Changes in sexually transmitted disease rates after HIV testing and posttest counseling, Miami, 1988 to 1989

Test and Prevent: Evaluation of a Pilot Program Linking Clients With Negative HIV Test Results to Pre-exposure Prophylaxis in Zimbabwe

BACKGROUND

As HIV testing increases worldwide, programs are reaching individuals without HIV infection who are at risk of exposure and may be candidates for oral pre-exposure prophylaxis (PrEP). Although linkage of individuals with HIV infection to treatment is a global priority (referred to as "test and treat"), less attention is given to individuals with negative HIV test results. We developed the "Test and Prevent" pilot program to intentionally link at-risk clients with negative HIV test results to PrEP services. The intervention included risk assessment of all clients with a negative result from HIV testing (with national risk assessment tool), accompanied referral, fast-tracking, and targeting follow-up.

METHODS

The intervention was conducted in Bulawayo, Zimbabwe, at 6 public sector sites from October 2019 to February 2020. We collected routine monitoring data from all study sites and tracked referral completion and PrEP initiation among clients who enrolled. We conducted in-depth interviews with providers (n=12), facility managers (n=5), and female clients (n=17) to explore acceptability.

RESULTS

Among clients referred for PrEP (n=206), 98% completed their referrals and started PrEP. However, only 3% of clients who received a negative test result during the study period were referred. Low referrals stemmed from lack of screening (39% of clients with negative HIV test results were not screened) and lack of eligibility among clients who were screened (only 6% of those screened qualified as candidates for PrEP per the national screening tool). Qualitative results indicate that some providers purposefully did not complete screening with clients they felt were not at risk and that workload could have contributed to low screening uptake.Qualitative interviews showed that Test and Prevent was acceptable among both providers and clients. Clients were happy to learn about PrEP following HIV testing, and the additional support of accompanied referrals and fast-tracking encouraged them to access PrEP and made them feel valued. Providers were burdened by workload constraints but felt that Test and Prevent was important and should be scaled to other sites.

CONCLUSION

Intentionally linking clients with negative results to PrEP immediately following HIV testing was found to be acceptable from both provider and client perspectives, yet screening procedures need closer examination and reinforcement for the program to realize a larger impact.

Impact of Counseling Methods on HIV Retesting Uptake in At-Risk Individuals: A Randomized Controlled Study

Systematic face-to-face pre-HIV test counseling is costly and may discourage clients to present for regular testing. In a randomized, controlled, non-inferiority trial conducted in four facilities providing free-of-charge anonymous HIV testing in Thailand, participants received either: standard counseling according to national guidelines (reference); computer-assisted counseling: interactive counseling on a tablet computer followed by an invitation to ask questions to the counselor; or on-demand counseling: invitation to ask questions to the counselor. Primary endpoint was a HIV retest within 7 months after enrolment visit. Following the planned interim analysis, on-demand counseling was discontinued for futility. In the final analysis in 1036 HIV-uninfected at-risk participants, computer-assisted counseling was non-inferior to standard counseling and had similar acceptability and improvements in HIV knowledge and sexual risk behaviors; however, it significantly reduced the time spent by counselors on counseling. Implementation of pre-HIV test computer-assisted counseling may ease the burden on staff involved in HIV testing.

As through a glass, darkly: the future of sexually transmissible infections among gay, bisexual and other men who have sex with men

