Overcoming barriers to HIV testing: preferences for new strategies among clients of a needle exchange, a sexually transmitted disease clinic, and sex venues for men who have sex with men

Self-testing as strategy to increase the uptake of HIV testing in South Africa

With better health care and greater access to antiretrovirals (ARVs) it has become important to increase the uptake of HIV testing. Major testing campaigns have been launched in South Africa, but no official provision exists for clients who prefer self-testing for HIV. The purpose of this study was to investigate which HIV-testing model (client-initiated, provider-initiated or self-testing) a sample of South Africans preferred and why. A semi-structured questionnaire was completed by 466 participants and 9 provinces were represented by the sample. The results indicated that 22.3% of the participants preferred self-testing for HIV (while 66.1% preferred client-initiated and 11.6% provider-initiated counselling and testing). Participants who preferred self-testing for HIV were predominantly (p < 0.05) male, white, lived in cities or towns, did not know their HIV status, and had no intention of being tested at a medical facility in future. The underlying themes of why participants preferred self-testing for HIV above testing in a medical facility were the need for privacy and confidentiality; the need to keep testing as well as the results secret; fear of discrimination and stigma; distrust in the health care system to keep results confidential; and an aversion to face-to-face counselling. Participants indicated that they would consider testing if self-testing for HIV with telephone counselling becomes readily available in their communities. HIV testing models in South Africa should be revisited and revised to offer people who would otherwise not be tested, with an alternative method of testing.

HIV test offers and acceptance: New York State findings from the behavioral risk factor surveillance system and the National HIV behavioral surveillance, 2011-2012

BACKGROUND

The New York State HIV testing law requires that patients aged 13-64 years be offered HIV testing in health care settings. We investigated the extent to which HIV testing was offered and accepted during the 24 months after law enactment.

METHODS

We added local questions to the Behavioral Risk Factor Surveillance System (BRFSS) and the National HIV Behavioral Surveillance (NHBS) surveys asking respondents aged 18-64 years whether they were offered an HIV test in health care settings, and whether they had accepted testing. Statewide prevalence estimates of test offers and acceptance were obtained from a combined 2011-2012 BRFSS sample (N = 6,223). Local estimates for 2 high-risk populations were obtained from NHBS 2011 men who have sex with men (N = 329) and 2012 injection drug users (N = 188) samples.

RESULTS

BRFSS data showed that 73% of New Yorkers received care in any health care setting in the past 12 months, of whom 25% were offered an HIV test. Sixty percent accepted the test when offered. The levels of test offer increased from 20% to 29% over time, whereas acceptance levels decreased from 68% to 53%. NHBS data showed that 81% of men who have sex with men received care, of whom 43% were offered an HIV test. Eighty-eight percent accepted the test when offered. Eighty-five percent of injection drug users received care, of whom 63% were offered an HIV test, and 63% accepted the test when offered.

CONCLUSIONS

We found evidence of partial and increasing implementation of the HIV testing law. Importantly, these studies demonstrated New Yorkers' willingness to accept an offered HIV test as part of routine care in health care settings.

Effect of testing experience and profession on provider acceptability of rapid HIV testing after implementation in public sexual health clinics in Sydney

OBJECTIVES

Rapid HIV testing (RHT) is well established in many countries, but it is new in Australia since a policy change in 2011. We assessed service provider acceptability of RHT before and after its implementation in four Sydney public sexual health clinics.

METHODS

Service providers were surveyed immediately after training in RHT and again 6-12 months later. Differences in mean scores between survey rounds were assessed via t-tests, with stratification by profession and the number of tests performed.

RESULTS

RHT was rated as highly acceptable among staff at baseline and acceptability scores improved between survey rounds. Belief in being sufficiently skilled and experienced to perform RHT (P = 0.004) and confidence in the delivery of nonreactive results increased (P = 0.007), while the belief that RHT was disruptive declined (P = 0.001). Acceptability was higher for staff who had performed a greater number of tests regarding comfort with their role in RHT (P = 0.004) and belief that patients were satisfied with RHT (P = 0.007). Compared with nurses, doctors had a stronger preference for a faster rapid test (P = 0.027) and were more likely to agree that RHT interfered with consultations (P = 0.014).

CONCLUSIONS

Differences in responses between professions may reflect differences in staff roles, the type of patients seen by staff and the model of testing used, all of which may affect the number of tests performed by staff. These findings may inform planning for how best to implement RHT in clinical services.

Differences in HIV risk behaviors among people who inject drugs by gender and sexual orientation, San Francisco, 2012

BACKGROUND

Sharing of drug injection equipment is a well-established risk factor for the transmission of viral infections, such as human immunodeficiency virus (HIV). However, there are multiple mechanisms through which people who inject drugs (PWID) can acquire and transmit HIV. Differences in drug using and sexual behaviors among heterosexual males, males who have sex with males (MSM), and females who inject drugs may explain health disparities.

METHODS

Data were collected in San Francisco by the National HIV Behavioral Surveillance (NHBS) System of PWID in 2012, and were analyzed to compare the sexual behaviors, drug use behaviors, and prevalence of viral infections among heterosexual males, MSM, and females.

RESULTS

Using a weighted analysis for the RDS sampling design, we estimate that 3.7% of heterosexual males who inject drugs, 24.0% of MSM, and 13.0% of females who inject drugs are living with HIV. Females and heterosexual males primarily injected heroin, while MSM primarily injected methamphetamine. MSM were most likely to have received goods or money for sex and have unprotected intercourse.

CONCLUSION

These data demonstrate differences in risk behaviors and prevalence of viral infections among heterosexual males, MSM, and females. The results also suggest that public health programs prioritizing the different populations of PWID are necessary.

Correlates of prior HIV testing among men who have sex with men in Cameroon: a cross-sectional analysis

Background

Regular HIV testing is vital for timely linkage to the HIV care continuum and ensuring the success of behavioral and biomedical interventions to prevent HIV acquisition. Men who have sex with men (MSM) are a key population for HIV prevention, treatment, and care efforts globally. This study measures the factors associated with prior HIV testing among MSM in Cameroon.

Methods

In 2011, 272 and 239 MSM aged ≥ 18 were recruited from Douala and Yaoundé respectively using respondent-driven sampling (RDS) for a cross-sectional surveillance study. Participants completed a structured socio-behavioral survey and were offered HIV and syphilis testing and counseling.

Results

The majority of men self-reported ever testing for HIV (81.6%; 413/506) and receiving their last HIV test result (95.4%; 394/413). Testing in the last 12 months was more prevalent in Douala (63.3%; 169/267) compared to Yaoundé (55.9%; 132/236). Median frequency of testing was every 18 months in Douala and every two years in Yaoundé. In multivariate RDS-weighted analysis, correlates of ever testing for HIV in Douala were: having higher than secondary education compared to having secondary education or less (aOR = 3.51, 95% CI: 1.32-9.34), ever accessing a community-based HIV service for MSM (aOR = 3.37, 95% CI: 1.57-7.24) and having ≥4 male oral or anal sexual partners in the past 12 months (aOR = 2.49, 1.08-5.74). In Yaoundé, having higher than secondary education (aOR = 7.96, 95% CI: 1.31-48.41) was associated with ever testing for HIV.

