Effectiveness of Brief Counseling in Reducing HIV Risk Behavior in Injecting Drug Users: Final Results of Randomized Trials of Counseling with and Without HIV Testing

We evaluated the behavioral effects of brief counseling designed to assist injecting drug users in problem-solving situations in which they engage, or are tempted to engage, in practices that place them at risk of infection with HIV. Two hundred ninety-five (295) heroin detoxification clients were randomly assigned to receive either 50 min of the experimental preventive counseling or a packet of educational brochures. Follow-up interviews were conducted 3 and 12 months after randomization to assess the effects of counseling versus brochures. In a follow-up study with 109 clients, the experimental counseling was modified to be conducted in the context of notifying drug users of their HIV test results. In the follow-up study, we conducted standard pretest counseling before randomizing subjects to receive or not to receive the 50 min of experimental counseling. Follow-up interviews conducted 6 and 12 months after randomization assessed the impact of the experimental counseling versus standard pretest counseling. Substantial decreases in injection-related and sexual risk behavior were observed among subjects in both conditions in both studies. The decreases were for the most part sustained to 12-month follow-up interviews. The results suggest that many drug users may not require intensive counseling to reduce or eliminate high-risk practices. We determined that the reductions in risk behavior for both groups and both studies were probably not the result of secular historical trends, contamination of the experimental by the comparison group, volunteer bias, or regression or maturation effects, but very likely were in part a consequence of participating in research. Implications include the potential preventive effectiveness of a widely practiced form of health promotion known as the health risk assessment.     

Development of a Community-Based Participatory Research Effort to Evaluate Conventional HIV Testing (CHT) and HIV Rapid Testing (HRT)

Abstract

A community-based participatory research (CBPR) project was created to study the effects of changing HIV testing protocols on client risk behaviors in an urban area. Concerns raised by the agency advisory group led to development of research questions that needed to be addressed within the community. The article focuses on development of the research partnership and study enrollment during the first year of the project. Challenges of assimilating rapid advances in health technology while conducting outreach to high-risk clients are discussed. Successes and lessons learned are described, including adaptation of theory-based interventions to research protocol and multi-level community coordination.     

HIV Counseling and Testing Practices at an Urban Hospital in Kampala, Uganda

While the majority of medical inpatients in Uganda are assumed to be HIV-positive, HIV testing is limited in inpatient settings. This study describes HIV testing practices and risk behavior among medical inpatients at an urban hospital in Uganda. We interviewed 395 adults on the day of discharge. Overall, 46% tested for HIV before or during admission. Of the 20% tested during hospitalization, 64% were HIV-positive. Among 47% who had sex in the previous year, only 14% used condoms consistently and only 20% knew the HIV status of their sexual partner, indicating that participants would benefit from risk-reduction counseling. Yet, only 26% of participants tested during hospitalization received post-test counseling. Half of the participants with HIV-related illnesses left the hospital without being offered the test, a missed opportunity for HIV prevention counseling and care. The findings indicate that hospitals are important venues for HIV counseling and testing.     

Clients' Perspective of the Role of Voluntary Counseling and Testing in HIV/AIDS Prevention and Care in Dar Es Salaam, Tanzania: The Voluntary Counseling and Testing Efficacy Study

There is a growing body of evidence that voluntary HIV counseling and testing (VCT) is effective for the primary prevention of HIV as well as for the care and support of individuals affected by HIV in developing countries. This qualitative study offers an additional perspective: the experiences and perceptions of men and women receiving VCT services. As a substudy of a large multisite clinical trial testing the effectiveness of VCT, 81 study participants at the Tanzania study site who were randomized to VCT at baseline were interviewed at the time of their 6-month follow-up. Findings are based on textual analysis of the following themes: HIV in the context of other life issues, motivations for receiving services, positive and negative consequences of VCT, and the role of VCT in risk reduction. Implications for service provision in developing countries are discussed.     

