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Wang Y, Mitchell J, Liu Y. Evidence and implication of interventions across various socioecological levels to address HIV testing uptake among men who have sex with men in the United States: A systematic review. SAGE Open Med 2022; 10:20503121221107126. [PMID: 35795867 PMCID: PMC9251980 DOI: 10.1177/20503121221107126] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 05/25/2022] [Indexed: 12/20/2022] Open
Abstract
Objectives Strengthening HIV testing uptake is critical to curtail the HIV epidemics among men who have sex with men in the United States. Despite the implementation of various interventions to promote HIV testing among men who have sex with men, few aggregated evidence is presented to reflect the "lessons learned" and inform future directions. The objective of this systematic review is to comprehensively summarize published studies that described, tested, and evaluated outcomes (e.g. efficacy, effectiveness, acceptability, feasibility and/or qualitative opinions) associated with an HIV testing intervention and identify gaps as well as opportunities to inform the design and implementation of future interventions to enhance HIV testing uptake among men who have sex with men in the United States. Methods We followed the PRISMA guidelines and conducted a systematic review of articles (published by 23 July 2021) by searching multiple databases (PubMed, MEDLINE, Web of Science and PsycINFO). Results Among the total number of 3505 articles found through multiple databases, 56 papers were included into the review. Interventional modules that demonstrated acceptability, feasibility and efficacy to improve HIV testing uptake among men who have sex with men include: HIV self-testing, interpersonal-level (e.g. peer-led, couple-based) interventions, personalized interventions and technology-based interventions (e.g. mHealth). Aggregated evidence also reflects the lack of individualized interventions that simultaneously address time-varying needs across multiple socioecological levels (e.g. individual, interpersonal, community, structural and societal). Conclusion Development of interventions to improve HIV testing rates and frequency of men who have sex with men has proliferated in recent years. Our review presents important implications in sustaining and improving interventions to address HIV testing uptake among men who have sex with men in the United States.
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Affiliation(s)
- Ying Wang
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Jason Mitchell
- Department of Health Promotion and Disease Prevention, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL, USA
| | - Yu Liu
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA
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2
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Ho CLL, Pan W, Taylor LD. Stigma of HIV Testing on Online HIV Forums: Self-Stigma and the Unspoken. J Psychosoc Nurs Ment Health Serv 2017; 55:34-43. [PMID: 28892555 DOI: 10.3928/02793695-20170905-01] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 07/31/2017] [Indexed: 11/20/2022]
Abstract
Most studies examining HIV-related content in web forums have revolved around the most frequently used terms in HIV-related messages and topics, as well as the supportive nature of those messages. The current study explored barriers that prevent individuals from seeking HIV testing (specifically stigma). The current study analyzed a total of 210 threads and 319 posts, yielding 13 threads that revealed how individuals self-stigmatize and expressed how the fear of being diagnosed prevented them from seeking HIV testing. Results suggest that forums or online communities may perpetuate subculture values that deviate from mainstream values. Another important finding is that there is a lack of HIV testing information in forums for adolescents, which may contribute to the trend of young individuals engaging in risky sexual behaviors not getting tested in a timely fashion. [Journal of Psychosocial Nursing and Mental Health Services, 55(12), 34-43.].
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3
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Abad N, Baack BN, O'Leary A, Mizuno Y, Herbst JH, Lyles CM. A Systematic Review of HIV and STI Behavior Change Interventions for Female Sex Workers in the United States. AIDS Behav 2015; 19:1701-19. [PMID: 25711295 DOI: 10.1007/s10461-015-1013-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The lives of female sex workers (FSW) in the US are typically marked by substance abuse, violence, trauma, and poverty. These factors place FSW at risk for acquiring and transmitting HIV and other sexually transmitted infections (STIs). The purpose of this systematic review is to examine HIV/STI interventions conducted in the US that aim to reduce sexual- or drug-related risk behavior among FSW. Eighteen studies describing 19 unique interventions met our selection criteria: five exclusively targeted FSW, two reported stratified data for FSW, and 12 included at least 50 % FSW. Results indicate that 15 interventions provided HIV/STI information, 13 provided substance abuse prevention information, and few included content tailored to specific needs of FSW. Our findings suggest that current HIV/STI prevention efforts in the US do not adequately address the needs of FSW. Interventions are needed to address issues facing FSW in order to reduce HIV/STI transmission in this high-risk group.
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Affiliation(s)
- Neetu Abad
- Division of STD Prevention, NCHHSTP, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mailstop E-44, Atlanta, GA, 30333, USA,
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4
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Caine K, Tierney WM. Point and counterpoint: patient control of access to data in their electronic health records. J Gen Intern Med 2015; 30 Suppl 1:S38-41. [PMID: 25480723 PMCID: PMC4265223 DOI: 10.1007/s11606-014-3061-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Information collection, storage, and management is central to the practice of health care. For centuries, patients' and providers' expectations kept medical records confidential between providers and patients. With the advent of electronic health records, patient health information has become more widely available to providers and health care managers and has broadened its potential use beyond individual patient care. Adhering to the principles of Fair Information Practice, including giving patients control over the availability and use of their individual health records, would improve care by fostering the sharing of sensitive information between patients and providers. However, adherence to such principles could put patients at risk for unsafe care as a result of both missed opportunities for providing needed care as well as provision of contraindicated care, as it would prevent health care providers from having full access to health information. Patients' expectations for the highest possible quality and safety of care, therefore, may be at odds with their desire to limit provider access to their health records. Conversely, provider expectations that patients would willingly seek care for embarrassing conditions and disclose sensitive information may be at odds with patients' information privacy rights. An open dialogue between patients and providers will be necessary to balance respect for patient rights with provider need for patient information.