Conclusions

Supporting regular HIV testing and linkage to care is important in a context of high HIV prevalence and limited use of condoms and condom-compatible lubricants. Building the capacity of MSM organizations and mainstream health services to deliver affordable, integrated, confidential, and MSM-sensitive HIV testing may assist in effectively engaging more MSM in the HIV treatment cascade. Giving specific attention to MSM who are younger, of lower socioeconomic status and less connected to community-based MSM organizations may increase HIV testing uptake. Given the levels of HIV testing and high HIV prevalence among MSM in Cameroon, optimizing the safe and effective provision and uptake of antiretroviral-based prevention and treatment approaches is paramount in changing the trajectory of the HIV epidemic among these men and within their sexual networks.

The impact of a locally applied vibrating device on outpatient venipuncture in children

OBJECTIVE

To assess the impact of a locally applied vibrating device on outpatient venipuncture in children.

METHOD

A retrospective review of survey data collected prospectively as part of a quality improvement project. Both patients and phlebotomists were surveyed. The sample consisted of 64 children aged 4 to 18 years (29 prior to the implementation of the vibrating device and 35 afterward) and 7 phlebotomists.

RESULTS

Prior to the use of the vibrating device, 17 children (59%) indicated that they wished something had been done to decrease venipuncture pain. Eighty percent of the cohort that used the vibrating device indicated that they would like it used for future procedures. Children with previous venipuncture experiences appeared to benefit most from use of the vibrating technique. The phlebotomists reported that vibration made the procedure easier in 81% of the cases; none reported that it complicated the procedure.

CONCLUSIONS

Locally applied vibration appears to be a well-accepted technique to minimize pediatric venipuncture discomfort that may facilitate completion of the procedure.

Why do men who have sex with men test for HIV infection? Results from a community-based testing program in Seattle

BACKGROUND

The Centers for Disease Control and Prevention recommends at least annual HIV testing for men who have sex with men (MSM), but motivations for testing are not well understood.

METHODS

We evaluated data from MSM testing for HIV at a community-based program in King County, Washington. Correlates of regular testing were examined using generalized estimating equation regression models.

RESULTS

Between February 2004 and June 2011, 7176 MSM attended 12,109 HIV testing visits. When asked reasons for testing, 49% reported that it was time for their regular test, 27% reported unprotected sex, 24% were starting relationships, 21% reported sex with someone new, 21% sought sexually transmitted infection/hepatitis screening, 12% reported sex with an HIV-infected partner, 2% suspected primary HIV infection, and 16% reported other reasons. In multivariable analysis, factors associated with regular testing included having a regular health care provider and the following in the previous year: having only male partners, having 10 or more male partners, inhaled nitrite use, not injecting drugs, and not having unprotected anal intercourse with a partner of unknown/discordant status (P ≤ 0.001 for all). Men reporting regular testing reported shorter intertest intervals than men who did not (median of 233 vs. 322 days, respectively; P < 0.001).

CONCLUSIONS

Regular testing, sexual risk, and new partnerships were important drivers of HIV testing among MSM, and regular testing was associated with increased testing frequency. Promoting regular testing may reduce the time that HIV-infected MSM are unaware of their status, particularly among those who have sex with men and women or inject drugs.

Preferences for rapid point-of-care HIV testing in Nova Scotia, Canada

Rapid point-of-care (POC) testing for HIV has been shown to increase the uptake of testing, rates of clients receiving test results, numbers of individuals aware of their status and timely access to care for those who test positive. In addition, several studies have shown that rapid POC testing for HIV is highly acceptable to clients in a variety of clinical and community-based health care settings. Most acceptability studies conducted in North America, however, have been conducted in large, urban environments where concentrations of HIV testing sites and testing innovations are greatest. Using a survey of client preferences at a sexual health clinic in Halifax, Nova Scotia, we suggest that HIV test seekers living in a region outside of Canada's major urban HIV epicentres find rapid POC testing highly acceptable. We compare the results of the Halifax survey with existing acceptability studies of rapid POC HIV testing in North America and suggest ways in which it might be of particular benefit to testing clients and potential clients in Nova Scotia and other regions of Canada that currently have few opportunities for anonymous or rapid testing. Overall, we found that rapid POC HIV testing was highly desirable at this study site and may serve to overcome many of the challenges associated with HIV prevention and testing outside of well-resourced metropolitan environments.

Perceived susceptibility to AIDS predicts subsequent HIV risk: a longitudinal evaluation of jail inmates

Theories of health behavior change suggest that perceived susceptibility to illness precedes health-protective behavior. We used a cross-lagged panel design to explore the relationship between perceived susceptibility to AIDS, and HIV risk behavior pre-incarceration and post-release in a sample of 499 jail inmates, a group at high risk for HIV. We also explored moderators of this relationship. HIV risk was calculated with a Bernoulli mathematical process model. Controlling for pre-incarceration HIV risk, perceived susceptibility to AIDS predicted less post-release HIV risk; the reverse relationship was not supported. Consistent with health behavior change theories, perceived susceptibility seemed to partially guide behavior. However, this relationship was not true for everyone. African-Americans and individuals high in borderline personality features exhibited no relationship between perceived susceptibility and changes in HIV risk. This suggests that targeted interventions are needed to use information about risk level to prevent HIV contraction.

Introducing rapid oral-fluid HIV testing among high risk populations in Shandong, China: feasibility and challenges

BACKGROUND

This study was conducted to ascertain the feasibility of using rapid oral fluid testing as an alternative HIV testing method in China.

METHOD

This is a mixed-method study among men who have sex with men (MSM), female sex workers (FSW) and VCT clients, conducted in 4 cities in Shandong Province. A pre-tested questionnaire was administered to 1137 participants through face-to-face interview to assess demographic characteristics, HIV testing histories and willingness to accept rapid oral fluid testing. VCT clients were provided with the saliva test kits for a screening test and errors in operation were recorded. Testing results were compared between oral and blood testing. Short feedback questionnaire was administered to 200 FSW who had undergone oral testing.

RESULTS

The rate of willingness to take oral-fluid HIV testing among MSM, FSW and VCT clients was 72.8%, 72.1% and 67.4% respectively. Common errors recorded during test kit operation by the 229 VCT clients included: unpreparedness, wrong swab sampling, wrong dilution, wrong testing and inability to read test results. Advantages of oral testing listed by participants included: less intrusive, painlessness, easy self- testing and privacy. Disadvantages included perceived unreliable results (55.5%) and not nationally recognised (9%). Comparison of saliva and the blood testing results recorded a consistency rate of 0.970 (χ2 = 153.348, P < 0.001), implying an excellent consistency.

CONCLUSION

Introduction of oral rapid fluid testing as an alternative HIV testing method in China is highly feasible but with some challenges including low recognition and operation errors.

