Cost effectiveness of facility and home based HIV voluntary counseling and testing strategies in rural Uganda

Background

In Uganda, the main stay for provision of human immunodeficiency virus (HIV) voluntary counseling and testing (VCT) has been at health facilities. Home based VCT on the other hand, was initiated in the country to improve service coverage.

Objective

To evaluate the cost effectiveness of facility- and home-based HIV VCT strategies in rural southwestern Uganda.

Methods

Data on costs and effectiveness of facility- and home-based HIV VCT intervention strategies was collected in two sub-Counties in rural southwestern Uganda. Costing was performed using the ingredients approach. Effectiveness was measured as the number of HIV sero-positive clients identified. Incremental Cost-Effectiveness Ratios (ICERs) were calculated from the provider perspective.

Results

The cost per client tested were US$6.4 for facility based VCT and US$5.0 for home based VCT. The corresponding costs per positive case identified were US$86.5 and US$54.7 respectively. The incremental cost to providers per additional positive case identified by facility based VCT was US$3.5.

Conclusion

Home based VCT was the least costly strategy per client tested and was also cost effective in identifying HIV sero-positive clients in rural areas. This strategy should therefore be promoted to improve service coverage and thereby facilitate early and extensive detection of clients eligible for treatment.     

Evolution of couples' voluntary counseling and testing for HIV in Lusaka, Zambia

BACKGROUND:: We describe promotional strategies for couples' voluntary HIV counseling and testing (CVCT) and demographic risk factors for couples in Lusaka, Zambia, where an estimated two thirds of new infections occur in cohabiting couples. PRINCIPAL FINDINGS:: CVCT attendance as a function of promotional strategies is described over a 6-year period. Cross-sectional analyses of risk factors associated with HIV in men, women, and couples are presented. Community workers (CWs) recruited from couples seeking CVCT promoted testing in their communities. Attendance dropped when CW outreach ended, despite continued mass media advertisements. In Lusaka, 51% of 8500 cohabiting couples who sought HIV testing were concordant negative for HIV (MF) and 26% concordant positive (MF); 23% had 1 HIV-positive partner and one HIV-negative partner, with 11% HIV-positive man/HIV-negative woman (MF) and 12% HIV-negative man/HIV-positive woman (FM). HIV infection was associated with men's age 30 to 39, women's age 25 to 34, duration of union <3 years, and number of children <2. Even among couples with either 1 or 2 or no risk factors, HIV prevalence was 45% and 29%, respectively. CONCLUSIONS:: Many married African adults do not have high-risk profiles, nor realize that only 1 may be HIV positive. Active and sustained promotion is needed to encourage all couples to be jointly tested and counseled.     

Knowledge of HIV/AIDS and attitude towards voluntary counseling and testing among adults

BACKGROUND: Nigeria has the third highest population of people living with human immunodeficiency virus (HIV). Despite this, the knowledge of HIV/AIDS and uptake of voluntary counseling and testing (VCT) is still low, especially in the rural areas. This study assessed knowledge of HIV/AIDS and attitude towards VCT among adults in a rural community in northern Nigeria. METHODS: A pretested questionnaire was administered on a cross-section of 210 adults in Danbare village, northern Nigeria. Information about knowledge of HIV/AIDS and attitudes toward VCT was elicited among respondents. RESULTS: The majority of respondents (59%) did not know the causative agent of AIDS; however, knowledge of route of disease transmission was high, with 71% and 64% of study participants mentioning sexual activity and unscreened blood transfusion, respectively, as possible transmission routes. Respondents listed avoidance of premarital sex, outlawing prostitution, condom use and screening of blood before transfusion as protective measures. Overall, 58 (27.6%), 80 (38.1%) and 72 (34.3%) of the respondents had good, fair and poor knowledge of HIV/AIDS, respectively. After adjusting for confounders, female gender and formal education remained significant predictors of HIV/AIDS knowledge. Reasons for rejection of VCT included fear of stigma, marital disharmony, incurable nature of the disease and cost of treatment. Formal education, female gender and HIV knowledge significantly predicted positive attitude toward VCT for HIV/AIDS among the study population. CONCLUSION: More than half of the respondents had adequate knowledge of HIV/AIDS, and the majority were willing to have VCT. However, misconceptions, fear, gaps in knowledge and limited access to VCT remain prevalent. Our findings suggest the need to provide health education and scale up VCT services in northern Nigeria by targeting the efforts of international and local development partners to underserved rural areas.     

