The effectiveness of HIV post-test counselling in determining healthcare-seeking behavior

To examine the relationship between HIV post-test counselling and healthcare-seeking behaviors among HIV-positive individuals, we conducted patient interviews and medical chart reviews on 100 HIV-positive patients at a public hospital. When performed, HIV post-test counselling effectively encourages HIV-positive individuals to seek medical care, especially when performed by trained personnel. The consistent use of post-test counselling may improve care for HIV-positive individuals and should be encouraged at all healthcare facilities that conduct HIV testing.     

Gender and race matching preferences for HIV post-test counselling in an African-American sample

This study tested whether having racially and gender-matched counsellors for HIV Post-test counselling were preferred. In the NIDA-funded EachOneTeachOne study, 115 African American respondents (19-68) were asked would they rather talk to someone of the same sex and race. Forty-three percent of the counsellor-respondent pairs were race concordant, and 58% were gender concordant. Chi-square statistics examined effects of gender, race and match. Out of those who desired a gender-match, 89% were men compared to 11% of women. Only 9% of African-Americans reported that they would feel more comfortable talking to an African-American counsellor. The sample size dropped due to non-response of the matching reference questions. Among the 39 race-counsellor concordant respondents (n=98), 23% expressed a preference for a race matched counsellor while no one with a race discordant counsellor expressed such a preference. Among the 56 respondents with a gender concordant counsellor (n=102), 27% said they would prefer a gender matched counsellor in the future; only 7% of those with a gender discordant counsellor expressed such as preference. Previously matched respondents were more likely to desire matched counsellors, but the majority still did not. Assumptions that race and gender matching are imperative are not supported by these findings.     

Integration of tuberculosis screening at an HIV voluntary counselling and testing centre in Haiti

OBJECTIVE: To describe the integration of tuberculosis screening into the activities of an HIV voluntary counselling and testing (VCT) centre in a country with endemic tuberculosis. SETTING: An HIV VCT centre in Port au Prince, Haiti. DESIGN: All patients presenting for HIV VCT who reported cough received same-day evaluation for active tuberculosis. Of the 1327 adults presenting to the centre for the first time between January and April 1997, 263 (20%) reported cough and of these 241 (92%) were evaluated. RESULTS: Of the 241 patients evaluated for cough, 76 (32%) were diagnosed with pulmonary tuberculosis. Of the 76 patients diagnosed with pulmonary tuberculosis, 28 (37%) had a positive smear for acid-fast bacilli (AFB), 14 (18%) had a negative AFB smear but a positive sputum culture for Mycobacterium tuberculosis, and 34 (45%) had culture-negative tuberculosis. Also, 31 out of 241 (13%) VCT clients evaluated for cough were diagnosed with bacterial pneumonia. CONCLUSION: This report confirms that in areas with a high HIV and tuberculosis prevalence, a high proportion of VCT clients have active pulmonary tuberculosis. The integration of tuberculosis screening offers several benefits, including the diagnosis and treatment of large numbers of individuals with tuberculosis, a decreased risk of nosocomial tuberculosis transmission, and the opportunity to provide tuberculosis prophylaxis to HIV-positive patients in whom tuberculosis has been excluded. Future studies are needed to determine the cost-effectiveness of integrated tuberculosis and HIV VCT services, and whether integration should be recommended in all countries with high HIV and tuberculosis rates.     

HIV抗体快速检测在自愿咨询检测中的应用

目的在AIDS自愿咨询检测(voluntary counselling and testing,VCT)中应用快速检测,并与免疫印迹试验(western blotting,WB)结果比较,探讨进一步缩短确证时间及提高HIV感染者CD4+T淋巴细胞检测率的措施。方法用2种快速试剂进行筛查,对一阴一阳或双阳性样本进行WB确证检测,并比较和评价检测结果,同时采集患者血样行CD4+T淋巴细胞检测。结果 1435份样本中,1种或2种快速试剂检测结果为阳性有398份,经WB检测确证377份阳性,符合率94.7%;2种快速试剂检测结果均为阳性的有379份,WB检测确证376份阳性,符合率99.2%;2种快速试剂检测结果为阴性的有1037份,经PCR检测未发现HIV RNA阳性样本。结论在VCT及各种应急检测时,可用快速试剂进行筛查,然后WB确证,以缩短等待时间,提高CD4+T淋巴细胞检测率。同时为保证检测质量,以防漏检,推荐使用2种质量优良的快速试剂同时筛查。     