The Voluntary HIV-1 Counseling and Testing Efficacy Study: Design and Methods

While HIV counseling and testing has been promoted as potentially effective for prevention, few controlled studies have been conducted. The Voluntary HIV Counseling and Testing Efficacy Study was a randomized clinical trial of the effectiveness of HIV counseling and testing in reducing sexual risk behavior in three developing countries: Tanzania, Kenya, and Trinidad. The trial will provide crucial information regarding the effectiveness, cost, and consequences of HIV counseling and testing for prevention. This paper describes the design and methods of the Voluntary HIV Counseling and Testing Efficacy Study. Following a discussion of the study objectives, the design and methods of the study are presented. Recruitment, consent, randomization, intervention, assessment, follow-up, training, and quality assurance procedures are described. Issues raised in the design and anticipated in the interpretation of the study outcomes are discussed, as well as potential policy and service delivery implications of the study findings.     

Impact of HIV Counseling and Testing on HIV-Infected Men Who Have Sex with Men: The South Beach Health Survey

The impact of HIV counseling and testing on sexual risk-taking and related behaviors reported by HIV-infected men who have sex with men (MSM) was examined in a cross-sectional study conducted among a representative sample of residents living in a resort area. Participants provided specimens of oral mucosal transudate for HIV-antibody testing, were interviewed in their homes, and completed a self-administered questionnaire. Specimens were tested by modified ELISA and, if repeatedly positive, confirmed by Western blot. Of 205 men enrolled, 51 (24.9%) tested positive for antibody to HIV. All 51 had been counseled and tested for antibody to HIV-1 (median = 4 tests); 37 (74%) of 50 reported that their most recent test was positive. Twenty (39.2%) said they had engaged in unprotected insertive anal intercourse in the past year; 15 (29.4%) engaged in unprotected insertive anal intercourse with partners who may have been susceptible to HIV infection. Men who reported that their last HIV-antibody test was positive were three times more likely to have engaged in unprotected insertive anal intercourse in the past year (45.9%) as those who did not know they were infected with HIV (15.4%). Counseling and testing is ineffective as a measure for promoting behavior change among HIV-positive MSM in South Beach. More effective social and behavioral interventions must be developed, implemented, and evaluated.     

Correlates of HIV Test Results Seeking and Utilization of Partner Counseling Services in a Cohort of Male Factory Workers in Zimbabwe

Correlates of individual HIV test results-seeking and utilization of partner counseling services were identified among male factory workers who participated in a longitudinal HIV prevention intervention study in Harare, Zimbabwe. Men working at participating factories were offered HIV voluntary counseling and testing (VCT) for themselves and their partners. While risk assessment counseling was offered in the workplace, result disclosure and partner counseling occurred at an off-workplace location. Of the 3,383 men undergoing risk assessment and testing, 1,903 (56%) chose to receive their test results and 230 (7%) brought their partners for VCT. Factors associated with receiving test results were history of STD and lower salary. Factors associated with bringing a partner for VCT were history of STD, being married, being employed at a factory with a peer educator, lower salary, and no prostitute contact. Incorporating VCT into STD treatment services is likely to reach a large number of men and their partners at highest risk for both types of infections. Because men are often the main decision-makers in sexual and reproductive matters, VCT must be easily accessible to urban, working African men.     

Assessing the Efficacy of a Voluntary HIV Counseling and Testing Intervention for Pregnant Women and Male Partners in Urumqi City, China

This study investigated the efficacy of voluntary counseling and testing (VCT) in an educated cohort of pregnant women attending antenatal clinics in Urumqi, China. VCT was given to women and their partners (experimental group) or women alone (control group). Both groups were given pre- and post-intervention questionnaires to assess HIV knowledge and willingness to get HIV testing. Multivariate analysis showed that all women improved significantly in HIV knowledge between baseline and follow-up. Moreover, HIV knowledge was significantly associated with HIV testing willingness. At follow-up, women in the control and experimental groups were 6.8 and 7.9 times more willing to receive HIV testing than at baseline, respectively. VCT seems effective in this cohort of educated pregnant women.     