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Affiliation(s)
- Kelly Caine
- Clemson University School of Computing, Clemson, SC, USA
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5
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Affiliation(s)
- Sandra Crouse Quinn
- a Minority Health Research Laboratory in the Department of Health Education , University of Maryland , College Park , MD , 20742 , USA
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6
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Forbes A. Recommendations from "Bringing Gender Home: Implementing Gender-Responsive HIV/AIDS Programming for U.S. Women and Girls". Womens Health Issues 2012; 21:S227-36. [PMID: 22055673 DOI: 10.1016/j.whi.2011.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Accepted: 07/25/2011] [Indexed: 11/25/2022]
Affiliation(s)
- Anna Forbes
- DHHS Office on Women's Health, Kensington, Maryland, USA.
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7
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A systematic review and comparison of HIV contact tracing laws in Canada. Health Policy 2011; 103:111-23. [PMID: 21871687 DOI: 10.1016/j.healthpol.2011.07.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2010] [Revised: 07/23/2011] [Accepted: 07/26/2011] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Public health officials and health providers need to be aware of the legislation documenting contact tracing in their jurisdiction to advise HIV positive clients of their rights, and to systematically perform their duties. The objective is to outline and compare the contact tracing laws in 13 jurisdictions in Canada, and to provide policy recommendations. METHODS A systematic review was performed to outline and compare the laws in Canadian jurisdictions regarding HIV contact tracing. Specific manual searches were done in websites of Canadian provincial and territorial departments of health. RESULTS For thirteen provinces and territories within Canada eleven laws were found. No laws directly pertaining to partner notification or contact tracing were found in Newfoundland and Labrador or Quebec. CONCLUSIONS Public health officials should ensure that contact tracing practices and policies accurately reflect the current regulations without compromising their patients' confidentiality. It is recommended that each province/territory would benefit from standardized contact tracing regulations which are imbedded in communicable disease legislation. Regulations with provisions for informed consent, confidentiality, multiple counselling sessions, clear procedures in duty to warn cases, and domestic violence screening would be considered best practice.
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8
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Markovitz AR, Thibault CS, Brandauer PW, Buskin SE. Primary Antiretroviral Drug Resistance in Newly Human Immunodeficiency Virus-Diagnosed Individuals Testing Anonymously and Confidentially. Microb Drug Resist 2011; 17:283-9. [DOI: 10.1089/mdr.2010.0066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Amanda R. Markovitz
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
- Blue Cross Blue Shield of Michigan, Southfield, Michigan
| | | | | | - Susan E. Buskin
- Public Health—Seattle and King County, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
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9
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Reed JB, Hanson D, McNaghten A, Bertolli J, Teshale E, Gardner L, Sullivan P. HIV testing factors associated with delayed entry into HIV medical care among HIV-infected persons from eighteen states, United States, 2000-2004. AIDS Patient Care STDS 2009; 23:765-73. [PMID: 19694550 DOI: 10.1089/apc.2008.0213] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Despite the importance of timely entry into care after HIV diagnosis, the timing of care entry has not been described recently in a large, diverse population of persons with HIV. Dates of HIV diagnosis and entry into HIV care were obtained by interview of HIV-infected adults, most of whom had entered care for HIV, in 18 U.S. states from 2000 through 2004. Time to care entry was analyzed as a dichotomous variable; delayed care entry was defined as care entry greater than 3 months after HIV diagnosis. Multivariable logistic regression models were used to describe HIV testing-related factors associated with delayed care entry. Among 3942 respondents, 28% had delayed care entry. Diagnostic testing-related characteristics associated with delayed care entry included anonymous and first-time HIV testing. Providers of HIV testing should be aware that those who test positive anonymously and those whose first HIV test is positive may have increased risk for delayed HIV care entry. Developing programs that reinforce timely linkage to HIV care, targeted at those at increased risk for delaying care entry, should be a public health priority.