HIV voluntary counselling and testing in community health services

HIV voluntary counseling and testing (VCT) has been given low priority as a possible strategy for combating HIV in developing countries. This is because of the high demands on logistics and skills that the intervention entails. It is the view that individuals have low motivation to know their test results and modify behavior, and the nonexistence of medical care that could make a difference. Although studies on the benefits and efficiency of VCT have shown that the intervention is effective in promoting behavioral change and is cost-effective as well, there is still a need to make VCT accessible to those who desperately need it and to expand and render it more acceptable, innocuous, and less expensive. To this effect, access should first be provided in existing community health services. In addition, other standards of quality necessary for the implementation of VCT services include building up of capacity and infrastructure, respect of confidentiality, counseling of couples when needed and feasible, availability of psychosocial support beyond the post-test period, and avoidance of coercion and social stigma and their consequences.     

Attitudes to voluntary counselling and testing for HIV among pregnant women in rural south-west Uganda

This paper describes the results of a study exploring the attitudes of women attending maternity clinics to voluntary counselling and testing during pregnancy in rural areas in south-west Uganda. It was a qualitative study using focus group discussions (FGDs). Twenty-four FGDs were carried out with 208 women attending maternity clinics in three sites in rural south-west Uganda. The FGDs were all recorded and transcribed, and analysed using standard computer-based qualitative techniques. Almost all women were willing in principle to take an HIV test in the event of pregnancy, and to reveal their HIV status to maternity staff. They were anxious, however, about confidentiality, and there was a widespread fear that maternity staff might refuse to assist them when the time came to deliver if their status were known. This applied more to traditional birth attendants than to biomedical health staff. There were also rumours about medical staff intentionally killing HIV-positive patients in order to stem the spread of the epidemic. Women were concerned that if their husbands found out they were HIV-positive they would be blamed and separation or domestic violence might result. In conclusion: although VCT during pregnancy is acceptable in principle, much will need to be done to ensure confidentiality and allay women's fears of stigmatisation and discrimination during delivery. Community sensitisation will be necessary and male partners will have to be involved if interventions are to be acceptable.     

A randomized trial on acceptability of voluntary HIV counselling and testing

OBJECTIVES: To examine factors affecting readiness for and acceptability of voluntary HIV counselling and testing (VCT). METHODS: Participants in a population-based HIV survey conducted in an urban population in Zambia in 1996 were offered VCT. Although 29% of them expressed interest in being tested (readiness), only 4% of this group used the services (i.e. acceptability). When the survey was repeated 3 years later, VCT was designed differently to assess acceptability. At the cluster level the participants were randomly allocated to VCT either at the local clinic (similar to 1996, n = 1102) or at an optional location (n = 1343). RESULTS: Readiness varied significantly by age group (47% in age group 20-24 years vs. 18% in age group 40-49 years). There were contrasts between young (15-24 years) and older age groups (25-49 years) regarding the main factors associated with readiness. Whereas self-perceived risk of being HIV infected was the only significant factor among the young, poor self-rated health and ever HIV tested were important factors among the older. The acceptability was 11.8% among the group allocated to VCT at the local clinic compared with 55.8% for the group allocated to an optional location (RR, 4.7). CONCLUSIONS: Perceived risk of HIV infection had a major influence on VCT readiness among young people, whereas declining general health status, as indicated by self-rated health, was most evident among those of older age. A strong effect of placement on acceptability of VCT was demonstrated, indicating this barrier to be important in explaining low demands for VCT in the past. Differences in perceptions of how confidentiality is handled at the two locations might be an important underlying factor.     