Social and cognitive variables predicting voluntary HIV counseling and testing among Tanzanian medical students

Objective

The present study aimed to predict Tanzanian medical students’ Voluntary Counseling and Testing (VCT) participation intention using the Health Belief Model (HBM) as a theoretical framework. Further, differences between respondents who had previously participated in VCT and respondents who had not were assessed.

Methods

Cross-sectional data were gathered from 186 Tanzanian medical students using a self-administered questionnaire.

Results

Almost half of the respondents (43.3%) reported having been tested for HIV. A prediction model containing HBM and demographic variables explained 31% of the variance in VCT-participation intention. Self-efficacy, fear of being HIV-positive, and perceived susceptibility contributed significantly to the final regression model. In addition, respondents who had previously participated in VCT expressed less fear of being stigmatized and being HIV-positive than respondents who had not.

Conclusion

Fear of being HIV-positive, self-efficacy, perceived susceptibility and fear of being stigmatized were associated with either VCT-participation intention or previous participation. Further, the HBM accounted for a limited proportion of the explained variance in Tanzanian students’ intention to participate in VCT. This suggests that the validity of the HBM in explaining HIV-preventive behavior in Sub-Saharan Africa should be questioned.

Practice implications

Interventions promoting VCT should incorporate program elements targeting self-efficacy, fear of being HIV-positive, perceived susceptibility and fear of being stigmatized.     

HIV voluntary counseling and testing and HIV incidence in male injecting drug users in northern Thailand: evidence of an urgent need for HIV prevention

HIV voluntary counseling and testing (VCT), an important strategy for HIV prevention and care, has been available in all government hospitals in Thailand since 1992. We assessed factors associated with HIV testing, its uptake, and estimates of HIV incidence after HIV testing among male northern Thai injecting drug users (IDUs) admitted for inpatient drug treatment. Participants were interviewed about risk behaviors and HIV testing history before VCT was provided as part of the study. Of 825 IDUs who participated, 36% reported a prior HIV test. Factors associated with prior HIV testing in multiple logistic regression analysis included higher education and having >1 lifetime sex partner. Needle sharing was not associated with prior HIV testing. Of the 298 men with a prior test, 80% reported a negative result on their last prior HIV test, of whom 28% tested positive in our study, leading to an estimated incidence rate of 10.2 per 100 person-years. Fifty-nine percent of the IDUs who reported a prior HIV test stated that they did not receive pre- and/or posttest counseling. HIV incidence among IDUs remains high despite having VCT. Extending HIV prevention and harm reduction programs is urgently needed for IDUs in the region.     

Estimating HIV incidence in voluntary counseling and testing clients in Uganda (1992-2003)

OBJECTIVES: To estimate HIV incidence from first-time testers among voluntary counseling and testing (VCT) clients in Uganda. METHODS: Data on 203,000 VCT clients tested from 1992 through 2003 were adjusted for temporal changes in the testing population. Differential mortality rates by HIV status were used to derive expected prevalence at future times from baseline prevalence within 5-year birth cohorts. Incidence was computed as the proportion of HIV-uninfected persons who seroconverted divided by the proportion negative at baseline. RESULTS: Annual HIV incidence per 100 uninfected persons increased from 0.9 (95% confidence interval [CI]: 0.8 to 1.1) in 1993 to 2.3 (95% CI: 2.2 to 2.5) in 2003 (chi test for trend, P < 0.001). Prevalence decreased from 23% to 13% in 1999 to 2000 and increased to 15% in 2003. Women had a higher incidence. Peak incidence shifted to older age groups over time. CONCLUSIONS: Estimating incidence from routine data presents a practical way of tracking HIV incidence and is a useful tool in targeting and evaluating the impact of prevention programs. Our analysis reveals a new phase of the HIV epidemic in Uganda: decreasing prevalence and increasing incidence, especially among middle-aged persons. These findings support the need for intensified prevention interventions among middle-aged persons in Uganda.     

