Opt-out HIV testing in prison: informed and voluntary?

HIV testing in prison settings has been identified as an important mechanism to detect cases among high-risk, underserved populations. Several public health organizations recommend that testing across health-care settings, including prisons, be delivered in an opt-out manner. However, implementation of opt-out testing within prisons may pose challenges in delivering testing that is informed and understood to be voluntary. In a large state prison system with a policy of voluntary opt-out HIV testing, we randomly sampled adult prisoners in each of seven intake prisons within two weeks after their opportunity to be HIV tested. We surveyed prisoners' perception of HIV testing as voluntary or mandatory and used multivariable statistical models to identify factors associated with their perception. We also linked survey responses to lab records to determine if prisoners' test status (tested or not) matched their desired and perceived test status. Thirty-eight percent (359/936) perceived testing as voluntary. The perception that testing was mandatory was positively associated with age less than 25 years (adjusted relative risk [aRR]: 1.45, 95% confidence interval [CI]: 1.24, 1.71) and preference that testing be mandatory (aRR: 1.81, 95% CI: 1.41, 2.31) but negatively associated with entry into one of the intake prisons (aRR: 0.41 95% CI: 0.27, 0.63). Eighty-nine percent of prisoners wanted to be tested, 85% were tested according to their wishes, and 82% correctly understood whether or not they were tested. Most prisoners wanted to be HIV tested and were aware that they had been tested, but less than 40% understood testing to be voluntary. Prisoners' understanding of the voluntary nature of testing varied by intake prison and by a few individual-level factors. Testing procedures should ensure that opt-out testing is informed and understood to be voluntary by prisoners and other vulnerable populations.     

Attitudes to HIV voluntary counselling and testing among mineworkers in South Africa: will availability of antiretroviral therapy encourage testing?

We conducted a study to identify attitudes that influence uptake of HIV voluntary counselling and testing (VCT) amongst gold mine workers in South Africa; 105 healthy men were interviewed. The level of basic knowledge of HIV was high, but reported awareness of the extent of HIV infection in the workforce and perceived personal risk of HIV infection was low. Health issues were considered the most important indication for HIV testing and one-third had been tested. Fear of testing positive for HIV and the potential consequences, particularly stigmatization, disease and death, were the major identified barriers to VCT. Half of the participants felt workplace education programmes needed to be improved to promote VCT access. Twenty-six per cent became more favourably inclined towards HIV testing in response to information on improvements that have been made to the confidentiality and convenience of the company's VCT service. Only 14% then indicated that they would be more likely to access VCT if antiretroviral therapy became available. A vigorous community education programme is essential if the introduction of ART is to be effective in promoting uptake of VCT.     

Would universal antenatal screening for HIV infection be cost-effective in a setting of very low prevalence? Modelling the data for Australia

BACKGROUND: The economics of universal antenatal human immunodeficiency virus (HIV) screening should be explored if mother-to-child transmission of HIV occurs, the health-service infrastructure for universal screening exists, and optimal risk-reducing treatments can be supplied. METHODS: We evaluated a hypothetical cohort of the antenatal population of Australia during 2001-2002, to examine whether universal antenatal HIV screening is cost-effective in this setting. A quasi-societal perspective was adopted, secondary data sources were used, and sensitivity analyses were undertaken. Costs and benefits incurred in the future were discounted to their present value. RESULTS: The intervention would be cost-effective if the prevalence of undiagnosed HIV in the currently unscreened Australian antenatal population was >or=0.004372%. We predict 6.95 new diagnoses of HIV, 1.73 infections avoided, and 46.97 discounted-life-years gained. Applying favorable and unfavorable values for key variables suggests that the prevalence at which the intervention would be cost-effective is 0.0016%-0.0106%. CONCLUSIONS: Universal antenatal HIV screening would be cost-effective at a very low prevalence and would generate net benefits under many scenarios; accurate statistics on the true prevalence of HIV in the currently unscreened antenatal population are required.     

Does rapid HIV testing result in an early diagnosis and reduce the waiting time for patients to receive medical care?

The implementation of rapid HIV testing in Brazil began in 2006 for specific groups, and from 2009 was extended to the Counseling and Testing Centers (CTC) in certain Brazilian capitals. The aim of this study was to compare two groups of individuals: those diagnosed with HIV infection by conventional testing and those diagnosed with rapid testing, with respect to: the waiting time before receiving medical care, the time of the first laboratory tests and the virological, immune and clinical status. This is a cross-sectional study to compare a group with individuals diagnosed by conventional testing (2006–2008) and another with those diagnosed by rapid testing (2010–2011).The median time between blood collection and diagnosis of HIV in the conventional test group was 76 days, while in the rapid test group 94.2% of the subjects received their results on the same day of blood collection (p?p?p?p?=?0.01). The introduction of rapid HIV testing as a diagnostic strategy has reduced the waiting times for medical care and laboratory tests and also allowed earlier diagnosis of HIV infection than with the conventional test.     