Characteristics of Individuals and Couples Seeking HIV-1 Prevention Services in Nairobi, Kenya: The Voluntary HIV-1 Counseling and Testing Efficacy Study

This paper describes the recruitment and baseline characteristics of men, women, and couples who enrolled in the Voluntary Counseling and Testing Efficacy Study at the study site in Nairobi, Kenya. The purpose of this study was to test the effectiveness of Voluntary HIV Counseling and Testing (HIV VCT) to reduce sexual risk behavior. Between June 1995 and March 1996, 500 individual men, 500 individual women, and 515 couple members were recruited for a total sample of 1,515 participants. Participants were young (average age 29 years) and of low income. High levels of risk behavior and self-reported STD symptoms and a high rate of HIV seropositivity among those tested at baseline (15% of men and 27% of women) indicate that an at-risk sample was recruited. Women and participants reporting symptoms of a sexually transmitted infected were significantly more likely to be infected with HIV. Findings suggest that HIV VCT services combined with STD diagnosis and treatment and economic development services could motivate more at-risk individuals and couples to receive counseling and testing.     

Screening for acute HIV infection in South Africa: finding acute and chronic disease*

Background

The yield of screening for acute HIV infection among general medical patients in resource‐scarce settings remains unclear. Our objective was to evaluate the strategy of using pooled HIV plasma RNA to diagnose acute HIV infection in patients with negative or discordant rapid HIV antibody tests in Durban, South Africa.

Methods

We prospectively enrolled patients with negative or discordant rapid HIV antibody tests from a routine HIV screening programme in an out‐patient department in Durban with an HIV prevalence of 48%. Study participants underwent venipuncture for pooled qualitative HIV RNA, and, if this was positive, quantitative RNA, enzyme immunoassay and Western blot (WB). Patients with negative or indeterminate WB and positive quantitative HIV RNA were considered acutely infected. Those with chronic infection (positive RNA and WB) despite negative or discordant rapid HIV tests were considered to have had false negative rapid antibody tests.

Results

Nine hundred and ninety‐four participants were enrolled with either negative (n=976) or discordant (n=18) rapid test results. Eleven [1.1%; 95% confidence interval (CI) 0.6–2.0%] had acute HIV infection, and an additional 20 (2.0%; 95% CI 1.3–3.1%) had chronic HIV infection (false negative rapid test).

Conclusions

One per cent of out‐patients with negative or discordant rapid HIV tests in Durban, South Africa had acute HIV infection readily detectable through pooled serum HIV RNA screening. Pooled RNA testing also identified an additional 2% of patients with chronic HIV infection. HIV RNA screening has the potential to identify both acute and chronic HIV infections that are otherwise missed by standard HIV testing algorithms.     

HIV Voluntary Counseling and Testing among Injection Drug Users in South China: A Study of a Non-Government Organization Based Program

HIV voluntary counseling and testing (VCT) programs are usually delivered by government health agencies in China. This study examined the feasibility of using a Chinese non-government organization (NGO) to deliver a VCT program to injection drug users (IDUs) in a southern Chinese city. The process data indicated the program successfully recruited and served 226 male and female IDUs in 4 months. The HIV prevalence rate of the study population was 57.5% by rapid HIV testing with a secondary rapid test to confirm. Quantitative and qualitative evaluations indicated that the VCT program was implemented appropriately and participants' HIV knowledge and safe drug and sex practices were significantly improved after participation in the VCT program. This study demonstrates the feasibility of a Chinese NGO to provide VCT for IDUs and documents the processes and outcomes of the program. There remains a great need to find additional sources to provide VCT and other HIV prevention services to IDUs and other high-risk populations in China. Chinese NGOs have the potential to fill this need.     