Use of UNAIDS tools to evaluate HIV voluntary counselling and testing services for mineworkers in South Africa

HIV voluntary counselling and testing (VCT) is now an integral part of many HIV care and control programmes. However, very little work has been done to assess the quality of VCT services. An evaluation of VCT services for mineworkers in Welkom, South Africa was conducted to assess client and counsellor satisfaction, the quality of the services and to identify barriers to uptake of VCT. A cross-sectional survey was carried out using tools developed by UNAIDS, consisting of semi-structured interviews and observation of counselling sessions. Twenty-two nurse counsellors and six community volunteers were interviewed. Twenty-four counselling sessions were observed and 24 client exit interviews were conducted. Although nine of the 22 nurse counsellors had only in-service rather than formal training for HIV counselling whereas all community volunteers had been formally trained, nurse counsellors demonstrated better interpersonal skills than did community volunteers. Both clients and counsellors identified fear of a positive result as a major barrier to HIV testing. Clients also raised concerns about confidentiality. UNAIDS evaluation tools were a feasible and an acceptable method of assessing VCT in this operational setting. The study identified areas where training needs to be strengthened and suggested ways of improving the services, and changes to the service have now been implemented in line with these recommendations.     

Sexual behaviours, perception of risk of HIV infection, and factors associated with attending HIV post-test counselling in Ethiopia.

OBJECTIVES: To describe sexual behaviours, perception of risk of HIV infection, and factors associated with attending HIV post-test counselling (PTC) among Ethiopian adults. METHODS: Data on socio-demographic characteristics, knowledge of HIV infection, sexual history, medical examination, and HIV and syphilis serological status were compared, through uni- and multivariate analysis, in relation to attending PTC within 60 days of HIV testing. RESULTS: Between February 1997 and June 1998, 751 factory workers were enrolled in a cohort study of HIV infection progression. Despite reporting high-risk sexual behaviours, mainly for males (64% of males and 6% of females had more than five sexual partners in their lifetime, 16% of males and 2% of females reported having had recent casual partners), and knowing that HIV is commonly transmitted heterosexually in Ethiopia (97% of answers being correct, both genders combined), only 17% of males and 2% of females acknowledged having had activities which had put them at risk of HIV infection. HIV prevalence was 12%, and did not differ by gender. Of all study participants, 327 (43.5%) returned for PTC within 60 days of HIV testing. PTC attendance did not differ by age, gender, or HIV serological status. Factors independently associated with PTC attendance in males were: good knowledge of HIV infection, [odds ratio (OR) = 1.661, belief that medical follow-up improves the course of HIV infection (OR = 2.02), history of genital symptoms (OR = 2.83), positive syphilis serology (OR = 2.62), recent weight loss (OR = 1.89), and, with a negative association, being a manual worker (OR = 0.40), and history of recent casual sexual relationships (OR = 0.35). In women, belief that HIV/AIDS can be cured (OR = 3.16), never having been married (OR = 5.02), having five or less children (OR = 2.16), having been raped (OR = 3.42), and having used health facilities in the past year (OR = 1.73) were all positively and independently associated with PTC attendance. CONCLUSION: Study participants reported high-risk sexual behaviours, yet had a low perception of individual risk. Men attended for PTC because of their knowledge of HIV infection, their past sexual history or their current health status. Women attended for PTC because of their plans for the future, marriage and/or children, rather than their past sexual exposure. Only in cases of rape were they willing to learn of their HIV status.     

Uptake of HIV voluntary counselling and testing services in rural Tanzania: implications for effective HIV prevention and equitable access to treatment

Objective To describe the associations between socio‐demographic, behavioural and clinical characteristics and the use of HIV voluntary counselling and testing (VCT) services among residents in a rural ward in Tanzania. Methods Eight thousand nine hundred and seventy participants from a community‐based cohort were interviewed, provided blood for research HIV testing, and were offered VCT. Univariate and multivariate logistic regression was used to identify socio‐demographic, clinical and behavioural factors associated with VCT use. Results Although 31% (1246/3980) of men and 24% (1195/4990) of women expressed an interest in the service, only 12% of men and 7% of women subsequently completed VCT. Socio‐demographic factors, such as marital status, area of residence, religion and ethnicity influenced VCT completion among males and females in different ways, while self‐perceived risk of HIV, prior knowledge of VCT, and sex with a high‐risk partner emerged as important predictors of VCT completion among both sexes. Among males only, those infected with HIV for 5 years or less tended to self‐select for VCT compared to HIV‐negatives (adjusted odds ratio = 1.43; 95% CI: 0.99–2.14). This contributed to a higher proportion of HIV‐positive males knowing their status compared to HIV‐positive females. Conclusions In this setting, a disproportionate number of HIV‐positive women are failing to learn their status, which has implications for equitable access to onward referral for care and treatment services. Evidence that some high‐risk behaviours may prompt VCT use is encouraging, although further interventions are required to improve knowledge about HIV risk and the benefits of VCT. Targeted interventions are also needed to promote VCT uptake among married women and rural residents.     