What is dementia? 8. Alzheimer's disease early diagnosis: a public health point of view

It is justified to develop early diagnosis for Alzheimer disease and related disorders in order to offer professional support to patients and informal caregivers. On the other hand, the usefulness of screening cases, which have no repercussion on daily life, is not proven considering the difficulty to discriminate early stages from age-related intellectual performance decline. Taking into account a general population point of view, we assume that there is a risk to evolve from early diagnosis to screening. This trend is increased by the fear of the general population, which sees Alzheimer disease as a new plague, the movement towards medicalization in the general population, and the pressure of the pharmaceutical industry. The definition of thresholds for screening, diagnosis and therapy is a central issue. Improving the sensitivity of a test by lowering the threshold leads to a reduction of specificity and a rise of the false positive rate. It is necessary to evaluate the negative impact of labelling normal persons as Alzheimer disease's patients. In the present situation, it would not be sensible to leave the responsibility of the diagnosis to primary care professionals and to give up the validation process performed by the expert or reference centres.     

Late diagnosis of HIV infection in women seeking counseling and testing services in São Paulo, Brazil

We investigated whether women positive for human immunodeficiency virus (HIV) infection were late in seeking an anonymous HIV counseling and testing service, and the factors associated with a low CD4 count, in S?o Paulo, Brazil. Seventy-one consecutive HIV-1-seropositive women were interviewed by means of a structured questionnaire. Blood samples were collected for CD4+ T-lymphocytes count and determination of HIV-1 subtypes. Hepatitis C, syphilis, human T-cell lymphotrophic virus type I (HTLV-I), and HTLV-II infections were assessed by serologic tests. More than 70% of the women had less than 500 CD4+ cells/mm3 (20% below 200). Low CD4 count was significantly associated with sex work history, condom use in the last 6 months, and seropositivity to HTLV-I and syphilis. There was no relation between low CD4 count and HIV-1 subtypes. These results indicate that in Sao Paulo many women are seeking an anonymous testing service late in the course of HIV infection. The main purposes of anonymous HIV testing services - early diagnosis of infection, and counseling to prevent infection - are not being achieved. Another strategy for reducing the interval between infection and diagnosis in women must be addressed.     

Behavior and health beliefs as predictors of HIV testing among women: a prospective study of observed HIV testing

Much of the research examining predictors of HIV testing has used retrospective self-report to assess HIV testing. Findings. therefore, may be subject to recall bias and to difficulties determining the direction of associations. In this prospective study, we administered surveys to women in community clinics to identify predictors of subsequent observed HIV testing, overcoming these limitations. Eighty-three percent were tested. In the adjusted multivariable model, being born in the U.S., perceived benefits of testing, worries about being infected with HIV, having had more than 15 lifetime sexual partners, and having had one or more casual sexual partners in the previous three months predicted acceptance of testing. Perceived obstacles to testing predicted non-acceptance. Those who had never been tested for HIV and those tested two to five years previously had greater odds of test acceptance than those who had been tested within the last year. The findings from this study with observed testing as the outcome, confirm some of the results from retrospective, self-report studies. Participants made largely rational decisions about testing, reflecting assessments of their risk and their history of HIV testing. Health beliefs are potentially modifiable through behavioral intervention, and such interventions might result in greater acceptance of testing.

Abbreviations: HIV: human immunodeficiency virus; AIDS: acquired immune deficiency syndrome; CDC: Centers for Disease Control and Prevention; ACASI: audio computer-assisted self-interview; TRA: theory of reasoned action; HBM: Health Belief Model; STI: sexually transmitted infection; STD: Sexually Transmitted Disease; AOR: adjusted odds ratio; CI: confidence interval     

Quantification of print,radio and television exposure among previous blood donors in Kenya: an opportunity for encouraging repeat donation in a resource‐limited setting?

Blood services in sub‐Saharan Africa experience blood shortages and low retention of voluntary, non‐remunerated donors. To boost collections by encouraging repeat donations, the Kenya National Blood Transfusion Service is exploring the likelihood of reaching previous donors through targeted print, radio and television advertising. We analysed data from a national AIDS Indicator Survey to determine whether previous donors have significant exposure to media. Respondents reporting history of blood donation had significantly higher exposure to print, radio and television media than those without history of blood donation. Targeted media campaigns encouraging repeat donation are likely to reach previous donors even in resource‐limited settings.     

Audit of HIV testing: who, why and when?

The risk factors, referral pattern and presence/absence of genital tract symptoms and/or sexually transmitted infections (STIs) in 189 patients having HIV counselling and/or testing at genitourinary medicine (GUM) clinics are reviewed. Eighty per cent were concerned about heterosexual transmission, 9.5% men who have sex with men (MSM) and 4.8% intravenous drug users (IDUs). Heterosexuals and first-time GUM attenders were more likely to have sought prior advice from their general practitioner (GP). The majority were asymptomatic for genital tract infections, but 83% accepted an STI screen, with 44 STIs being diagnosed. Only one individual who had attended primarily for HIV screening was found to have an STI. About half of individuals presented within the window period, and of those stating that they wished to proceed with deferred testing, half subsequently failed to return, resulting in wasted health adviser appointments.     