The Dynamics of Repeat HIV Testing, and Interventions for Repeat HIV Testers

This paper attempts to better understand the dynamics of repeat HIV testing behavior. It suggests that different types of HIV risk dynamics characterize different types of repeat testers, and proposes a new set of alternatives to use to triage repeat testers for further intervention. Those for whom repeat testing is more optimal would be tested and counseled as usual (e.g., in the case of those originally tested during the window period), or would be tested and then referred to HIV prevention case management (e.g., in the case of chronic high-risk individuals). Those for whom repeat testing is less than optimal (e.g., the neurotic worried well those with information deficits prompting repeat testing) may or may not be tested, depending on the specifics of their situation, and would be provided with services to address the causes of their repeat testing and to reduce its occurrence.     

High HIV Seropositivity at an Anonymous Testing Site in Chennai, India: Client Profile and Trends over Time

Despite the magnitude of the HIV epidemic in India, few centers exist that provide anonymous HIV testing that is also accompanied by adequate counseling and referral. This study describes the trends in demographic profiles, HIV serostatus, and risk factors among 1,745 male and female clients who accessed an anonymous counseling and testing center in Chennai, India from 1994 to 1998. The prevalence of HIV in this sample was 51%, indicating that the clinic is successful in its outreach to at-risk individuals. The increasing number of clients over time suggests that this clinic has been well-received by the community. Correlates of being HIV-positive included occasional condom use, being married, being referred by an HIV-positive sex partner, working as a truck driver or migrant, or having a spouse in these professions. The success of this clinic serves as a model for similar centers in India, and points to the widespread need for anonymous testing and counseling.     

Improving Students' Sexual History Inquiry and HIV Counseling with an Interactive Workshop Using Standardized Patients

Sexual history and HIV counseling are essential clinical skills. Our project's purpose was to evaluate a standardized patient (SP) educational intervention teaching third-year medical students sexual history taking and HIV counseling. A 4-hour SP workshop was delivered to one-half of the class. Four weeks later, all students engaged in an SP examination including one station on assessing sexual history taking and HIV counseling. Workshop participants scored one standard deviation higher on sexual history and HIV counseling items than nonparticipants. Our sexual history and HIV counseling curriculum was associated with students asking more thorough sexual histories and providing more HIV counseling.     

Cost-Effectiveness of Counseling and Testing to Prevent Sexual Transmission of HIV in the United States

In this paper we review the cost-effectiveness of HIV counseling and testing in various settings and populations in preventing the sexual transmission of human immunodeficiency virus, and we discuss how multiple and changing goals have influenced economic evaluations of these programs. The literature indicates that these interventions are generally cost-effective if targeted to groups of infected or high-risk individuals, although there is continuing debate over the efficacy of HIV counseling and testing in changing sexual behavior. For these reasons, HIV counseling and testing programs should be part of an overall prevention strategy which also includes more intensive sexual risk-reduction interventions such as individual, small-group, and community-level approaches.     

Providers' Awareness of HIV Testing Policies and Perceived Testing Practices

The objective of this study was to examine providers' awareness of state guidelines regarding HIV testing of pregnant women and their perceptions of access to care for HIV-positive pregnant women. State health departments, county health clinics, and other health care practitioners (private physicians, nurse practitioners, and health educators) were surveyed regarding awareness of state policies on HIV testing, particularly of pregnant women, as well as perceptions of current practices in the care of HIV-positive pregnant women. About two thirds of state offices of public health (70%), county public health providers (62.7%), and private providers (66.7%) were able accurately to describe the HIV reporting policy of their state, and providers across settings perceived that only about half of pregnant women were being provided with information regarding the prevention of vertical transmission during pregnancy. A mechanism is needed to routinely update public health departments and providers regarding state HIV reporting policies.     