Acceptability and intended usage preferences for six HIV testing options among internet-using men who have sex with men

Background

Men who have sex with men (MSM) continue to be disproportionately impacted by the Human Immunodeficiency Virus (HIV) epidemic in the United States (US). Testing for HIV is the cornerstone of comprehensive prevention efforts and the gateway to early engagement of infected individuals in medical care. We sought to determine attitudes towards six different HIV testing modalities presented collectively to internet-using MSM and identify which options rank higher than others in terms of intended usage preference.

Methods

Between October and November 2012, we surveyed 973 HIV-negative or -unknown status MSM and assessed their acceptability of each of the following services hypothetically offered free of charge: Testing at a physician’s office; Individual voluntary counseling and testing (VCT); Couples’ HIV counseling and testing (CHCT); Expedited/express testing; Rapid home self-testing using an oral fluid test; Home dried blood spot (DBS) specimen self-collection for laboratory testing. Kruskal-Wallis tests were used to determine whether the stated likelihood of using each of these modalities differed by selected respondent characteristics. Men were also asked to rank these options in order of intended usage preference, and consensual rankings were determined using the modified Borda count (MBC) method.

Results

Most participants reported being extremely likely or somewhat likely to use all HIV testing modalities except DBS self-collection for laboratory testing. Younger MSM indicated greater acceptability for expedited/express testing (P < 0.001), and MSM with lower educational levels reported being more likely to use CHCT (P < 0.001). Non-Hispanic black MSM indicated lower acceptability for VCT (P < 0.001). Rapid home self-testing using an oral fluid test and testing at a physician’s office were the two most preferred options across all demographic and behavioral strata.

Conclusions

Novel approaches to increase the frequency of HIV testing among US MSM are urgently needed. Combination testing packages could enable high risk MSM in putting together annual testing strategies personalized to their circumstances, and warrant due consideration as an element of combination HIV prevention packages.

Will an unsupervised self-testing strategy be feasible to operationalize in Canada? Results from a pilot study in students of a large canadian university

Background. A convenient, private, and accessible HIV self-testing strategy stands to complement facility-based conventional testing. Over-the-counter oral HIV self-tests are approved and available in the United States, but not yet in Canada. Canadian data on self-testing is nonexistent. We investigated the feasibility of offering an unsupervised self-testing strategy to Canadian students. Methods. Between September 2011 and May 2012, we recruited 145 students from a student health clinic of a large Canadian university. Feasibility of operationalization (i.e., self-test conduct, acceptability, convenience, and willingness to pay) was evaluated. Self-test conduct was computed with agreement between the self-test performed by the student and the test repeated by a healthcare professional. Other metrics were measured on a survey. Results. Participants were young (median age: 22 years), unmarried (97%), and 47% were out of province or international students. Approximately 52% self-reported a history of unprotected casual sex and sex with multiple partners. Self-test conduct agreement was high (100%), so were acceptability (81%), convenience (99%), and willingness to pay (74%) for self-tests. Concerns included accuracy of self-tests and availability of expedited linkages. Conclusion. An unsupervised self-testing strategy was found to be feasible in Canadian students. Findings call for studies in at-risk populations to inform Canadian policy.

Factors associated with willingness to accept oral fluid HIV rapid testing among most-at-risk populations in China

BACKGROUND

The availability of oral fluid HIV rapid testing provides an approach that may have the potential to expand HIV testing in China, especially among most-a-risk populations. There are few investigations about the acceptability of oral fluid HIV testing among most-at-risk populations in China.

METHOD

A cross-sectional study with men who have sex with men (MSM), female sex workers (FSW) and voluntary counseling and testing (VCT) clients was conducted in three cities of Shandong province, China from 2011 to 2012. Data were collected by face-to-face questionnaire.

RESULTS

About 71% of participants were willing to accept the oral fluid HIV rapid testing, and home HIV testing was independently associated with acceptability of the new testing method among MSM, FSW and VCT clients (AOR of 4.46, 3.19 and 5.74, respectively). Independent predictors of oral fluid HIV rapid testing acceptability among MSM were having ever taken an oral fluid HIV rapid test (AOR= 15.25), having ever taken an HIV test (AOR= 2.07), and education level (AOR= 1.74). Engagement in HIV-related risk behaviors (AOR= 1.68) was an independent predictor of acceptability for FSW. Having taken an HIV test (AOR= 2.85) was an independent predictor of acceptability for VCT clients. The primary concern about the oral fluid HIV testing was accuracy. The median price they would pay for the testing ranged from 4.8 to 8.1 U.S. dollars.

CONCLUSION

High acceptability of oral fluid HIV rapid testing was shown among most-at-risk populations. Findings provide support for oral rapid HIV testing as another HIV prevention tool, and provide a backdrop for the implementation of HIV home testing in the near future. Appropriate pricing and increased public education through awareness campaigns that address concerns about the accuracy and safety of the oral fluid HIV rapid testing may help increase acceptability and use among most-at-risk populations in China.

Provision of rapid HIV tests within a health service and frequency of HIV testing among men who have sex with men: randomised controlled trial

OBJECTIVE

To determine if the provision of rapid HIV testing to men who have sex with men attending a health service would increase their frequency of HIV testing over time.

DESIGN

Non-blinded randomised controlled trial.

SETTING

Public sexual health service in Australia.

PARTICIPANTS

Men who reported having a male sexual partner within the previous year and an HIV test within the previous two years. Of 400 men entered, 370 (92.5%) completed the study.

INTERVENTIONS

Men attending the service between September 2010 and March 2011 were randomised 1:1 to either ongoing access to rapid HIV testing obtained with finger prick or to conventional HIV serology with venepuncture, over 18 months.

MAIN OUTCOME MEASURE

The incidence of all HIV testing after enrolment, including testing outside the study clinic, analysed by intention to treat.

RESULTS

Of 200 men randomised to the rapid testing arm, 196 were followed for 288 person years. Of 200 men randomised to the conventional testing arm, 194 were followed for 278 person years. Median time since the last HIV test was six months for both arms. Men in the rapid test arm had 469 tests (mean 1.63 tests a year), and men in the conventional test arm had 396 tests (mean 1.42 tests a year); incidence rate ratio 1.15, 95% confidence interval 0.96 to 1.38; P=0.12. In a post hoc analysis, rates of initial HIV testing during follow-up were 1.32 and 1.01 tests a year, respectively (1.32, 1.05 to 1.65; P=0.02).

CONCLUSIONS

Provision of access to rapid HIV testing in a health service did not result in a sustained increase over time in HIV testing by men who have sex with men; however, the rate of initial HIV testing did increase by a third. Further research is required to determine how to achieve sustained increases in the frequency of HIV testing by populations at risk.

TRIAL REGISTRATION

ACTR No 12610000430033.

Preferred HIV testing services and programme characteristics among clients of a rapid HIV testing programme

BACKGROUND

In the current context of diversity and coexistence of HIV testing approaches, limited information exists on test recipient's views of HIV testing services and programme attributes that could ease the testing process and make it more appealing for at risk individuals who don't know their HIV status. This study analyzed ratings given to different testing sites and programme characteristics that might facilitate testing.