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Affiliation(s)
- J. Bailey Reed
- Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia
| | - Debra Hanson
- Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia
| | - A.D. McNaghten
- Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia
| | - Jeanne Bertolli
- Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia
| | - Eyasu Teshale
- Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia
| | - Lytt Gardner
- Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia
| | - Patrick Sullivan
- Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia
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10
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Anonymous HIV testing with participant-controlled access to results using handheld computers: a new model of HIV testing used in a household survey in rural South Africa. Sex Transm Dis 2008; 35:372-6. [PMID: 18362858 DOI: 10.1097/olq.0b013e31815fd3fc] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Tesoriero JM, Battles HB, Heavner K, Leung SYJ, Nemeth C, Pulver W, Birkhead GS. The effect of name-based reporting and partner notification on HIV testing in New York State. Am J Public Health 2008; 98:728-35. [PMID: 18356570 DOI: 10.2105/ajph.2007.092742] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined the effect of New York's HIV Reporting and Partner Notification law on HIV testing levels and on the HIV testing decisions of high-risk individuals. METHODS In-person interviews were administered to 761 high-risk individuals to assess their knowledge, attitudes, and behaviors regarding HIV testing and reporting. Trends in HIV testing were also assessed in publicly funded HIV counseling and testing programs, Medicaid, and New York's Maternal Pediatric Newborn Prevention and Care Program. RESULTS High-risk individuals had limited awareness of the reporting and notification law, and few cited concern about named reporting as a reason for avoiding or delaying HIV testing. HIV testing levels, posttest counseling rates, and anonymous-to-confidential conversion rates among those who tested HIV positive were not affected by the law. Medicaid-related HIV testing rates also remained stable. HIV testing during pregnancy continued to trend upward following implementation of the law. Findings held true within demographic and risk-related subgroups. CONCLUSIONS HIV reporting has permitted improved monitoring of New York's HIV/AIDS epidemic. This benefit has not been offset by decreases in HIV testing behavior, including willingness to test among those at high risk of acquiring HIV.
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Affiliation(s)
- James M Tesoriero
- Office of Program Evaluation and Research, AIDS Institute, New York State Department of Health, Riverview Center, 150 Broadway, Suite 516, Menands, NY 12204, USA.
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12
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Tesoriero JM, Battles HB, Heavner K, Leung SYJ, Nemeth C, Pulver W, Birkhead GS. The Effect of Name-Based Reporting and Partner Notification on HIV Testing in New York State. Am J Public Health 2008. [DOI: 10.2105/ajph.2006.092742] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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13
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Rosser BRS, Horvath KJ. Predictors of success in implementing HIV prevention in rural America: a state-level structural factor analysis of HIV prevention targeting men who have sex with men. AIDS Behav 2008; 12:159-68. [PMID: 17440806 PMCID: PMC3719399 DOI: 10.1007/s10461-007-9230-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2006] [Accepted: 03/14/2007] [Indexed: 10/23/2022]
Abstract
Relatively few studies have examined the impact of modifying structural factors on HIV prevention efforts in the United States despite their high potential for lowering HIV prevalence rates. The aim of this study was to identify state-level characteristics of successful HIV prevention implementation. Structured interviews with 73 key informants in 13 rural states identified 'more successful' and 'less successful' states in HIV prevention. States were compared on demographic, religious, gay community, and funding variables. The 7 more successful states had both a wider variety and more MSM-targeted interventions. Overall funding, degree of epidemic, and "ruralness" were not significantly associated with success. Rather, successful states had less religious and Evangelical Protestant adherents and more 'gay community' infrastructure. They also spent a greater proportion of funds contracting community-based organizations and on MSM-targeted programming. Success in HIV prevention varies across rural states. Key demographic, social and economic indicators distinguish success in HIV prevention.
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Affiliation(s)
- B R Simon Rosser
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, 1300 S. 2nd St., Suite 300, Minneapolis, MN 55454, USA.
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14
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Grusky O, Roberts KJ, Swanson AN, Joniak E, Leich J, McEvoy G, Murphy K, Schilt K, Wilson V. Anonymous versus confidential HIV testing: client and provider decision making under uncertainty. AIDS Patient Care STDS 2005; 19:157-66. [PMID: 15798383 DOI: 10.1089/apc.2005.19.157] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Six intensive observational studies of HIV testing sites were undertaken in order to improve understanding of confidential and anonymous testing. Three sites offered only confidential testing (a large health maintenance organization's Urgent Care clinic, the same organization's HIV clinic, and a private medical practitioner's office), one offered only anonymous testing (a free clinic), and two offered a choice of confidential or anonymous testing (a thrift shop alternate testing site and a mobile testing unit). Multiple data collection strategies were used including direct field observation, semistructured interviews with clients and providers, and document and policy analysis. Using an organizational/interactional uncertainty framework, this study found that the choice between anonymous and confidential testing is a central aspect of the HIV testing process, that some clients are unclear about the differences between anonymous and confidential testing, that alternate testing sites' providers play a significant role in encouraging confidential rather than anonymous testing in order to further their organization's resource needs and public health goals, and that testing counselors' may consider that some clients prefer anonymous testing because of fear of stigma, discrimination, or loss of privacy.
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Affiliation(s)
- Oscar Grusky
- Department of Sociology, University of California, Los Angeles, Los Angeles, California 90095-1551, USA.