The trajectory of sexually transmissible infection (STI) incidence among gay and other men who have sex with men (MSM) suggests that incidence will likely remain high in the near future. STIs were hyperendemic globally among MSM in the decades preceding the HIV epidemic. Significant changes among MSM as a response to the HIV epidemic, caused STI incidence to decline, reaching historical nadirs in the mid-1990s. With the advent of antiretroviral treatment (ART), HIV-related mortality and morbidity declined significantly in that decade. Concurrently, STI incidence resurged among MSM and increased in scope and geographic magnitude. By 2000, bacterial STIs were universally resurgent among MSM, reaching or exceeding pre-HIV levels. While the evidence base necessary for assessing the burden STIs among MSM, both across time and across regions, continues to be lacking, recent progress has been made in this respect. Current epidemiology indicates a continuing and increasing trajectory of STI incidence among MSM. Yet increased reported case incidence of gonorrhoea is likely confounded by additional screening and identification of an existing burden of infection. Conversely, more MSM may be diagnosed and treated in the context of HIV care or as part of routine management of pre-exposure prophylaxis (PrEP), potentially reducing transmission. Optimistically, uptake of human papillomavirus (HPV) vaccination may lead to a near-elimination of genital warts and reductions in HPV-related cancers. Moreover, structural changes are occurring with respect to sexual minorities in social and civic life that may offer new opportunities, as well as exacerbate existing challenges, for STI prevention among MSM.

"Late for testing, early for antiretroviral therapy, less likely to die": results from a large HIV cohort study in China, 2006-2014

BACKGROUND

Timely HIV testing and initiation of antiretroviral therapy are two major determinants of survival for HIV-infected individuals. Our study aimed to explore the trend of late HIV/AIDS diagnoses and to assess the factors associated with these late diagnoses in China between 2006 and 2014.

METHODS

We used data from the Chinese Comprehensive Response Information Management System of HIV/AIDS (CRIMS). All individuals who tested positive for HIV between 2006 and 2014 in China and were at least 15 years of age were included. A late diagnosis was defined as an instance in which an individual was diagnosed as having AIDS or WHO stage 3 or 4 HIV/AIDS, or had a CD4 cell count less than 200 cells/mm³ at the time of diagnosis.

RESULTS

Among the 528,234 individuals (≥15 years old) newly diagnosed with HIV between 2006 and 2014, 179,700 (34.0%) people were considered to have received late diagnoses. The late diagnosis rate decreased from 33.9% in 2006 to 29.7% in 2014 (P < 0.01). Late diagnoses were more likely to be found among those who were 45-54 years old (adjusted odds ratio [aOR]: 3.25, 95% confidence interval [CI]: 3.17-3.34) or 55+ years old (OR: 2.94, 95% CI: 2.86-3.02), male (aOR: 1.15, 95% CI: 1.13,1.17), employed as a farmer or rural laborer (aOR: 1.13, 95% CI: 1.11-1.14), infected through blood or plasma transfusion (aOR: 4.18, 95% CI: 4.02, 4.35), diagnosed at hospitals (OR: 1.17, 95% CI: 1.15, 1.19), of Han ethnicity (aOR: 1.30, 95% CI: 1.28, 1.32), and married (OR: 1.12, 95% CI: 1.11,1.13). Of those people living with HIV (PLHIV) who received late diagnoses, 7.4%(8637) and 46.1%(28,462) ultimately died with or without receiving antiretroviral therapy within a year of diagnosis, respectively.

CONCLUSION

A large proportion of individuals with HIV/AIDS receive late diagnoses, and this proportion has witnessed a slight decline in recent years. Expanded testing is needed to increase early HIV diagnosis and antiretroviral therapy should be recommended to all diagnosed individuals as early as possible to reduce AIDS-related death.

Reactions to Testing HIV Negative: Measurement and Associations with Sexual Risk Behaviour Among Young MSM Who Recently Tested HIV Negative

Receiving an HIV-positive test result is associated with reduced condomless anal sex (CAS), but little is known about negative test results. The recent development of the Inventory of Reactions to Testing HIV Negative confirmed that there are diverse reactions to receiving a negative test result, which have implications for risk behaviour. The goals of the current study were to validate the measure in a sample of young men who have sex with men who recently tested HIV-negative (N = 1113) and to examine its associations with CAS. Factor analysis identified four factors, three of which were the same as the original factors (Reinforced Safety, Luck, and Invulnerability) and one that was novel (Reinforced Risk). Construct validity was demonstrated with associations between subscales and constructs from the IMB model of HIV prevention. Lower Reinforced Safety and higher Luck and Reinforced Risk were associated with more CAS. Associations between Reinforced Safety and Luck with CAS were stronger for those who reported more lifetime HIV tests. Findings highlight the importance of reactions to testing HIV-negative and suggest that they become more important with repeated testing.

