Bright Spot: HIV Counseling, Testing and Referral (CTR)

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This bright spot was originally published in the 100 Million Healthier Lives Change Library and is brought to you through partnership with 100 Million Healthier Lives and the Institute for Healthcare Improvement.


Detailed Description

HIV Counseling, Testing, and Referral (CTR) is a collection of activities designed to increase clients' knowledge of their HIV status; encourage and support risk reduction; and secure needed referrals for appropriate services (medical, social, prevention, and partner services). Implementation plan, monitoring, and evaluation tools can be found on the Effective Interventions website. 

Expected Outcomes

Awareness of HIV status, linkage to care, reengagement in care

Key Steps for Implementation

Public Health Strategies: HIV Testing

Section One: Organization Capacity (pages 2-5) Examining organization infrastructure needed to support a rapid HIV testing (RT) program

  • Sec. 1, p. 2 Maintaining confidential client records
  • Sec. 1, p. 3 Staffing-technical qualifications
  • Sec. 1, p. 4 Staffing-planning and organization
  • Sec. 1, p. 5 Funding issues

Section Two: Operational Considerations (pages 6-12) Assessing operational considerations that need to be in place to support RT

  • Sec. 2, p. 6 Ensure appropriate physical space to conduct CTR and/or RT.
  • Sec. 2, p. 7 Provide HIV test counseling in accordance with CDC and/or state approved standards, as appropriate.
  • Sec. 2, p. 8 Facilitate and deliver results of confirmatory testing for all clients whose preliminary test results are positive.
  • Sec. 2, p. 9 Refer all HIV-positive clients to HIV primary and specialty medical care.
  • Sec. 2, p. 10 Provide assistance with partner notification and comply with HIV disease reporting requirements and other requirements for confirmed positive test results.
  • Sec. 2, p. 11 Refer HIV-positive clients to a range of support services including: case management; alcohol and substance abuse treatment; entitlement programs; prevention counseling; housing; legal services; and others as needed.
  • Sec. 2, p. 12 Implement an Exposure Control Plan to protect employees from exposure to blood-borne pathogens, ensure required staff training, provide staff vaccination against hepatitis B, and properly dispose of regulated medical waste.

Section Three: Laboratory Issues (pages 13-15) Assessing laboratory QA issues that are essential to ensuring accurate and correct testing

  • Sec. 3, p. 13 Obtain CLIA Certificate of Waiver and/or other registration as required by your state, identify a qualified laboratory director if required, and obtain needed supplies.
  • Sec. 3, p. 14 Establish a comprehensive quality assurance (QA) plan that ensures proper supervision, outlines step-by-step instructions, and ensures staff competency in performing and interpreting the test.
  • Sec. 3, p. 15 Ensure that testing is being carried out correctly, results are accurate, and mistakes are found and corrected to avoid adverse effects.

Section Four: Staff Training (pages 16-17) Examining the entire range of staff training needs

  • Sec. 4, p. 16 Staff need to receive training in all aspects of the program including HIV test counseling, organization policies and procedures, and how to conduct the test.
  • Sec. 4, p. 17 Staff needs to receive training in all aspects of the program including confidentiality training, QA and quality control (QC) procedures, documentation and records management, and bloodborne pathogens training. Adapted from "Considering Whether to Implement A Rapid Testing Program Using Rapid HIV Testing Technology: A Self-Assessment for Agencies," New York State Department of Health AIDS Institute.


CBOs should involve clients and the community in designing and implementing prevention services to ensure that important cultural issues are incorporated. The Office of Minority Health of the Department of Health and Human Services has published the National Standards for Culturally and Linguistically Appropriate Services in Health Care, which should be used as a guide for ensuring cultural competence in programs and services.

Policies, Laws and Regulations

It is important to keep in mind that CTR deals with the provision of services that require specialized training and deals with private client medical information. CBOs must know their state laws regarding who may implement CTR procedures and about disclosure of a client's HIV status (whether positive or negative) to sex partners and other third parties. CBOs must know and follow all applicable state and local laws, regulations, and policies related to reporting of HIV test results to the health department. CBOs must inform clients about state laws regarding the reporting of child abuse, sexual abuse of minors, and elder abuse or imminent danger or harm.

Required Staffing (FTEs)

The number of staff needed depends on the number of tests to be done and the type of test used (rapid or conventional). The number of tests completed per hour depends on the needs of the clients|the abilities of the staff|and the type of test used.

Special Infrastructure

CTR can be implemented at any location where confidentiality of clients can be assured (e.g., private area or room) and where a specimen can be collected according to minimal standards as outlined by the Occupational Safety and Health Administration. Additionally, if rapid testing is used, the setting must have a flat surface, acceptable lighting, and ability to maintain temperature in the range recommended by the test manufacturer for performing the test.


For registration information for attending CTR trainings, please visit the HIP Training Calendar and select CTR under All Interventions and Courses. The CDC on-line "Rapid HIV Testing Training Course' will offer an opportunity for HIV Prevention Providers working in non-clinical settings to gain knowledge and skills on administering rapid HIV testing. Rapid HIV Testing will allow providers greater reach into places where HIV testing has not been available. The on-line course has four modules, and takes approximately 5 hours to complete.

  • Overview and Introduction to Rapid HIV Testing
  • Safe Work Practices and Specimen Collection for Rapid HIV Testing
  • Quality Assurance and Quality Control in a Rapid HIV Testing Environment
  • HIV Prevention Counseling and Providing Rapid HIV Test Results

All materials in the course are based on CDC guidelines, protocols and established best practices related to rapid HIV testing, as seen in clinical and non-clinical settings. To register for the Rapid HIV Testing course, please visit the HIP Training Calendar and select "Rapid HIV Testing - Online" from the Interventions and Courses drop down menu.

Types of Staff

CTR needs paid or volunteer staff members who are trained in HIV CTR. If rapid HIV testing will be used, involved staff members must also be trained to perform rapid HIV tests. All polices, quality assurance requirements, and local and state requirements related to rapid HIV testing must be followed.

Return on Investment Details

Benefits: Decreased HIV transmission rates, Decreased HIV incidence, Decreased HIV morbidity and mortality

Outcome Measures

Outcome monitoring and evaluation help you determine if your non-clinical HIV program is having its intended effect in two ways:

  • Outcome monitoring asks: Are we meeting our goals and objectives?
  • Outcome evaluation asks: Are our program activities making a measurable impact on clients and the community?

Measure Examples: By December 31, 2013, increase from 10% to 40% the number of clients who use condoms with main and casual sex partner(s). By December 31, 2013, increase from 15% to 40% the number of clients who attend the first appointment to any referred service.

Process Measures

Process monitoring and evaluation help you look at your non-clinical HIV program's implementation in two ways.

For example:

  • Process monitoring asks: How are we delivering program activities and who are we reaching?
  • Process evaluation asks: Are we doing what we planned and are there ways to be more effective?

Measure Examples:

  • Timeliness of test result
  • Timeliness of linkage to care
  • Timeliness of referral to prevention services
  • Maintaining confidentiality
  • Maintaining client satisfaction with service delivery


Website of HIV Effective Interventions
HIV: Effective Interventions
Resource - Website/webpage
Brought to you by CDC

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