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15
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Muula AS, Mfutso-Bengo JM. Important but neglected ethical and cultural considerations in the fight against HIV/AIDS in Malawi. Nurs Ethics 2004; 11:479-88. [PMID: 15362357 DOI: 10.1191/0969733004ne726oa] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Southern African countries have the highest HIV infection rates in the world. In most of the countries in the region, the rate among adults is at least 10%. The fight against HIV/ AIDS has mostly been inadequate owing to the lack of proper consideration of ethical and cultural issues. In this article, the authors discuss the ethical and cultural dilemmas concerning HIV/AIDS, with Malawi as a case in point. It is argued that increasing financial resources alone, as exemplified by the Global Fund to Fight AIDS, Tuberculosis and Malaria initiative, without proper attention to ethical issues, morals and appropriate legal obligations, are unlikely to reduce the spread of HIV in southern Africa.
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Affiliation(s)
- Adamson S Muula
- Department of Community Health, University of Malawi College of Medicine, Private Bag 360, Blantyre 3, Malawi.
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Abstract
OBJECTIVE To lay the groundwork for a better understanding of patient views on medical confidentiality. DESIGN Studies were found by searching medline, bioethicsline, and selected bibliographies. Articles concerning physician perspectives or implications of legal and administrative regulations were excluded. Only peer-reviewed journal articles reporting original research on patients' confidentiality views and conduct were included. MAIN RESULTS Many patients are unaware of or misunderstand their legal or ethical right to medical confidentiality protections, which leads them to both over- and underestimate confidentiality protections. The possibility that medical information might be revealed, intentionally or not, to acquaintances in a clinic or other social community troubles patients as much as information release to insurers or employers. A significant minority of patients distrust confidentiality protections, leading some to report that they delay or forgo medical care. If doubtful that confidentiality will be upheld, patients will act independently to protect information. CONCLUSIONS Our review found a wider variety of understandings and beliefs about medical confidentiality among patients than are often indicated in the writings of practitioners or legal experts. As medical confidentiality regulations evolve, these differences need to be recognized and accounted for in interactions between practitioners and patients.
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Affiliation(s)
- Pamela Sankar
- Center for Bioethics, University of Pennsylvania, Philadelphia, PA 19104-3308, USA.
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17
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Ellen JM, Bonu S, Arruda JS, Ward MA, Vogel R. Comparison of clients of a mobile health van and a traditional STD clinic. J Acquir Immune Defic Syndr 2003; 32:388-93. [PMID: 12640196 DOI: 10.1097/00126334-200304010-00007] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The objective of this study was to determine if there were any demographic, behavioral, and clinical differences between clients seen aboard a mobile sexually transmitted disease (STD)/HIV clinic compared with those seen in a traditional municipal STD/HIV health clinic for receipt of STD/HIV services. Clients seen in the two different settings were interviewed about demographic characteristics, reasons for their visit, STD history, their HIV/STD risk factors, and the risk factors of their sex partners. Clients in both settings were also offered testing for syphilis, gonorrhea, chlamydia, and HIV. Results suggested that clients seen at the mobile clinic were older, more likely to be injecting drug users themselves and/or to have sex partners who were, or had engaged in prostitution for money or drugs. Over half (54.4%) of the mobile clinic clients sought testing for HIV, and they were far less likely to be seeking care for symptoms of an STD. In contrast, only 7.1% of municipal clinic clients indicated HIV testing as the reason for their visit, whereas nearly two thirds (64.5%) reported symptoms of disease. Two percent of municipal clinic clients and 5.4% of mobile clinic clients had a positive HIV test ( p<.001), and 17.8% of STD clinic clients and 5.6% of mobile van clients had a positive gonorrhea and/or test ( p<.001). These data suggest that a mobile STD/HIV clinic may be an effective strategy to reach individuals at high risk for HIV who are not being served by traditional municipal STD/HIV health clinics.
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Affiliation(s)
- Jonathan M Ellen
- Department of Pediatrcs, Johns Hopkins University School of Medicine Institute, Baltimore,Maryland 21287, USA.
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18
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Detection of Hepatitis C Antibody With At-Home Collection Kits Using an Innovative Laboratory Algorithm. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2001. [DOI: 10.1097/00019048-200112000-00004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Lazebnik R, Hermida T, Szubski R, Dieterich-Colón S, Grey SF. The proportion and characteristics of adolescents who return for anonymous HIV test results. Sex Transm Dis 2001; 28:401-4. [PMID: 11460024 DOI: 10.1097/00007435-200107000-00007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The proportion of adolescents who return for HIV test results varies widely, and knowledge of what characteristics affect their return is limited. GOAL To quantify the proportion of adolescents who return for results of anonymous HIV tests, and to identify the characteristics that predict their return. STUDY DESIGN This retrospective study evaluated 285 adolescents consenting to anonymous HIV tests in an urban clinic that provides medical services free of charge without eligibility requirements to a mostly working, uninsured population. RESULTS Of the adolescents studied, 42% returned for test results. Three characteristics independently predicted their return: (1) coming to the clinic only for HIV testing, (2) having private health insurance, and (3) engaging in unprotected sex while using drugs or alcohol. CONCLUSIONS Except for having unprotected sex while using drugs or alcohol, the characteristics that placed adolescents at risk for HIV infection did not predict their return for test results. Given the low return rate for anonymous testing in this setting, confidential testing, which permits follow-up evaluation of those failing to return for test results, should be considered.