METHODS

We analyzed data from 3120 persons attending a mobile HIV testing programme located on a central street in the gay district of Madrid.

RESULTS

64% were men (of which, 55% had had sex with other men), 59.5% were <30 years, 35.4% foreigners, 50.6% had a university degree,71.7% a regular employment, 59.3% reported multiple partners and inconsistent condom use and 56.5% had been tested for HIV. Non Governmental Organizations and specific HIV/STI centres received the maximum rating from over 60% of participants, followed by self-testing (38.9%). Pharmacies (20.8%) and hospital emergency departments (14.2%) were the worst valued testing sites. Over 80% gave the highest rating to having immediate test results, not needing a previous appointment, and free testing, while less than 50% gave the maximum rating to privacy and anonymity.

CONCLUSIONS

HIV testing services that don't require an appointment, based on free tests with rapid results are most valued by a young, not socially marginalized but high risk sexual exposure population. On the contrary, issues traditionally highly valued by health care providers or AIDS social organizations (privacy and anonymity) are much less valued.

Acceptability of HIV self-testing: a systematic literature review

Background

The uptake of HIV testing and counselling services remains low in risk groups around the world. Fear of stigmatisation, discrimination and breach of confidentiality results in low service usage among risk groups. HIV self-testing (HST) is a confidential HIV testing option that enables people to find out their status in the privacy of their homes. We evaluated the acceptability of HST and the benefits and challenges linked to the introduction of HST.

Methods

A literature review was conducted on the acceptability of HST in projects in which HST was offered to study participants. Besides acceptability rates of HST, accuracy rates of self-testing, referral rates of HIV-positive individuals into medical care, disclosure rates and rates of first-time testers were assessed. In addition, the utilisation rate of a telephone hotline for counselling issues and clients` attitudes towards HST were extracted.

Results

Eleven studies met the inclusion criteria (HST had been offered effectively to study participants and had been administered by participants themselves) and demonstrated universally high acceptability of HST among study populations. Studies included populations from resource poor settings (Kenya and Malawi) and from high-income countries (USA, Spain and Singapore). The majority of study participants were able to perform HST accurately with no or little support from trained staff. Participants appreciated the confidentiality and privacy but felt that the provision of adequate counselling services was inadequate.

Conclusions

The review demonstrates that HST is an acceptable testing alternative for risk groups and can be performed accurately by the majority of self-testers. Clients especially value the privacy and confidentiality of HST. Linkage to counselling as well as to treatment and care services remain major challenges.

Addressing unmet need for HIV testing in emergency care settings: a role for computer-facilitated rapid HIV testing?

HIV testing in emergency departments (EDs) remains underutilized. The authors evaluated a computer tool to facilitate rapid HIV testing in an urban ED. Randomly assigned nonacute adult ED patients were randomly assigned to a computer tool (CARE) and rapid HIV testing before a standard visit (n = 258) or to a standard visit (n = 259) with chart access. The authors assessed intervention acceptability and compared noted HIV risks. Participants were 56% nonWhite and 58% male; median age was 37 years. In the CARE arm, nearly all (251/258) of the patients completed the session and received HIV results; four declined to consent to the test. HIV risks were reported by 54% of users; one participant was confirmed HIV-positive, and two were confirmed false-positive (seroprevalence 0.4%, 95% CI [0.01, 2.2]). Half (55%) of the patients preferred computerized rather than face-to-face counseling for future HIV testing. In the standard arm, one HIV test and two referrals for testing occurred. Computer-facilitated HIV testing appears acceptable to ED patients. Future research should assess cost-effectiveness compared with staff-delivered approaches.

Willingness to use couples voluntary counseling and testing services among men who have sex with men in seven countries

The willingness of male-male dyads to use couples voluntary HIV counseling and testing (CVCT) has not been previously investigated globally among men who have sex with men (MSM). Using online advertisements, data were collected from 3245 MSM in seven countries who were ≥ 18 years of age and had ≥1 male sex partner in the previous 12 months. The analysis examined associations between individual characteristics and willingness to utilize CVCT. The willingness to utilize CVCT was compellingly high, ranging from 79% in Australia and UK to 90% in Brazil. Older MSM and those who reported not knowing their sero-status reported lower odds of willingness to use CVCT. The relationship between being in a relationship and willingness to use CVCT varied across countries, perhaps reflecting varied local understandings of the nature and content of CVCT. Further work is required to examine willingness to use CVCT among a more heterogeneous population of MSM, and to examine how CVCT services are locally perceived in order to provide information vital for the development of locally appropriate messages to promote CVCT for MSM.

Attitudes toward couples-based HIV counseling and testing among MSM in Cape Town, South Africa

Couples-based voluntary HIV counseling and testing (CVCT) allows couples to receive their HIV test results together and has been demonstrated to be effective in reducing HIV transmission, increasing and sustaining condom use, and reducing sexual risk-taking among at-risk heterosexual couples. However, the acceptability of CVCT among MSM has yet to be evaluated in an African setting. The results from seven focus group discussions and 29 in-depth interviews conducted in Cape Town, South Africa exhibit overwhelmingly high acceptance of CVCT. Participants were attracted to the counseling components of the service, stating that these would allow for the couple to increase their commitment and to explore methods of how to effectively reduce their risk of acquiring or transmitting HIV in the presence of a trained counselor. These results suggest CVCT would be highly welcomed and could work to fill the significant lack of services available and accessible to MSM couples in Cape Town.

Missed opportunities for hepatitis C testing in opioid treatment programs

HCV has surpassed HIV as a cause of death in the United States and is particularly prevalent among injection drug users. I examined the availability of on-site HCV testing in a nationally representative sample of opioid treatment programs. Nearly 68% of these programs had the staff required for HCV testing, but only 34% offered on-site testing. Availability of on-site testing increased only slightly with the proportion of injection drug users among clients. The limited HCV testing services in opioid treatment programs is a key challenge to reducing HCV in the US population.

Evaluating the implementation of nurse-initiated HIV rapid testing in three Veterans Health Administration substance use disorder clinics

Individuals with substance use disorders (SUDs) are at higher risk of HIV infection, yet recent studies show rates of HIV testing are low among this population. We implemented and evaluated a nurse-initiated HIV oral rapid testing (NRT) strategy at three Veterans Health Administration SUD clinics. Implementation of NRT includes streamlined nurse training and a computerized clinical reminder. The evaluation employed qualitative interviews with staff and a quantitative evaluation of HIV testing rates. Barriers to testing included lack of laboratory support and SUD nursing resistance to performing medical procedures. Facilitators included the ease of NRT integration into workflow, engaged management and an existing culture of disease prevention. Six-months post intervention, rapid testing rates at SUD clinics in sites 1, 2, and 3 were 5.0%, 1.1% and 24.0%, respectively. Findings indicate that NRT can be successfully incorporated into some types of SUD subclinics with minimal perceived impact on workflow and time.