Comparison of three methods to measure HIV incidence among persons seeking voluntary, anonymous counseling and testing

OBJECTIVES: The authors compared 3 practical methods to estimate human HIV incidence rates using existing data from persons seeking anonymous testing in San Francisco between 1996-2002. Each method was assessed for strengths and limitations. METHODS: Three different approaches were used to determine HIV incidence: one based on self-reported dates of prior tests, one based on linking records of prior tests using an anonymous unique testing code, and one based on the Serologic Testing Algorithm for Recent HIV Seroconversion (STARHS). RESULTS: The 3 methods found comparable rates of seroconversion overall (1.0, 1.2, and 1.3 per 100 person-years) and among men who have sex with men (1.4, 1.6, and 2.0 per 100 person-years). Incidence for all 3 methods saw a peak during 1999 followed by a decline. Greatest variability of incidence was observed among lower-risk populations, in whom few infections were expected. CONCLUSIONS: The 3 methods had complementary strengths and limitations, which may prevent proper interpretation of HIV incidence if any one method is analyzed alone. HIV incidence rates among persons seeking HIV testing should be interpreted cautiously using corroborative data on risk behavior and sexually transmitted diseases and other contextual information.     

The role for government health centers in provision of same-day voluntary HIV counseling and testing in Kenya

OBJECTIVE: To explore the role of primary health centers in provision of voluntary counseling and testing (VCT) in Kenya. DESIGN AND SETTING: Prospective service evaluation at 3 (1 urban and 2 rural) government health centers. SUBJECTS: Consecutive adult clients. MAIN OUTCOME MEASURES: Uptake of services, user characteristics, quality of service. RESULTS: Counseling services received 2315 new clients over 26 months. The last quarter averaged 101 clients per clinic. More than 80% of clients lived locally. Overall 93% opted to test, 91% receiving results, 82% on the same day. Most clients tested HIV negative (81%). Youth and men were well represented. Few couples (10%) attended. Seventeen percent of women were pregnant. Self-referral was common and illness was an uncommon reason for testing (<20%). Thirty-one percent of clients were referred from VCT to other health center services. Counseling was perceived as high quality by users and providers. Validation of the test algorithm showed a sensitivity of 98.0% and specificity of 98.7%. CONCLUSION: Government health centers in Kenya can be appropriate providers of VCT. This pilot helped initiate a new strategy of health center-based VCT in Kenya and this has facilitated rapid expansion and more equitable provision for Kenyans.     

Using HIV voluntary counseling and testing data for monitoring the Uganda HIV epidemic, 1992-2000

OBJECTIVE: To assess trends in the prevalence of HIV infection among voluntary counseling and testing (VCT) clients in Uganda and to describe the utility of VCT data for monitoring the HIV epidemic in 1992-2000. METHODS: We analyzed routinely collected data from first-time VCT clients not reporting illness as a reason for testing. We developed a model adjusting for test site, couple testing, and premarital testing, assessed trends in adjusted prevalence of HIV infection and shifts in age-specific peak prevalence, and compared antenatal clinic (ANC) surveillance data and VCT prevalence trends. RESULTS: Among 201,741 clients, adjusted prevalence of HIV infection declined from 23% in 1992 to 13% in 2000 (P < 0.001) (men, 17%-9% [P < 0.001]; women, 31%-18% [P < 0.001]). The prevalence declined for all age groups except men older than 39 years and women older than 34 years. The prevalence increased for women older than 39 years (P < 0.003). Between 1992 and 2000, peak prevalence declined for both men (31% to 24%) and women (44% to 41%), whereas the age at which the peak occurred increased for both men (36 to 41 years) and women (31 to 36 years). VCT and ANC prevalence trends were similar. CONCLUSION: In Uganda, the prevalence of HIV infection among male and female VCT clients declined from 1992 to 2000, similar to ANC surveillance data, but did not decline in older age groups. In regions with well-established VCT programs, VCT data may provide a useful and convenient tool for monitoring the HIV epidemic.     

Genotypes and viral load of hepatitis C virus among persons attending a voluntary counseling and testing center in Ethiopia