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Affiliation(s)
- R Lazebnik
- Department of General Academic Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Cleveland, Ohio 44106-6019, USA
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20
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Burris S. Surveillance, social risk, and symbolism: framing the analysis for research and policy. J Acquir Immune Defic Syndr 2000; 25 Suppl 2:S120-7. [PMID: 11256732 DOI: 10.1097/00042560-200012152-00006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Name-based surveillance for HIV, considered alone, is a useful public health measure; its benefits outweigh its direct costs. There is little evidence that name-based surveillance directly deters individuals at risk of HIV from being tested, or exposes them to significant social risks. Yet such surveillance is chronically controversial. Understood in a broader context of the social risks and symbolic politics of HIV, as subjectively experienced by people at risk, this opposition is both rational and instructive. Although often discussed, the social risks of HIV infection are poorly understood. To the extent these risks have been addressed by privacy and antidiscrimination laws, the solution has been less complete than many public health professionals appear to believe: developments in law and policy, including the increasing prevalence of criminal HIV transmission laws and proposed changes in HIV testing and counseling standards, are contextual factors that help explain the opposition to name-based surveillance. Rather than focusing piecemeal on specific "barriers" to testing and care, an appreciation of the surveillance debate in context suggests a positive undertaking in public health policy to provide the conditions of opportunity, information, motivation and confidence that people with HIV need to accept an effective program of early intervention.
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Affiliation(s)
- S Burris
- Temple University Beasley School of Law, Temple University, Philadelphia, Pennsylvania 19122, USA.
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21
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Surveillance, Social Risk, and Symbolism: Framing the Analysis for Research and Policy. J Acquir Immune Defic Syndr 2000. [DOI: 10.1097/00126334-200012152-00006] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
INTRODUCTION HIV-prevention behavior is affected by the environment as well as by characteristics of individuals at risk. HIV-related structural factors are defined as barriers to, or facilitators of, an individual's HIV prevention behaviors; they may relate to economic, social, policy, organizational or other aspects of the environment. IMPACT OF STRUCTURAL INTERVENTIONS A relatively small number of intervention studies demonstrates the potential of structural interventions to increase HIV prevention in the United States and internationally. The promise of structural interventions has also been shown in studies of interventions to prevent disease or promote public health in areas other than HIV. FRAMEWORK OF STRUCTURAL FACTORS Frameworks help define and exemplify structural barriers and facilitators for HIV prevention. One framework developed at Centers for Disease Control and Prevention gives examples of structural facilitators in terms of the economic resources, policy supports, societal attitudes, and organizational structures and functions associated with governments, service organizations, businesses, workforce organizations, faith communities, justice systems, media organizations, educational systems, and healthcare systems. Frameworks should assist researchers and health officials to identify important areas for structural research and programming. CONCLUSIONS A structural approach is timely and innovative. Despite limitations, including the challenge of a new perspective on prevention and the difficulty of evaluating their effects, researchers and public health officials are urged to pursue structural interventions to prevent HIV.
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Affiliation(s)
- E Sumartojo
- Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA
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23
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Lobato MN, Klevens RM, Li J, Slutsker L, Fleming PL. Unreported AIDS-defining opportunistic illnesses in persons reported with HIV-related severe immunosuppression. J Acquir Immune Defic Syndr 1999; 22:71-4. [PMID: 10534149 DOI: 10.1097/00042560-199909010-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
To better estimate the distribution of AIDS cases after the 1993 change in the case definition, we assessed the proportion of persons whose AIDS diagnosis was based on laboratory criteria for severe immunosuppression (CD4 count <200 cells/microl or <14%) and who also had an unreported opportunistic illness (OI) at the time of the CD4 report. Five U.S. reporting sites (Arizona; Los Angeles County, California; New Jersey; Oregon; and Washington State) reviewed AIDS cases reported between January 1 and June 30, 1993. From these sites, 3289 immunologic cases were reported; of these cases, 322 (9.8%; range, 1.6%-16.1%) were in persons who had an unreported OI. More of those who had an unreported OI were male, members of racial groups other than white, injection drug users, and had a CD4 count of <50 cells/microl at AIDS diagnosis. Because of recent advances in OI prophylaxis and treatment of HIV infection, studies monitoring HIV-related morbidity should assess the occurrence of OIs in a sample of persons reported with HIV and severe immunosuppression. Such assessment will ensure representative ascertainment of initial AIDS-defining OIs and thus improve the usefulness of the data for public health planning and the allocation of resources for patient care.
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Affiliation(s)
- M N Lobato
- Division of HIV/AIDS Prevention-Surveillance and Epidemiology, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA
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Woods WJ, Dilley JW, Lihatsh T, Sabatino J, Adler B, Rinaldi J. Name-based reporting of HIV-positive test results as a deterrent to testing. Am J Public Health 1999; 89:1097-100. [PMID: 10394324 PMCID: PMC1508832 DOI: 10.2105/ajph.89.7.1097] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES This study evaluated attitudes toward name-based reporting of HIV. METHODS One hundred thirty high-risk, male repeat testers received information on the public health benefits of name-based reporting and reported their intentions to test. RESULTS Of the 67 men who were randomly selected and asked their intentions before hearing the benefits, 63% said they would not test if reporting were required. After hearing the benefits, 19% changed their minds (P < .014). Of the 63 men who were asked only after hearing the benefits, 44% would not test. CONCLUSIONS Implementing name-based reporting without working before-hand to change attitudes could undermine the benefits of both testing and HIV surveillance.