Rapid point-of-care HIV testing in pregnant women: a systematic review and meta-analysis

Rapid, point-of-care human immunodeficiency virus (HIV) testing has the potential to enhance strategies to prevent mother-to-child transmission (MTCT) of HIV infection. Rapid tests need minimal laboratory infrastructure and can be performed by health workers with minimal training. In our systematic review and meta-analysis, we aimed to summarize the overall diagnostic accuracy of rapid HIV tests in pregnancy, and outcomes such as acceptability, patient preference, feasibility and impact of rapid testing. We searched four major databases, identified and screened 1377 citations, and included 17 studies that met our eligibility criteria. Analyses of these studies suggested that the overall sensitivity and specificity of blood-based rapid tests was high compared with oral rapid tests. A two-step testing strategy, particularly parallel testing, was found to be superior to single-test strategy in labour and delivery settings. Acceptability of rapid tests and patient preference was variable across studies. Overall, rapid HIV testing was highly accurate compared with conventional tests and offer a clear advantage of enabling the implementation of timely interventions to reduce MTCT of HIV. To improve diagnostic accuracy and to reduce false-positive results, it may be necessary to use two rapid tests during labour and delivery.     

High Rates and Positive Outcomes of HIV-Serostatus Disclosure to Sexual Partners: Reasons for Cautious Optimism from a Voluntary Counseling and Testing Clinic in Dar es Salaam, Tanzania

The rates, barriers, and outcomes of HIV serostatus disclosure to sexual partners are described for 245 female voluntary counseling and testing (VCT) clients in Dar es Salaam, Tanzania. VCT clients were surveyed 3 months after HIV testing to describe their HIV-serostatus disclosure experiences. Sixty-four percent of HIV-positive women and 79.5% of HIV-negative women (p = 0.028) reported that they had shared HIV test results with their partners. Among women who did not disclose, 52% reported the reason as fear of their partner's reaction. Both 81.9% of HIV-negative women and 48.9% of HIV-positive women reported that their partner reacted supportively to disclosure (p < 0.001). Less than 5% of women reported any negative reactions following disclosure. VCT should continue to be widely promoted. However, intervention approaches such as development of screening tools and new counseling approaches are important to ensure the safety of women who want to safely disclose HIV serostatus to their sexual partners.     

Receipt and timing of HIV drug resistance testing in six U.S. jurisdictions

The Department of Health and Human Services recommends drug resistance testing at linkage to HIV care. Because receipt and timing of testing are not well characterized, we examined testing patterns among persons with diagnosed HIV who are linked to care. Using surveillance data in six jurisdictions for persons aged ≥13 years with HIV infection diagnosed in 2013, we assessed the proportion receiving testing, and among these, the proportion receiving testing at linkage. Multivariable log-binomial regression modeling estimated associations between selected characteristics and receipt of testing (1) overall, and (2) at linkage among those tested. Of 9,408 persons linked to care, 66% received resistance testing, among whom 68% received testing at linkage. Less testing was observed among male persons who inject drugs (PWID), compared with men who have sex with men (adjusted prevalence ratio [aPR]: 0.88; 95% confidence interval [CI]: 0.81–0.97) and persons living in areas with population <500,000 compared with those in areas with population ≥2,500,000 (aPR: 0.88; CI: 0.84–0.93). In certain jurisdictions, testing was lower for persons with initial CD4 counts ≥500?cells/mm³, compared with those with CD4 counts <200?cells/mm³ (aPR range: 0.80–0.85). Of those tested, testing at linkage was lower among male PWID (aPR: 0.85; CI: 0.75–0.95) and, in some jurisdictions, persons with CD4 counts ≥500?cells/mm³ (aPR range: 0.63–0.73). Two-thirds of persons with diagnosed HIV who were linked to care received resistance testing, and most received testing at linkage as recommended. Improving receipt and timing of testing among male PWID, persons in less populous settings, and in all jurisdictions, regardless of CD4 count, may improve care outcomes.