What are the barriers to offering HIV testing in an antenatal setting? A national study of obstetricians

OBJECTIVE: To investigate factors that influence the antenatal screening practice of obstetricians and identify barriers to the implementation of universal antenatal HIV screening. DESIGN: A survey of all obstetricians registered with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. METHODS: A questionnaire was mailed to all obstetricians in Australia, followed by two reminders. RESULTS: The overall response rate was 70% (817/1172) and of these 70% always offered an HIV test during pregnancy. Obstetricians offering the test were more likely to female or younger in age. Of respondents who always offered testing, 90% disagreed with only testing women with risk factors compared with only 34% of those who undertook a selective screening approach (adjusted odds ratio, 87.7; 95% confidence interval, 40-192; P = 0.001). Obstetricians who practiced selective screening were influenced by whether the woman had antenatal blood tests prior to her obstetric appointment or a previous negative HIV test. Obstetricians who practiced universal screening were more likely to be concerned about false-positive results. Many obstetricians, irrespective of their screening practice, agreed that many of the components of pretest counseling were inappropriate for the majority of women. CONCLUSIONS: A majority of obstetricians in Australia are offering all pregnant women an HIV test. Consideration should be given to tailoring pretest counseling requirements to the antenatal setting. Ongoing education regarding the limitations of selective screening and management of women with false-positive results is also highlighted by this study.     

Testing for limits of cognitive reserve capacity: a promising strategy for early diagnosis of dementia?

Examination of the range and limits of cognitive reserve capacity (plasticity) by means of cognitive training is proffered as a promising diagnostic strategy for the early (premorbid) identification of dementia, particularly Alzheimer's disease, in nonclinical populations. First data are presented from a sample of elderly independent-living people classified as healthy or at risk (beginning dementia) on the basis of a standardized psychiatric interview. Randomly assigned groups participated in a cognitive training program based on figural relations, a component of fluid intelligence. Stepwise regression analyses demonstrated that only healthy elderly profited from training and that only post-training scores predicted the psychiatric "at risk" diagnosis. The results hold promise for further development of testing-the-limits of individual differences in cognitive reserve capacity to identify premorbid states of dementia in nonclinical samples.     

Reticence in disclosure of HIV infection and reasons for bereavement: impact on perinatally infected adolescents’ mental health and understanding of HIV treatment and prevention in Johannesburg,South Africa

Survival rates of perinatally infected HIV-positive adolescents (PIA) are increasing in sub-Saharan Africa. There is a gap in understanding how disclosure and bereavement have an impact on PIA beliefs and understanding of their HIV infection and its management. In-depth interviews were conducted with 25 purposively selected adolescents aged 13–19 years from 5 public health clinics in Johannesburg, South Africa. Data were analysed using NVivo 10 using a thematic approach. PIA experience incomplete disclosure both of their HIV status and reasons for their bereavements, which limits their understanding of how they became infected, vertical transmission and prevention options like prevention of mother-to-child transmission (PMTCT). Most participants were orphaned and were experiencing complicated grieving (i.e., engaged in unresolved tasks of grieving) which had a negative impact on their mental health, and ability to accept their HIV status and adhere to treatment. PIA need improved communication regarding vertical transmission and how they became HIV-positive, as well as reasons for death of their loved ones to properly understand their HIV status and engage effectively in management. Honest communication about how relatives died and truthful engagement in the process of disclosure of HIV status is necessary to reduce stigma and complicated grieving, and improve mental health in this population.     

Insulin resistance in HIV infection: drugs, host responses, or restoration to health?

Protease inhibitors (PIs) are widely assumed to be associated with a syndrome of insulin resistance accompanied by hyperlipidemia and fat redistribution. Insulin resistance in HIV infection has numerous other causes, however, which include not only the direct effects of antiretroviral drugs but also factors such as aging and restoration to health accompanied by fat accumulation. Studies of PIs in HIV-infected and noninfected patients indicate that some of these drugs are associated with reduced insulin sensitivity (greater acute versus chronic effects) that may be due to direct blockade of the insulin-sensitive glucose transporter in muscle and fat cells. Other studies have shown that insulin levels increase over time with antiretroviral therapy, likely the result of improved health, fat accumulation, and aging, and that increases in visceral fat and upper trunk fat are associated with a higher risk of insulin resistance in HIV-infected and -uninfected individuals alike. This article summarizes a presentation on insulin resistance in HIV infection made by Carl Grunfeld, MD, PhD, at the 10th Annual Ryan White HIV/AIDS Program Clinical Update in Phoenix in June 2007.