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Affiliation(s)
- W J Woods
- University of California San Francisco, Center for AIDS Prevention Studies 94105, USA.
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Berger SG, Hong BA, Eldridge S, Connor D, Vedder KN. Return rates and partner notification in HIV-positive men seeking anonymous versus confidential antibody testing. AIDS Patient Care STDS 1999; 13:363-8. [PMID: 10842857 DOI: 10.1089/apc.1999.13.363] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This study investigated whether HIV-positive men who seek confidential versus anonymous HIV counseling and testing differ in demographic variables, risk behaviors, return rates for posttest appointments, and agreement to partner notification. chi 2 tests were not statistically significant for return rates for post-test appointments or partner notification between the two groups. HIV-positive individuals in the confidential groups were more likely to utilize medical and follow-up services than those in the anonymous group. Anonymous and confidential counseling and testing both appear to achieve the public health objectives of HIV case finding and referral. Hypotheses are offered regarding what may be a progression of testing behaviors (i.e., from anonymous to confidential) with suggestions for future research are suggested.
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Affiliation(s)
- S G Berger
- AIDS Clinical Trials Unit, Washington University School of Medicine, St. Louis, Missouri, USA
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26
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Abstract
With more treatment options emerging for human immunodeficiency virus (HIV) infection, the policy of reporting HIV-infected individuals by name merits reevaluation. This paper reviews the benefits and risks of name reporting of persons infected with HIV. Public health departments have linked name reporting with medical referrals, risk reduction counseling, and partner notification programs. Yet some studies indicate that people are less likely to be tested for HIV infection when name reporting is implemented. Whether name reporting actually improves individual or public health, therefore justifying the increased risk of loss of confidentiality and possibly reduced testing rates, remains unknown. The lack of health outcome data on name reporting allows beliefs rather than facts to dominate debate about this policy. Before this practice is more widely adopted, a determination should be made as to whether the potential benefits of name reporting outweigh the risks.
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Affiliation(s)
- G N Colfax
- San Francisco Department of Public Health, AIDS Office, CA 94102-6033, USA.
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Gostin LO, Ward JW, Baker AC. National HIV case reporting for the United States. A defining moment in the history of the epidemic. N Engl J Med 1997; 337:1162-7. [PMID: 9329940 DOI: 10.1056/nejm199710163371611] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- L O Gostin
- Georgetown University Law Center, Washington, DC 20001, USA
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Hertz-Picciotto I, Lee LW, Hoyo C. HIV test-seeking before and after the restriction of anonymous testing in North Carolina. Am J Public Health 1996; 86:1446-50. [PMID: 8876517 PMCID: PMC1380659 DOI: 10.2105/ajph.86.10.1446] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This study assessed the impact on HIV test-seeking of North Carolina's restriction of anonymous testing to 18 of its 100 counties as of September 1, 1991. METHODS Trends from 4 months prerestriction to the 16-month restriction period in counties retaining vs counties eliminating anonymous testing were compared. RESULTS HIV testing increased throughout the state, but more rapidly where anonymous testing was retained than elsewhere: 64% vs 44%. These differences held for all sociodemographic subgroups and were most pronounced among adolescents and African Americans and other non-Whites. CONCLUSIONS The data are consistent with a detrimental effect of elimination of anonymous testing, although confounding from differences in AIDS awareness or in repeat tests is possible.
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Affiliation(s)
- I Hertz-Picciotto
- Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill 27599-7400, USA
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Affiliation(s)
| | - Margaret Scott
- National HIV Education Program for DoctorsAustralasian Society for HIV MedicineSydneyNSW
| | - Susan S Irvine
- National HIV Education Program for DoctorsAustralasian Society for HIV MedicineSydneyNSW
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30
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Magnusson RS. Australian HIV/AIDS legislation: a review for doctors. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 1996; 26:396-406. [PMID: 8811215 DOI: 10.1111/j.1445-5994.1996.tb01929.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Hirano D, Gellert GA, Fleming K, Boyd D, Englender SJ, Hawks H. Anonymous HIV testing: the impact of availability on demand in Arizona. Am J Public Health 1994; 84:2008-10. [PMID: 7998649 PMCID: PMC1615379 DOI: 10.2105/ajph.84.12.2008] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The purpose of this study was to evaluate the impact of anonymous testing availability on human immunodeficiency virus (HIV) test demand in Arizona. Testing patterns before and after the introduction of anonymous testing were compared. Client knowledge of new test policy and delay in testing until an anonymous option was available were assessed. Test numbers among men who have sex with men showed a statistically significant increase after introduction of an anonymous testing option. Arizona continues to maintain anonymous testing availability. Public health agencies should consider how test policy may influence people's HIV test decisions.