A review of self-testing for HIV: research and policy priorities in a new era of HIV prevention

Global progress toward universal human immunodeficiency virus (HIV) testing remains slow. Interest in HIV self-testing is high and may increase knowledge of HIV status; however, empirical research on selftesting is limited, resulting in lack of evidence on which to base policy recommendations.

Inadequate uptake of testing for human immunodeficiency virus (HIV) remains a primary bottleneck toward universal access to treatment and care, and is an obstacle to realizing the potential of new interventions for preventing HIV infection, including treatment for prevention and preexposure prophylaxis. HIV self-testing offers an approach to scaling up testing that could be high impact, low cost, confidential, and empowering for users. Although HIV self-testing was first considered >20 years ago, it has not been widely implemented. We conducted a review of policy and research on HIV self-testing, which indicates that policy is shifting toward a more flexible approach with less emphasis on pretest counseling and that HIV self-testing has been adopted in a number of settings. Empirical research on self-testing is limited, resulting in a lack of an evidence base upon which to base policy recommendations. Relevant research and investment in programs are urgently needed to enable consideration of developing formalized self-testing programs.

All black people are not alike: differences in HIV testing patterns, knowledge, and experience of stigma between U.S.-born and non-U.S.-born blacks in Massachusetts

Non-U.S.-born black individuals comprise a significant proportion of the new diagnoses of HIV in the United States. Concurrent diagnosis (obtaining an AIDS diagnosis in close proximity to an initial diagnosis of HIV) is common in this subpopulation. Although efforts have been undertaken to increase HIV testing among African Americans, little is known about testing patterns among non-U.S.-born black people. A cross-sectional survey was self-administered by 1060 black individuals in Massachusetts (57% non-U.S.-born) to assess self-reported rates of HIV testing, risk factors, and potential barriers to testing, including stigma, knowledge, immigration status, and access to health care. Bivariate analysis comparing responses by birthplace and multivariate logistic regression assessing correlates of recent testing were completed. Non-U.S.-born individuals were less likely to report recent testing than U.S.-born (41.9% versus 55.6%, p<0.0001). Of those who recently tested, the majority did so for immigration purposes, not because of perceived risk. Stigma was significantly higher and knowledge lower among non-U.S.-born individuals. In multivariate analysis, greater length of time since immigration was a significant predictor of nontesting among non-U.S.-born (adjusted odds ratio [AOR] 0.56, 95% confidence interval [CI] 0.36-0.87). Poor health care access and older age were correlated to nontesting in both U.S.- and non-U.S.-born individuals. Our findings indicate that differences in HIV testing patterns exist by nativity. Efforts addressing unique factors limiting testing in non-U.S.-born black individuals are warranted.

Supervised and unsupervised self-testing for HIV in high- and low-risk populations: a systematic review

BACKGROUND

Stigma, discrimination, lack of privacy, and long waiting times partly explain why six out of ten individuals living with HIV do not access facility-based testing. By circumventing these barriers, self-testing offers potential for more people to know their sero-status. Recent approval of an in-home HIV self test in the US has sparked self-testing initiatives, yet data on acceptability, feasibility, and linkages to care are limited. We systematically reviewed evidence on supervised (self-testing and counselling aided by a health care professional) and unsupervised (performed by self-tester with access to phone/internet counselling) self-testing strategies.

METHODS AND FINDINGS

Seven databases (Medline [via PubMed], Biosis, PsycINFO, Cinahl, African Medicus, LILACS, and EMBASE) and conference abstracts of six major HIV/sexually transmitted infections conferences were searched from 1st January 2000-30th October 2012. 1,221 citations were identified and 21 studies included for review. Seven studies evaluated an unsupervised strategy and 14 evaluated a supervised strategy. For both strategies, data on acceptability (range: 74%-96%), preference (range: 61%-91%), and partner self-testing (range: 80%-97%) were high. A high specificity (range: 99.8%-100%) was observed for both strategies, while a lower sensitivity was reported in the unsupervised (range: 92.9%-100%; one study) versus supervised (range: 97.4%-97.9%; three studies) strategy. Regarding feasibility of linkage to counselling and care, 96% (n = 102/106) of individuals testing positive for HIV stated they would seek post-test counselling (unsupervised strategy, one study). No extreme adverse events were noted. The majority of data (n = 11,019/12,402 individuals, 89%) were from high-income settings and 71% (n = 15/21) of studies were cross-sectional in design, thus limiting our analysis.

CONCLUSIONS

Both supervised and unsupervised testing strategies were highly acceptable, preferred, and more likely to result in partner self-testing. However, no studies evaluated post-test linkage with counselling and treatment outcomes and reporting quality was poor. Thus, controlled trials of high quality from diverse settings are warranted to confirm and extend these findings. Please see later in the article for the Editors' Summary.

High rates of late HIV diagnosis among people who inject drugs compared to men who have sex with men and heterosexual men and women in Australia

We aimed to estimate temporal trends in the proportion of HIV diagnoses which could be characterized as recent infections in Australia for men who have sex with men (MSM), people who inject drugs (PWID), and heterosexual men and women using modified back-projection methodology based on data sources from HIV/AIDS Surveillance database. The proportion of HIV diagnoses among MSM that can be classified as recent infections increased in MSM, heterosexual men and women consistently. However, after initial increases during 1996-2000, the proportion of overall recent infections estimated among PWID declined by 50% in 2007 compared to 2000 (from 23 to 11%). These data suggest that late HIV diagnoses were more common among PWID compared to other groups. Ongoing prevention efforts need to be coupled with targeted testing and treatment efforts to increase the diagnosis of recent infection in PWID and reduce apparent inequities in access to screening.

Low-cost tools for diagnosing and monitoring HIV infection in low-resource settings

Low-cost technologies to diagnose and monitor human immunodeficiency virus (HIV) infection in developing countries are a major subject of current research and health care in the developing world. With the great need to increase access to affordable HIV monitoring services in rural areas of developing countries, much work has been focus on the development of point-of-care technologies that are affordable, robust, easy to use, portable and of sufficient quantitative accuracy to enable clinical decision-making. For diagnosis of HIV infection, some low-cost tests, such as lateral flow tests and enzyme-linked immunosorbent assays, are already in place and well established. However, portable quantitative tests for rapid HIV monitoring at the point of care have only recently been introduced to the market. In this review, we discuss low-cost tests for HIV diagnosis and monitoring in low-resource settings, including promising technologies for use at the point of care, that are available or close to market.

Piloting HIV rapid testing in community-based settings in Estonia

BACKGROUND

In the European Union it is estimated that up to 30% of HIV-infected people are not aware of their status. Community-based testing (CBT) models are implemented to increase the uptake of HIV testing.

AIMS

The aim of this project was to assess the feasibility and acceptance of HIV rapid testing in CBT settings in Estonia to identify non-clinical recruitment venues for people more likely to engage in high-risk behaviours.

METHODS

Participants for this anonymous, cross-sectional study were recruited from a syringe exchange programme and gay-oriented locations using convenience sampling. Socio-demographic and HIV testing preferences data were collected using a semi-structured questionnaire. HIV rapid testing was performed using Determine HIV-1/2 (Abbott) rapid test system.