The prevalence of different genotypes of hepatitis C virus (HCV) in Ethiopia is not known. HCV genotypes influence the response to therapy with alpha‐interferon alone or in combination with ribavirin. A cross sectional study was conducted on attendees of voluntary counseling and testing center. Serum samples from 1,954 (734 HIV positive and 1,220 HIV negative) individuals were screened for HCV antibody. Active HCV infection was confirmed by quantitative PCR in 18 of the 71 samples with anti‐HCV antibodies. The HCV viral load ranged from 39,650 to 9,878,341 IU/ml (median 1,589,631 IU/ml) with no significant difference [χ²(17) = 18.00, P = 0.389] between persons positive or negative for HIV. The viral load of HCV was, however, higher in older study subjects (r = 0.80, P = 0.000). HCV genotypes were determined using the VERSANT HCV Genotype Assay (LiPA) and sequence analysis of the NS5b region of the HCV genome. Diverse HCV genotypes were found including genotypes 1, 2, 4, and 5. There was no difference in the distribution regarding the HIV status. As in other parts of the world, genotyping of HCV must be considered whenever HCV is incriminated as a cause of hepatitis. J. Med. Virol. 83:776–782, 2011. © 2011 Wiley‐Liss, Inc.     

早期科研训练与同阶段实验课程的有机组合具备可行性

目的通过学生评价,研究临床医学(八年制)早期科研训练。方法对湘雅医学院八年制临床医学专业2016级及2017级共202名学生分别发放相应问卷,描述相关问题并就某些问题的调查结果进行分析与应用。结果2017级学生:70.0%认为时间安排合理;52.5%觉得早期科研训练有意义并且能认真学;77.5%愿意提早进入医学院学习;57.5%不同意将早期科研训练理论课算入成绩;85.0%认为南校区的数理化学习有效果;92.5%认为在实验课上很少或基本没有受到启发;67.5%对科研过程没有更多的了解;50.0%会花费精力去研究非医学领域问题;97.5%会重新选择临床医学(八年制);学生认为最需注重实验能力的培养以及科研选题难在医学知识缺乏。2016级学生:51.2%认为时间安排不合理;51.2%对科研过程没有更多的了解;80.5%对科研训练实施方案满意;学生认为最需注重提升学生的创新能力以及科研选题难在不了解前沿进展。结论早期科研训练与同阶段实验课程的有机组合具备可行性。     

Knowledge and attitude toward HIV voluntary counseling and testing services among pregnant women attending an antenatal clinic in Sudan

Human immunodeficiency virus (HIV) infection and the development of the acquired immunodeficiency syndrome (AIDS) are increasing at an alarming rate especially in the sub-Saharan region. Pregnant women susceptible to HIV and its transmission to the fetus provide a unique opportunity for implementing preventive strategy against HIV infection of newborn babies. During the period of August-December 2005 a cross-sectional study was conducted at the Fath-Elrahman Elbashir antenatal clinic, Khartoum Teaching Hospital, to investigate pregnant women's basic knowledge and attitude toward HIV and mother to child transmission as well as voluntary counseling and testing. Pre-tested structured questionnaires were given to antenatal attendants by professional counselors. Their basic socio-demographic and obstetric characteristics were obtained. Respondents' knowledge about HIV and mother to child transmission were tested. In addition, their willingness toward HIV testing was also reported. Out of the 1,005 women investigated, 79% had basic knowledge about HIV. Those who were resident in Khartoum and whose age was > or =26.1 years and their education level was secondary and above were found to be more knowledgeable about HIV. More than half of respondents were aware of mother to child transmission. Older (> or =26.1 years), educated, and working mothers were found to be more knowledgeable about mother to child transmission. Willingness to undergo the test was demonstrated in 72.8% of respondents. However, only 30.3% had the test done. Older women, primigravidae, and Muslims have higher acceptance of voluntary counseling and testing. There is a need to extend the voluntary counseling and testing program in all antenatal clinics. In addition, there is a need to increase the level of education and raise health awareness about HIV and mother to child transmission.     

Couples at risk: HIV-1 concordance and discordance among sexual partners receiving voluntary counseling and testing in Uganda