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Affiliation(s)
- D Hirano
- Arizona Department of Health Services, Phoenix 85007
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Abstract
Privacy and confidentiality are critical issues for people with HIV (human immunodeficiency virus) infection or AIDS (acquired immune deficiency syndrome). This paper reports on a series of 80 detailed interviews conducted in five cities in Australia and New Zealand, within a variety of organisations specialising in the provision of HIV testing and HIV/AIDS treatment services. The aim of the interviews was to survey current practices and procedures relating to the handling of HIV-related health information, and to sample on an informal basis the attitudes of health professionals and HIV-positive persons to specific privacy issues arising with respect to HIV/AIDS health care. The interviews revealed numerous practical issues, innovative procedures, and problems that are of direct relevance to the provision of HIV/AIDS health care services, and to medical practice generally. Despite the genuine commitment to privacy evidenced by most interviewees, the range of examples of careless and blatant breaches of confidentiality indicated by interviewees underscores the need for a concerted effort by those handling HIV information to adhere to legal and professional standards.
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Affiliation(s)
- R S Magnusson
- Faculty of Law, University of Melbourne, Parkville, Vic
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Tveit KS, Nyfors A, Nilsen A. HIV-seropositive rate and HIV test activity among STD clinic attendees in Bergen, Norway. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 1994; 26:511-6. [PMID: 7855548 DOI: 10.3109/00365549409011808] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
We wanted to determine the HIV seropositive rate and to study the connection between previous HIV testing, acceptance of HIV testing and sexual behaviour among STD clinic patients in Bergen, Norway. Patients attending the STD clinic in 1986-93 requesting HIV testing were registered, and all patients visiting the clinic in April-June 1989 received a questionnaire and were asked if they wanted to be HIV tested. The overall HIV seropositive rate was 0.4% (14/3805); in homo-/bisexual men: 2.9% (8/278); IVDUs: 0.4% (1/236) and in heterosexual non-IVDUs: 0.2% (5/3291). Among the 599 individuals offered anonymous HIV testing, 42.2% were HIV tested and 69.2% did not object to HIV-testing. IVDUs/prostitutes (p < 0.001), customers of prostitutes (p < 0.001), homo-/bisexuals (p < 0.01), and patients receiving blood transfusion (p < 0.005) had all been HIV tested more frequently than 'other heterosexuals'. Respondents reporting casual sex, casual sex abroad, infection with STDs, and a greater number of partners were more frequently HIV tested and also accepted HIV testing more frequently than respondents without such behaviour, indicating that there is some rationale behind the decision to be tested.
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Affiliation(s)
- K S Tveit
- Department of Dermatology, Haukeland University Hospital, Bergen, Norway
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Doyle M, Taylor RJ. Prevalence of human immunodeficiency virus risk factors in patients attending an accident and emergency department. Arch Emerg Med 1992; 9:196-202. [PMID: 1388496 PMCID: PMC1285860 DOI: 10.1136/emj.9.2.196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The prevalence of human immunodeficiency virus (HIV) risk factors was evaluated by questionnaire survey in 1565 consecutive patients who attended an adult A&E department in Brisbane over a 2-month period. The survey revealed that a total of 144 (9.2%) patients could be considered at risk of HIV infection (high-risk group) because of known seropositivity, admission to HIV high-risk factors or engaging in high-risk activities. The remaining 1421 patients who did not acknowledge any high-risk behaviour were classified as an 'unknown-risk' group. More than 70% of the HIV high-risk patient group were under the age of 30 years. A total of 275 (17.6%) patients presented with open wounds and/or needed hospitalization (23 [1.5%] high-risk patients). Of the 490 respondents who engaged in short term sexual relationships, 310 (63.3%) practised unprotected coitus, 32 of these including four seropositives were classified in the high-risk group. The patients were asked if they were in favour of an HIV testing service at their local A&E department; 1324 (86.6%) were in agreement 121 of whom were in the high-risk group. There was no significant difference (chi 2 = 0.093: P greater than 0.7) in opinion between the 'unknown risk' and high-risk patient groups on this matter.