RESULTS

With a participation rate of 88.3%, this project enrolled 308 persons and identified 58 preliminary positive cases. Out of them, 52 reported injecting drug use in last 12 months and 30 reported no previous HIV test. Approximately 45% of all participants preferred rapid testing while 25% reported a preference for a full blood test.

CONCLUSIONS

This project demonstrates that HIV rapid testing in community-based settings in Eastern Europe can be an effective approach for reaching people who engage in high-risk behaviours and increasing the number of HIV-infected people who are aware of their status.

Rapid HIV testing using Determine™ HIV 1/2 antibody tests: is there a difference between the visual appearance of true- and false-positive tests?

HIV point-of-care tests (POCTs) give occasional false positive results, causing unnecessary patient anxiety. We aimed to elicit whether false- and true-positive POCTs differed visually. Seventeen false- and 17 true-positive serum samples were randomized into pairs, comprising one false- and one true-positive sample. Two independent readers identified each POCT as negative or positive and compared line strength between pairs. Six further readers graded line strength, 0-5, from POCT photographs. All true-positive samples were identified positive and 8/17 false-positive samples negative, on repeat testing of stored sera. Eight out of the 9 remaining false-positive tests were described as having weaker pigment uptake than their paired true-positive POCT. Mean grade of line strength was 4.2 in true- and 0.9 in false-positive samples, on photographic evaluation. These results suggest false-positive POCTs may differ visually from true-positive POCTs. If larger studies confirm these findings, we may be able to alleviate anxiety in low risk patients with faintly positive POCTs awaiting their confirmatory laboratory result, where the possibility of a false-positive result could be emphasized.

Field-based video pre-test counseling, oral testing, and telephonic post-test counseling: implementation of an HIV field testing package among high-risk Indian men

In India, men who have sex with men (MSM) and truck drivers are high-risk groups that often do not access HIV testing due to stigma and high mobility. This study evaluated a field testing package (FTP) that identified HIV positive participants through video pre-test counseling, OraQuick oral fluid HIV testing, and telephonic post-test counseling and then connected them to government facilities. A total of 598 MSM and truck drivers participated in the FTP and completed surveys covering sociodemographics, HIV testing history, risk behaviors, and opinions on the FTP. MSM and truck drivers equally preferred video counseling, although MSM who had been previously tested preferred traditional methods. Nearly all participants preferred oral testing. Rates of counseling completion and linkage to government centers were low, with one-third of newly identified positives completing follow-up. With increased public-private coordination, this FTP could identify many hard-to-reach preliminary positive individuals and connect them to government testing and care.

African American patient experiences with a rapid HIV testing program in an urban public clinic

BACKGROUND

Of 1174 new human immunodeficiency virus (HIV) cases diagnosed in Philadelphia, Pennsylvania, in 2008, a total of 771 (66%) were among African Americans. Philadelphia recently introduced a citywide rapid HIV testing program in public clinics.

METHODS

We conducted a qualitative study among 60 African Americans undergoing rapid HIV testing in one of Philadelphia's public clinics located in a zip code with high HIV incidence. Employing grounded theory, we used semistructured interviews to assess patients' motivations, perceptions, and clinical experiences with rapid HIV testing. Interviews were transcribed and coded; 20% were double coded to enhance reliability.

RESULTS

Primary motivations for undergoing rapid HIV testing included: testing during routine clinical care, presenting for care with symptomatic sexually transmitted infections or opportunistic infections, knowing someone living with HIV/ AIDS, and perceiving oneself at risk for HIV. Most patients reported positive experiences with rapid testing and preferred it to conventional testing because it eliminated the need for return visits and decreased anxiety; however, many expressed concerns about accuracy of rapid HIV testing. Barriers to HIV testing among this population included low self-perceived risk, HIV stigma, and reported homophobia in respondents' communities.

CONCLUSION

This rapid testing program was acceptable, convenient, and preferred over conventional HIV testing. Providing educational information about rapid and confirmatory HIV testing may further enhance acceptability of rapid HIV testing in this population. Nationwide expansion of rapid HIV testing in public health centers is an important and acceptable means of achieving President Obama's National AIDS Strategy goals of reducing racial disparities in HIV infection and improving linkage to HIV/AIDS treatment and care services.

Distracting children during blood draw: looking through distraction cards is effective in pain relief of children during blood draw

This study aims to investigate the effects of distraction method by way of looking through distraction cards/Flippits® to reduce procedural pain and anxiety during blood draw. In this method we distract attention of the children with distraction cards/Flippits®. Flippits® consist of various eye-catching pictures and shapes. Then we asked the children questions about the cards during the blood draw procedure that he or she can only answer if he or she examines the cards carefully. This study is a prospective, randomized controlled trial. The sample consisted of 123 children of ages between 6 and 12. We randomly assigned subjects into two groups. Group 1 received no intervention, whereas Group 2 received distraction in the form of looking through distraction cards/Flippits®. Pre-procedural and procedural anxiety was assessed using the anxiety scale from the Children's Anxiety and Pain Scales by parents' and observer's report. Procedural pain was assessed using Faces Pain Scale-Revised by children, parent and observer reports. Results show that pre-procedural anxiety did not differ significantly. However, the experimental group had significantly lower pain levels than the control group during the blood draw procedure. Also experimental group had significantly lower anxiety levels than the control group.

Routine prenatal HIV testing: women's concerns and their strategies for addressing concerns

The purpose of this exploratory study was to solicit women’s opinions about the process of routine prenatal HIV testing to identify strategies for routine testing that will address women’s concerns, increase their level of comfort with testing, and support universal prenatal HIV testing. A convenience sample of English-speaking women between 18 and 45 years of age who were HIV-negative or of unknown HIV status were recruited for focus groups at four diverse community sites in four states. Focus group discussion questions addressed health care provider approaches and actions that would make a woman feel more comfortable with the process of routine prenatal HIV testing. Twenty-five women agreed to participate; most women (64%) were of Black, non-Hispanic race/ethnicity; 44% were 25–34 years of age. Thematic analysis of women’s concerns about routine prenatal HIV testing fell into the following categories: fear, protecting the baby, protecting the woman, confidentiality, and stigma. Women’s strategies for addressing these concerns were related to themes of education and information, normalizing HIV testing, patient–provider relationships, systems, and private communication. Participants offered numerous insightful and practical suggestions for addressing their concerns thereby supporting universal routine prenatal HIV testing. The themes that arose in this study support the conclusion that women will be more comfortable with routine prenatal HIV testing if they are fully informed and knowledgeable about the rationale for HIV testing during pregnancy and their right to decline, and if testing is carried out in a confidential and supportive health care environment.

