCs in China to examine current practices of HIV testing in CHCs, the attitude of staff, and the perceived facilitators and barriers when providing HIV testing to patients attending CHCs including to key populations. We found that only a quarter of CHC staff would provide HIV testing even when a patient requested it. Of note, less than half of doctors and a third of nurses have received training on HIV diagnoses, indicating that more widespread education for CHC staff is urgently needed if HIV test coverage in China is to increase. Several barriers were identified which will need to be addressed before encouraging other CHCs to provide HIV testing. These included providing more education and clinical resources, addressing financial concerns and stigmatizing attitudes (e.g. nearly half the respondents believed that people from high-risk populations would scare other patients away, and over a third were worried that they could be infected with HIV). Despite these perceived barriers, the majority of staff agreed that HIV testing was an important part of healthcare.
Our study confirms that there is untapped potential to improve HIV testing rates in China through encouraging CHCs to offer testing. WHO strongly recommends that primary care should provide HIV prevention, therapy and care for members of key populations [26]. Many countries have already included HIV testing as part of screening of key populations within general practice. For example, in the UK, HIV testing is offered by general practitioners in a patient’s initial consultation if they are from an HIV endemic area [27]. In France, offering HIV testing to patients aged 15–70 years with or without high-risk behaviors for HIV is another attempt to increase earlier diagnosis of people with HIV infection [18]. These strategies have proven to be cost-effective [28]. In our study, the attitude of staff in CHCs towards HIV testing appear to be positive with 81% agreeing that HIV testing is an important part of healthcare and those CHCs situated in regions with higher prevalence of HIV (e.g. western) were more likely to have offered HIV testing.
The revamping of CHCs in China and the development of general practice as the “first contact of care in community” has played a key role in the recent healthcare reforms [29]. HIV testing availability is one of the key motivators for having a test done [30]. It seems both acceptable and practical for CHCs to provide HIV testing services based on the wide availability and accessibility of CHCs. In cities, nearly three quarters of CHCs (71%) have been converted from smaller district-level hospitals with on-site capacity for further laboratory investigations (95%) [22]. This may provide a unique opportunity to improve the early detection and management (or at least referrals to appropriate HIV services) for people living with HIV. If an individual is found to be HIV positive and CHC staff are not comfortable in managing HIV, they are encouraged to refer patients beyond their current service capability to hospitals [31]. However, consistent with the financial barriers identified in our study, HIV testing is not currently freely available in primary care and the insurance coverage is fragmented with differing levels of coverage and access to health care by different insurance schemes, leaving gaps that require out-of-pocket payments by patients. This is reflected in our study’s finding that only a quarter of staff in CHCs would offer HIV testing even on request from the patient. The most cited barrier was the staff members’ concerns about the patients’ ability to pay or reimbursement issues related to HIV testing. Further study is required to examine the willingness-to-pay for HIV testing in China and explore the options on how to offer affordable HIV tests within CHCs that may help to increase testing rates especially for members of key populations.
WHO recommends HIV testing and counseling should be offered to people from key populations when they visit a doctor for any health problem [32] or at least once a year for key populations like sexually active men who have sex with men [33]. Our study found that only 6% of CHC staff were involved in providing care to people living with HIV within the preceding month and, a further 10% of them have consulted patients at high risk for HIV in the same period. This suggests that at least some people living with HIV and people belonging to populations at risk for HIV infection are willing to visit primary care doctors in the community. Our findings are consistent with a British study that reported people at-risk for HIV infection were willing to visit their general practitioners as their first point of contact for healthcare [34]. The advantage of incorporating HIV testing into CHCs is that they are closer to where people live and, if the service is integrated into routine care, it could help normalize HIV testing and other services for key populations.
Before encouraging HIV testing through CHCs, several barriers will need to be addressed. We identified concerns from CHC staff over challenges in dealing with the perceived clinical complexities of people from key populations. Nearly half of CHC staff surveyed were also worried that people belonging to key populations might scare other patients away, and about a third were concerned of being infected themselves, despite the risk being extremely low. These fears are consistent with other research findings from China [18]. About half the CHC staff cited lack of training as the biggest barrier against offering HIV testing in CHCs and CME may serve as a useful avenue for further training in HIV testing and counseling. Indeed, we found those who were currently offering HIV testing were those who had already had specific training in HIV. Moreover, part of preparing CHCs to offer HIV testing also lies in ensuring privacy and confidentiality of patients requesting HIV testing. Previous surveys of people from high-risk populations have mentioned privacy concerns around HIV testing [10,11,12]. In our study, half of the staff thought it was difficult to ensure patient confidentiality within the current environment in their CHC. A protected space that ensures privacy in discussing and testing for HIV within CHCs, as well as improvement in training to ensure professionalism, are required before this service is to be introduced.
The strength of the study was its high response rates from a large number of randomly sampled CHCs in Mainland China. Overall, 84% of chosen CHCs participated, and 89% of staff from the CHCs completed the surveys. This high response rate was attributed to the strong network of general practitioners organized at national and provincial levels, and the follow up from the research team (i.e. telephone calls to the clinicians-in-charge to ensure surveys were completed). Our study findings should be read in light of its limitations. This is a cross-sectional study that provided an overview of the current practices and attitudes of CHC staff in China. There is potential for selection bias which might reduce the generalizability of our findings, but we used a three-stage stratified sampling strategy to minimize this. Further qualitative research is needed to elicit and address specific issues that an individual CHC may have regarding offering HIV testing to their patients, particularly to members of key populations. For instance, we did not distinguish the subpopulations that makes up the category of ‘key populations’ in our survey (i.e. female sex workers, men who have sex with men, intravenous drug users) who have differences in cultural norms and thus the attitude of providers towards each subpopulation may differ accordingly. Nevertheless, our survey uncovered common stigmatizing attitudes expressed by some CHC staff which needs to be addressed if HIV testing is to be encouraged through CHCs. In addition, further study to evaluate the cost-effectiveness of offering HIV testing through CHCs in China would be valuable in providing supporting evidence for encouraging all CHCs to offer a HIV testing service. Our study showed that CHC providers are reporting that members of key populations are attending CHCs, and if CHC staff could target testing to members of these populations, it may be a cost-effective means to provide HIV testing. Further research will be needed to estimate what proportion of CHC attendees belong to key populations. Another potential advantage of integrating HIV testing into CHCs is that it may lessen stigma associated with HIV testing, but it will necessitate broad consensus to develop appropriate protocols and further training for primary care providers. Finally, if a patient tests positive, an appropriate referral to receive ongoing HIV care (i.e. linkage to care) is critical. Our study did not collect information on CHC staff’s willingness to ensure linkage to care, and this is an area that warrants further research.