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Affiliation(s)
- M Doyle
- Accident and Emergency Department, Hope Hospital, Salford
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Goldberg DJ, Johnstone FD. HIV testing programmes in pregnancy. BAILLIERE'S CLINICAL OBSTETRICS AND GYNAECOLOGY 1992; 6:33-51. [PMID: 1633659 DOI: 10.1016/s0950-3552(05)80116-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Landis SE, Schoenbach VJ, Weber DJ, Mittal M, Krishan B, Lewis K, Koch GG. Results of a randomized trial of partner notification in cases of HIV infection in North Carolina. N Engl J Med 1992; 326:101-6. [PMID: 1445500 DOI: 10.1056/nejm199201093260205] [Citation(s) in RCA: 148] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND We sought to compare two methods of notifying sex partners of subjects infected with the human immunodeficiency virus (HIV) or persons who had shared needles with them (needle-sharing partners): "patient referral," in which the responsibility for notifying partners was left to the patient, and "provider referral," in which providers attempted to notify partners. METHODS Names of sex partners and needle-sharing partners and information on how to locate them were obtained from consenting HIV-infected subjects identified in the HIV-testing programs at three public health departments in North Carolina. The subjects were randomly assigned to a patient-referral group (in which patients had the initial responsibility for notifying their partners) or a provider-referral group (in which the study counselor notified the partners). The success of attempts to notify partners was monitored by means of interviews with counselors conducted both in the field and at the health department. RESULTS Of 534 HIV-positive persons identified at the health departments, 247 (46 percent) did not return for counseling after the test, 8 were counseled outside the study, and 117 (22 percent) were ineligible. Of the 162 invited to participate, 88 (54 percent) declined and 74 (46 percent) agreed. The subjects were mostly male (69 percent), black (87 percent), homosexual or bisexual (76 percent of the men), and had a median age of 30 years. Thirty-nine were assigned to the provider-referral group and 35 to the patient-referral group. In the provider-referral group 78 of 157 partners (50 percent) were successfully notified, whereas in the patient-referral group only 10 of 153 (7 percent) were notified. Of the partners notified by the counselors, 94 percent were not aware that they had been exposed to HIV. Overall, 23 percent of the partners notified and tested were HIV-positive. CONCLUSIONS In this trial, leaving the notification of partners up to the subjects (patient referral) was quite ineffective, despite the North Carolina law requiring that partners be notified. Partner notification by public health counselors (provider referral) was significantly more effective. Although the effectiveness of notification procedures is constrained by the accuracy of the information provided by HIV-infected patients, counselors who notify the partners of an infected patient can refer them to educational, medical, and support services targeted to persons at high risk for HIV infection and may encourage the adoption of less risky behavior.
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Affiliation(s)
- S E Landis
- Department of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill
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Lo B. Ethical dilemmas in HIV infection: what have we learned? LAW, MEDICINE & HEALTH CARE : A PUBLICATION OF THE AMERICAN SOCIETY OF LAW & MEDICINE 1992; 20:92-103. [PMID: 1630147 DOI: 10.1111/j.1748-720x.1992.tb01176.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The acquired immunodeficiency syndrome (AIDS) has raised perplexing ethical and public policy dilemmas. Early in the epidemic, closing of bathhouses, testing blood donors for human immunodeficiency virus (HIV) infection, and notifying seropositive blood donors evoked passionate controversies. Current dilemmas include testing and using promising new treatments, notifying partners of seropositive persons, and, most recently, restricting the clinical activities of seropositive health,care workers who perform invasive procedures.These dilemmas about HIV infection involve scientific judgments, cultural norms, and social values. In the HIV epidemic, public rhetoric and political pressure have been prominent. On the one hand, some persons have launched moralistic crusades against homosexuals and injection drug users. For these persons, AIDS symbolizes the breakdown of traditional family values and the social order. On the other hand, some advocates for persons with HIV infection have used confrontational tactics such as sit-ins and disruptive demonstrations.
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Rodos JJ. The NHSC mandate. Am J Public Health 1991; 81:1213. [PMID: 1951840 PMCID: PMC1405630 DOI: 10.2105/ajph.81.9.1213-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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40
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Lo B. Clinical ethics and HIV-related illnesses: issues in treatment and health services research. MEDICAL CARE REVIEW 1991; 47:15-32. [PMID: 10106524 DOI: 10.1177/107755879004700103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- B Lo
- University of California, San Francisco
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Danila RN, Shultz JM, Osterholm MT, Henry K, Simpson ML, MacDonald KL. HIV-1 counseling and testing sites, Minnesota: analysis of trends in client characteristics. Am J Public Health 1990; 80:419-22. [PMID: 2316761 PMCID: PMC1404588 DOI: 10.2105/ajph.80.4.419] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We report here a summary of the data obtained from two HIV-1 antibody counseling and testing sites in Minneapolis-St. Paul for the first 48 months of operation (24,911 persons tested). The HIV-1 antibody seroprevalence rate for all persons tested was 5 percent. The highest seroprevalence rates were in male homosexual/bisexual intravenous drug users (23 percent) and homosexual/bisexual men (13 percent). There was a significant decrease in the HIV-1 antibody seroprevalence rate among clients during the 48-month period from 14 percent in the first six months to 3 percent in the last six months. This decrease coincided with an increase in the number of low-risk female clients and low-risk heterosexual male clients, and a decrease in the number of homosexual/bisexual males participating in the programs. These findings suggest the need for development and implementation of other strategies to identify and reach persons at highest risk for HIV-1 infection.
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Affiliation(s)
- R N Danila
- Acute Disease Epidemiology Section, Minnesota Department of Health, Minneapolis 55440
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Abstract
What is known about the biology of AIDS is reviewed, and the social factors which influence disease transmission and public attitudes are considered. After an evaluation of the methods available to control the epidemic, the reasons for the limited success of public health measures thus far undertaken are considered. The ethical debate on public health policy is analysed, and the need for a nationwide educational programme on AIDS is emphasised--one which is responsive to the rights and obligations of citizens in a democratic society.
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Affiliation(s)
- L Eisenberg
- Department of Social Medicine, Harvard Medical School, Boston, Massachusetts
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