Short communication routine HIV testing in the emergency department: assessment of patient perceptions

The CDC released revised HIV testing guidelines in 2006 recommending routine, opt-out HIV testing in acute care settings including emergency departments (ED). Patient attitudes have been cited as a barrier to implementation of routine HIV testing in the ED. We assessed patients' perceptions of HIV testing in the ED through a contextual qualitative approach. The study was conducted during a 72-h period. All adults presenting to the ED without life-threatening trauma or psychiatric crisis completed a standardized questionnaire. The questionnaire explored HIV testing history, knowledge of testing resources, and qualitative items addressing participant perceptions about advantages and disadvantages to ED testing. After completion of the interview, participants were offered a free, confidential, rapid HIV test. Among 329 eligible individuals approached, 288 (87.5%) completed the initial interview. Participants overwhelmingly (n=247, 85.8%) reported support for testing and identified increased knowledge (41%), prevention (12.5%), convenience (11.8%), and treatment (4.9%) among the advantages. Fear and denial about one's HIV status, reported by <5% of patients, were identified as the most significant barriers to ED testing. Bivariate analysis determined race and ethnicity differences between individuals completing the interview and those who refused (p<0.05). Among individuals consenting for testing (n=186, 64.6%), no positives were detected. Most patients support HIV testing in the ED, noting knowledge of status, prevention, convenience, and linkage to early treatment as distinct advantages. These data are of particular benefit to decision makers considering the addition of routine HIV testing in EDs.

Barriers to HIV testing among HIV/AIDS concurrently diagnosed persons in New York City

OBJECTIVES

To assess barriers to human immunodeficiency virus (HIV) testing, health care contacts history, and HIV testing history among patients diagnosed concurrently with HIV and acquired immunodeficiency syndrome (AIDS).

METHODS

We surveyed patients concurrently diagnosed with HIV/AIDS who had participated in the partner notification program of the New York City Department of Health and Mental Hygiene, between January 2008 and December 2008.

RESULTS

The most common reason interviewees volunteered for delaying testing (64%) was that they did not believe they were at risk for HIV. When read a list of potential barriers, 69% of interviewees replied affirmatively that they did not test for HIV because they did not believe they were at risk, and 52% replied affirmatively that they did not test because they thought their behaviors kept them safe from getting HIV. Half of all interviewees reported having insurance during part or all of the year before they were diagnosed with HIV/AIDS, and 70% had at least 1 health care visit in the year before they were diagnosed with HIV/AIDS.

CONCLUSIONS

A lack of perception of risk was the most common reason for not testing for HIV sooner among these concurrently diagnosed patients. The majority of these patients were accessing medical care, indicating that this population could have benefited from routine HIV testing.

Reasons for not HIV testing, testing intentions, and potential use of an over-the-counter rapid HIV test in an internet sample of men who have sex with men who have never tested for HIV

BACKGROUND

Correlates of main reasons for not HIV testing, HIV testing intentions, and potential use of an over-the-counter rapid HIV test (OTCRT) among men who have sex with men who have never tested for HIV (NTMSM) are unknown.

METHODS

We evaluated these correlates among 946 NTMSM from 6 US cities who participated in an internet-based survey in 2007.

FINDINGS

Main reasons for not testing were low perceived risk (32.2%), structural barriers (25.1%), and fear of testing positive (18.1%). Low perceived risk was associated with having fewer unprotected anal intercourse (UAI) partners and less frequent use of the internet for HIV information; structural barriers were associated with younger age and more UAI partners; fear of testing positive was associated with black and Hispanic race/ethnicity, more UAI partners, and more frequent use of the internet for HIV information. Strong testing intentions were held by 25.9% of all NTMSM and 14.8% of those who did not test because of low perceived risk. Among NTMSM who were somewhat unlikely, somewhat likely, and very likely to test for HIV, 47.4%, 76.5%, and 85.6% would likely use an OTCRT if it was available, respectively.

CONCLUSIONS

Among NTMSM who use the internet, main reasons for not testing for HIV vary considerably by age, race/ethnicity, UAI, and use of the internet for HIV information. To facilitate HIV testing of NTMSM, programs should expand interventions and services tailored to address this variation. If approved, OTCRT might be used by many NTMSM who might not otherwise test for HIV.

HIV treatment as prevention: the utility and limitations of ecological observation

Results from several observational studies of HIV-discordant couples and a randomized controlled trial (HIV Prevention Trials Network 052) show that antiretroviral therapy (ART) can greatly reduce heterosexual HIV transmission in stable HIV-discordant couples. However, such data do not prove that ART will reduce HIV incidence at the population level. Observational investigations using ecological measures have been used to support the implementation of HIV treatment for the specific purpose of preventing transmission at the population level. Many of these studies note ecological associations between measures of increased ART uptake and decreased HIV transmission. Given the urgency of implementing HIV prevention measures, ecological studies must de facto be used to inform current strategies. However, the hypothesis that widespread ART can eliminate HIV infection may have raised expectations beyond what we may be able to achieve. Here we review and discuss the construct of the exposure and outcome measures and analysis methods used in ecological studies. By examining the strengths and weaknesses of ecological analyses, we aim to aid understanding of the findings from these studies to inform future policy decisions regarding the use of ART for HIV prevention.

High levels of acceptability of couples-based HIV testing among MSM in South Africa

The acceptability of couples-based voluntary HIV counseling and testing (CVCT) has not been previously investigated among men who have sex with men (MSM) in South Africa. Using online advertisements, data were collected from 486 MSM, who were 18 years of age or older with a current residence in South Africa and had at least one male sex partner in the previous 12 months. The analysis examined associations between individual characteristics and willingness to utilize CVCT services. The willingness to utilize CVCT services was compellingly high (89%) among this sample of mostly White/European African (89%) and HIV-negative (83%) men. MSM who reported higher numbers of completed school years were less likely to report willingness to use CVCT. Willingness did not vary significantly across other individual demographic or behavioral characteristics. Our results show an overwhelmingly high acceptance of CVCT services. Future studies should survey a more heterogeneous population of MSM, explore the complex nature of same-sex male relationships, and why respondents would or would not use these HIV testing services.

The uptake and accuracy of oral kits for HIV self-testing in high HIV prevalence setting: a cross-sectional feasibility study in Blantyre, Malawi

BACKGROUND

Although HIV testing and counseling (HTC) uptake has increased dramatically in Africa, facility-based services are unlikely to ever meet ongoing need to the full. A major constraint in scaling up community and home-based HTC services is the unacceptability of receiving HTC from a provider known personally to prospective clients. We investigated the potential of supervised oral HIV self-testing from this perspective.

METHODS AND FINDINGS

Adult members of 60 households and 72 members of community peer groups in urban Blantyre, Malawi, were selected using population-weighted random cluster sampling. Participants were offered self-testing plus confirmatory HTC (parallel testing with two rapid finger-prick blood tests), standard HTC alone, or no testing. 283 (95.6%) of 298 selected adults participated, including 136 (48.0%) men. 175 (61.8%) had previously tested (19 known HIV positive), although only 64 (21.5%) within the last year. HIV prevalence was 18.5%. Among 260 (91.9%) who opted to self-test after brief demonstration and illustrated instructions, accuracy was 99.2% (two false negatives). Although 98.5% rated the test "not hard at all to do," 10.0% made minor procedural errors, and 10.0% required extra help. Most participants indicated willingness to accept self-test kits, but not HTC, from a neighbor (acceptability 94.5% versus 46.8%, p = 0.001).