HIV and family planning service integration and voluntary HIV counselling and testing client composition in Ethiopia

Integrating voluntary HIV counselling and testing (VCT) with family planning and other reproductive health services may be one effective strategy for expanding VCT service delivery in resource poor settings. Using 30,257 VCT client records with linked facility characteristics from Ethiopian non-governmental, non-profit, reproductive health clinics, we constructed multi-level logistic regression models to examine associations between HIV and family planning service integration modality and three outcomes: VCT client composition, client-initiated HIV testing and client HIV status. Associations between facility HIV and family planning integration level and the likelihood of VCT clients being atypical family planning client-types, versus older (at least 25 years old), ever-married women were assessed. Relative to facilities co-locating services in the same compound, those offering family planning and HIV services in the same rooms were 2-13 times more likely to serve atypical family planning client-types than older, ever-married women. Facilities where counsellors jointly offered HIV and family planning services and served many repeat family planning clients were significantly less likely to serve single clients relative to older, married women. Younger, single men and older, married women were most likely to self-initiate HIV testing (78.2 and 80.6% respectively), while the highest HIV prevalence was seen among older, married men and women (20.5 and 34.2% respectively). Compared with facilities offering co-located services, those integrating services at room- and counsellor-levels were 1.9-7.2 times more likely to serve clients initiating HIV testing. These health facilities attract both standard material and child health (MCH) clients, who are at high risk for HIV in these data, and young, single people to VCT. This analysis suggests that client types may be differentially attracted to these facilities depending on service integration modality and other facility-level characteristics.     

Introduction of voluntary counselling and rapid testing for HIV in rural South Africa: from theory to practice

Expanding access to voluntary counselling and testing (VCT) for HIV is an important first step in the development of a comprehensive package of HIV services. This article describes the introduction of VCT among five primary health care (PHC) facilities in a rural South African setting, alongside a multidimensional impact assessment as part of a national pilot programme. A baseline review of services demonstrated low levels of VCT, which were predominantly hospital-based. Twenty health workers in five PHC facilities were trained to provide VCT using rapid-testing assays. The feasibility of VCT introduction and its overall acceptability to clients and providers were evaluated using clinic testing registers, semi-structured interviews with counsellors and mock client encounters. One year after its introduction, a major increase in the quantity of HIV testing, the proportion of clients who receive their results, and the proportion who present voluntarily was observed. The majority of those presenting were women, and 20-40 year olds predominated. There was a high level of acceptance among health workers, and the quality of VCT was rated very good in mock client encounters. This work demonstrates one effective model for improving access to VCT through existing primary health care services in a rural South African context.     

Post-abortion care and voluntary HIV counselling and testing--an example of integrating HIV prevention into reproductive health services

OBJECTIVE: To assess the acceptance and outcome of voluntary HIV counselling and testing (VCT) among women who had an unsafe abortion. METHOD: 706 women were provided with post-abortion contraceptive service and offered VCT. We collected data on socioeconomic characteristics and contraceptive use and determined the HIV status of those who accepted VCT. Using a nested case-control design, we compared women who accepted HIV testing with women who did not. To study the association between socioeconomic factors, HIV testing acceptance and condom use in more detail, we did stratified analyses based on age and marital status. RESULTS: 58% of the women who had an unsafe abortion accepted HIV testing. Women who earned an income were more likely to accept testing than housewives. Women who accepted testing were more likely to accept using a condom. The HIV prevalence rate was 19% among single women aged 20-24 years and 25% among single women aged 25-45 years. CONCLUSION: HIV testing and condoms were accepted by most women who had an unsafe abortion. The poor reproductive health of these women could be improved by good post-abortion care that includes contraceptive counselling, VCT and condom promotion.     