OBJECTIVE: To determine correlates of HIV-1 concordance for couples receiving voluntary HIV counseling and testing. DESIGN: Cross-sectional study of couples receiving voluntary HIV counseling and testing in Kampala, Uganda. METHODS: An interview and physical examination were conducted for 49 HIV-1-concordant (both partners infected with HIV) and 126 HIV-1-discordant (1 partner infected with HIV and 1 partner HIV negative) couples. Blood samples from all participants were tested for HIV-1 and syphilis serology. CD4 cell count and HIV load were characterized for all HIV-infected persons. Urine samples were tested for Neisseria gonorrhoeae and Chlamydia trachomatis using ligase chain reaction. Associations between couples' HIV status and key sociodemographic, behavioral, and biomedical factors were analyzed. RESULTS: Men in HIV-concordant couples were more likely than men in HIV-discordant couples to be living together with their sexual partner (odds ratio [OR], 11.3; 95% confidence interval [CI], 2.8-53.7; P=0.004), to be uncircumcised (OR, 4.5; 95% CI, 1.1-18.8; P=0.042), and to have higher HIV loads (OR for each log increase, 3.0; 95% CI, 2.0-4.7; P<0.001). Women in HIV-concordant couples were more likely than women in HIV-discordant couples to be living together with their sexual partner (OR, 19.0; 95% CI, 3.8-84.8), to have an uncircumcised male partner (OR, 6.5; 95% CI, 1.6-26.4), to have had a sexually transmitted disease in the 6 months before enrollment (OR, 1.9; 95% CI, 0.9-4.5), and to have higher HIV loads (OR for each log increase, 2.2; 95% CI, 1.5-3.2). CONCLUSIONS: Several behavioral and biologic risk factors were associated with HIV concordance for couples. Providing early sexually transmitted disease diagnosis and treatment, antiretroviral therapy, and specially designed counseling to HIV-discordant couples may help prevent HIV transmission in couples where being in a stable sexual relationship is a major risk factor for HIV infection.     

Newborn screening for X-linked adrenoleukodystrophy: Further evidence high throughput screening is feasible

X-linked adrenoleukodystrophy (ALD) is characterized by adrenal insufficiency and neurologic involvement with onset at variable ages. Plasma very long chain fatty acids are elevated in ALD; even in asymptomatic patients. We demonstrated previously that liquid chromatography tandem mass spectrometry measuring C26:0 lysophosphatidylcholine reliably identifies affected males. We prospectively applied this method to 4689 newborn blood spot samples; no false positives were observed. We show that high throughput neonatal screening for ALD is methodologically feasible.     

The medication experience: preliminary evidence of its value for patient education and counseling on chronic medications

Objective

To describe medication therapy management (MTM) pharmacists’ encounters with patients’ medication experiences, to examine the utility of the medication experience in practice, and to explore the value of the medication experience in patient education and counseling on medications.

Methods

A focus group of 10 MTM pharmacists, and 1 pharmacist's 9-month practice diary were analyzed to reveal patients’ medication experiences and the utility and value of the medication experience in practice.

Results

MTM pharmacists commonly encountered patients’ medication experiences in their practices. The medication experience was often at the root of drug therapy problems (DTPs) the practitioners identified. The pharmacists identified several examples of drug therapy problems with an associated medication experience at the root. The medication experience was a meaningful construct to guide patient education and counseling on new chronic medications to ultimately prevent DTPs, and valuable for tailoring patient education and counseling on medications to resolve DTPs.

Conclusion

Our study provides preliminary evidence of the value of the medication experience for patient education and counseling on chronic medications in practice.

Practice implications

The medication experience is a valuable tool for practitioners to understand patients’ needs, identify and resolve DTPs, and tailor patient education and counseling for chronic medications.     

Botswana's Tebelopele voluntary HIV counseling and testing network: use and client risk factors for HIV infection, 2000-2004

BACKGROUND:: HIV services, including voluntary counseling and testing (VCT) and antiretroviral (ARV) therapy, expanded rapidly in Botswana from 2000 through 2004. METHODS:: Client data from Botswana's Tebelopele VCT network were analyzed to describe clients, factors associated with HIV infection, and trends in VCT use. RESULTS:: Tebelopele provided free, anonymous, same-day HIV tests for 117,234 clients from 2000 through 2004. Before ARV therapy was available, 8.3% of clients sought a test because of illness, and 26.3% were HIV-positive. After ARV therapy became available, 20.1% of clients sought a test because of illness, and 38.8% were HIV-positive. Most VCT clients (82.7%) were unmarried; 89.8% reported no or 1 sexual partner in the last 3 months; and 50.2% of unmarried clients reported always using condoms in the last 3 months. In multivariate analysis, higher educational level, marriage, and always using condoms were associated with a lower risk of HIV. Having only 1 recent sexual partner was associated with less condom use and a higher risk of being HIV-positive for men. CONCLUSIONS:: VCT has been well accepted in Botswana. Analysis of this data set supports efforts to promote 100% condom use and to emphasize that partner reduction must be combined with condom use and HIV testing to protect against HIV.