CONCLUSIONS

Oral supervised self-testing was highly acceptable and accurate, although minor errors and need for supervisory support were common. This novel option has potential for high uptake at local community level if it can be supervised and safely linked to counseling and care.

Preliminary program evaluation of emergency department HIV prevention counseling

OBJECTIVE

Controversy surrounds the linkage of prevention counseling with emergency department (ED)-based HIV testing. Further, the effectiveness and feasibility of prevention counseling in the ED setting is unknown. We investigate these issues by conducting a preliminarily exploration of several related aspects of our ED's HIV prevention counseling and testing program.

METHODS

Our urban, academic ED provides formal client-centered prevention counseling in conjunction with HIV testing. Five descriptive, exploratory observations were conducted, involving surveys and analysis of electronic medical records and programmatic data focused on (1) patient perception and feasibility of prevention counseling in the ED, (2) patient perceptions of the need to link prevention counseling with testing, and (3) potential effectiveness of providing prevention counseling in conjunction with ED-based HIV testing.

RESULTS

Of 110 ED patients surveyed after prevention counseling and testing, 98% believed privacy was adequate, and 97% reported that their questions were answered. Patients stated that counseling would lead to improved health (80%), behavioral changes (72%), follow-up testing (77%), and discussion with partners (74%). However, 89% would accept testing without counseling, 32% were willing to seek counseling elsewhere, and 26% preferred not to receive the counseling. Correct responses to a 16-question knowledge quiz increased by 1.6 after counseling (95% confidence interval 1.3 to 12.0). The program completed counseling for 97% of patients tested; however, 6% of patients had difficulty recalling the encounter and 13% denied received testing. Among patients undergoing repeated testing, there was no consistent change in self-reported risk behaviors.

CONCLUSION

Participants in the ED prevention counseling and testing program considered counseling acceptable and useful, though not required. Given adequate resources, prevention counseling can be provided in the ED, but it is unlikely that all patients benefit.

Iterative evaluation in a mobile counseling and testing program to reach people of color at risk for HIV--new strategies improve program acceptability, effectiveness, and evaluation capabilities

This article highlights findings from an evaluation that explored the impact of mobile versus clinic-based testing, rapid versus central-lab based testing, incentives for testing, and the use of a computer counseling program to guide counseling and automate evaluation in a mobile program reaching people of color at risk for HIV. The program's results show that an increased focus on mobile outreach using rapid testing, incentives and health information technology tools may improve program acceptability, quality, productivity and timeliness of reports. This article describes program design decisions based on continuous quality assessment efforts. It also examines the impact of the Computer Assessment and Risk Reduction Education computer tool on HIV testing rates, staff perception of counseling quality, program productivity, and on the timeliness of evaluation reports. The article concludes with a discussion of implications for programmatic responses to the Centers for Disease Control and Prevention's HIV testing recommendations.

Knowledge of free voluntary HIV testing centres and willingness to do a test among migrants in Cayenne, French Guiana

In Cayenne, French Guiana, 80% of HIV-positive patients followed at the hospital are migrants. Behavioural information is crucial for optimising HIV testing for this vulnerable group. Predictors of ignorance of the existence of free voluntary counselling and testing (VCT) centre and willingness to get tested were investigated in 2006 among 398 migrants from Haiti, Guyana, Suriname and Brazil using a structured questionnaire. Only 27% of migrants knew simultaneously about the existence of free VCT, its localisation and its operating hours. Factors associated with ignorance of the existence of free VCT centre were birthplace in Haiti, being in French Guiana for less than three years, not thinking one's birth country as strongly affected by HIV and not thinking to be personally at risk for HIV. Factors independently associated with willingness to get tested were thinking to be at risk for HIV, birthplace in Brazil and Haiti, having a high-integration level and fear of suffering if HIV test was positive. In order to improve testing among migrants, the accessibility of testing facilities and the knowledge of their whereabouts and operating hours must be improved to promote the desired behaviour among the majority of migrants which is often willing to do the test.

Client characteristics and HIV risk associated with repeat HIV testing among women in Ethiopia

In Ethiopia, the number of HIV tests administered doubled from 2007 to 2008. However, very little is known about the number of clients testing repeatedly in one year, or their motivations for doing so. We examine repeat HIV testing among 2,027 Ethiopian women attending eight VCT facilities in 2008. Multivariate logistic regression was used to examine associations between repeat HIV testing and demographic, behavioral, and psychosocial characteristics, as well as HIV status. Nearly 40% of clients had tested previously for HIV. Women with high sexual risk are nearly four times more likely than those with no sexual risk to have tested previously, but HIV prevalence was lower among repeat testers (6.5%) than first-time testers (8.5%). Moderate perceived vulnerability, or feeling powerless to prevent HIV infection, is associated with a 50% increased likelihood of being a repeat tester. High perceived behavioral risk is associated with a 40% reduction in the likelihood a woman is testing for at least the second time. Costs associated with repeat testing should be balanced against identification of new HIV cases and prevention benefits.

Choice of Rapid HIV testing and entrance into care in Baltimore City sexually transmitted infections clinics

Point-of-service (POS) HIV testing in sexually transmitted infection (STI) clinics is one public health strategy to increase knowledge of serostatus and to facilitate entry into care. Variation has been reported in clients' views of test reliability and rates of test acceptance. Our objective was to characterize STI clinic patients' choice of POS versus conventional testing (enzyme-linked immunosorbant assay [ELISA] followed by Western blot, with results in 1 week) in Baltimore, Maryland (a high-prevalence city) when both were offered (May through August 2008), then to compare rates of engaging in care. Odds ratios (OR) with 95% confidence intervals (CI) described factors associated with test type choice, as well as HIV test type with entrance into care. The overall prevalence of HIV among testers was 1.1% (60/5101). Those reporting receptive anal sex (OR 1.4; 95% CI 1.1-1.7), illicit drug use (OR 1.3; 95% CI 1.0-1.6), or an HIV-positive sexual contact (OR 1.5; 95% CI 1.0-2.2) were more likely to choose POS testing, as were those who had been tested for HIV previously (OR 1.3; 95% CI 1.1-1.5). Hispanics were less likely to choose POS testing (OR 0.6; 95% CI 0.4- 0.7). Entry into care was low in both categories of test takers (52% in POS testers versus 42% in conventional testers, p = 0.58). Patients at the highest risk for HIV preferred POS testing in STI clinics. Strengthening linkage to care is important for optimizing outcomes of HIV-positive patients presenting to STI clinics.

Confidentiality of the medical records of HIV-positive patients in the United Kingdom - a medicolegal and ethical perspective

This article examines the legal and ethical issues that surround the confidentiality of medical records, particularly in relation to patients who are HIV positive. It records some historical background of the HIV epidemic, and considers the relative risks of transmission of HIV from individual to individual. It explains the law as it pertains to confidentiality, and reports the professional guidance in these matters. It then considers how these relate to HIV-positive individuals in particular.