Sociodemographic and clinical characteristics of clients presenting for HIV voluntary counselling and testing in Moshi, Tanzania

HIV voluntary counselling and testing (VCT) reduces high-risk sexual behaviour. Factors associated with HIV infection in VCT clients have not been well characterized in northern Tanzania. We prospectively surveyed 813 VCT clients in Moshi, Tanzania. Clients were administered a questionnaire on sociodemographic characteristics, sexual behaviour, and health status. Blood was taken for rapid HIV antibody testing. Factors associated with HIV seropositivity were identified using multivariate logistic regression analysis. Of 813 clients, the seroprevalence was 16.7%. The strongest associations with seropositivity were reporting diarrhoea (odds ratio [OR] 10.4, 95% confidence interval [CI] 3.6-29.9), an ill sexual partner (OR 6.3, 95% CI 3.0-12.9), or being a woman (OR 3.5, 95% CI 2.0-6.3). In a separate regression, the number of symptoms also predicted HIV infection (OR 2.1, 95% CI 1.6-2.6). VCT clients who tested positive had more HIV-related symptoms suggesting presentation at a later stage of HIV infection.     

Return to post-test counselling by out-of-treatment injecting drug users participating in a cross-sectional survey in north Vietnam

Return to post-test counselling is essential for optimal individual and public health impact of voluntary counselling and testing (VCT) services. Our study assessed factors associated with return to post-test counselling among 309 out-of-treatment injecting drug users who underwent VCT as part of a cross-sectional survey in Bac Ninh, Vietnam during August and September 2003. The overall return rate to post-test counselling was 54% (n=167). While participants in the rural study district were significantly less likely (chi2=5.8; p<0.05) to return compared with participants in the town centre (42.7 versus 58.1%), return rates did not significantly vary by age, perception of personal HIV risk, HIV serostatus diagnosed by the study, counsellor, history of HIV testing or prior knowledge of HIV status. In a multivariate analysis, higher return rate was associated with residence in Bac Ninh town centre (adjusted OR=1.9; CI=1.1-3.1). Of HIV-positive participants (n=131), 45% (n=59) did not return to collect test results. In view of the findings it is crucial to address risk perception and benefits of collecting test results during pre-test counselling sessions in order to maximize the desired impact of community-based VCT services targeting IDUs in Vietnam.     

Attitudes to voluntary counselling and testing prior to the offer of Nevirapine to prevent vertical transmission of HIV in northern Tanzania

In developed countries much progress has been made in reducing vertical transmission of HIV using antiretroviral therapies. To achieve similar gains in Africa the acceptability of routine HIV testing of pregnant women is becoming increasingly important. Evidence of reluctance of pregnant women to undergo HIV testing has led to suggestions to offer antiretroviral therapy to pregnant women without prior HIV testing. In this study we set out to identify risk factors for preferring to avoid HIV testing among women attending an antenatal clinic in northern Tanzania in the context of a hypothetical offer of Nevirapine and to explore the issues raised in more detail in focus group discussions. Two hundred and fifty women attending an antenatal clinic in late pregnancy were interviewed. Almost half of the women preferred to be offered Nevirapine without HIV testing. In a multiple logistic model having a partner with a history of a sexually transmitted disease (OR 2.72, 95% CI 1.14-6.47, p = 0.02) and having a partner who had another sexual partner in the last year (OR 1.89, 95% CI 1.04-3.45, p = 0.04) were positively associated with a preference to avoid HIV testing; while the presence of a partner living at home or feeling able to ask their partner to go for an HIV test were negatively associated with a preference to avoid HIV testing (OR 0.46, 95% CI 0.24-0.89, p = 0.02 and OR 0.56, 95% CI 0.3-1.05, p = 0.07 respectively). FGDs (focus group discussions) suggested that the major concern of women was for the reaction of their male partners to the possibility of a positive HIV test and low confidence in the confidentiality of HIV testing. This fear may lead to low uptake of antiretroviral programmes and treatment without prior testing should be considered.