Sex-Related HIV Risk Reduction Behavior among Adolescents in DATOS-A

This study examines the effect of drug treatment on reducing HIV-related risky sex behavior among 796 adolescents entering drug treatment programs in four cities in the United States. More than half of the adolescents (54%) reported reductions in risky sex behavior after treatment. Conduct-disordered adolescents with abuse history, unmet physical and emotional needs, and low commitment to school were associated with lack of improvement. Furthermore, conduct-disordered adolescents who perceived treatment to be effective were more likely to show posttreatment improvement, with the exceptions that those who scored high on hostility or low in self-perception were not likely to improve. Among adolescents without conduct disorder, receipt of mental health services was associated with improvements in their risky sex behavior. The effect of drug treatment on HIV risk reduction can be increased when attention is focused on adolescents’ pretreatment risk factors, service needs, intreatment responses, and key personality characteristics.

Heterosexual Behavioral Maintenance and Change Following HIV Counseling and Testing

This study investigated heterosexual HIV risk behaviors, changes in stage of change for safer sex and factors associated with such changes, among a diverse sample of 560 heterosexually active individuals presenting at publicly funded HIV C&T sites. Questionnaires were administrated before HIV C&T, and three months afterwards. Positive serostatus was the most significant predictor of safer behavior after C&T. Many seronegative participants stopped sex with non-main partners. Behaviors with main partners were particularly resistant to change. Predictors of change varied by stage at pre-test. C&T services should tailor approaches and referrals based on stage of change and other client characteristics.

Testing negative means I'm lucky, making good choices, or immune: diverse reactions to HIV test results are associated with risk behaviors

BACKGROUND

HIV testing may lead to behavioral changes among some individuals, but no scale has been developed to assess potential mechanisms.

PURPOSE

We aimed to develop and evaluate the psychometric properties of a scale to measure psychological reactions to the receipt of a negative HIV test and explore the scale's associations with unprotected anal intercourse (UAI).

METHODS

Two focus groups were conducted to develop the Inventory of Reactions to Testing HIV Negative, which was subsequently tested on 725 men who have sex with men in the New York City area.

RESULTS

Factor analyses confirmed the presence of three subscales-Reinforced Safety, Invulnerability, and Luck. Regression analyses demonstrated that the subscales interacted with HIV testing behavior to influence UAI.

CONCLUSIONS

These findings support the notion that there is heterogeneity in how individuals respond to a negative HIV test, with some individuals subsequently being influenced towards increased engagement in HIV risk behaviors.

"Notify your partners--it's the law": HIV providers and mandatory disclosure

HIV care providers in the United States must counsel clients about disclosure to sexual partners and report anyone who is suspected of noncompliance. This study compared provider attitudes and practices in relation to counseling clients about mandatory disclosure in North Carolina and Alabama, the 2 states with similar HIV epidemiology but different laws for HIV control. Personal interviews were conducted with 20 providers in each state (n = 40). The results were analyzed in a qualitative, cross-comparison method to identify patterns of convergence or difference. Providers in both states believed that clients often failed to notify sexual partners and were secretive if questioned about disclosure. Differences in counseling styles and procedures for each state were noteworthy. Compared to Alabama, North Carolina had harsher penalties for nondisclosure, stricter and more standardized procedures for counseling, and providers expressed greater support for HIV criminalization. Although most North Carolina providers viewed the stricter standards as beneficial for HIV care and control, Alabama providers were likely to view such standards as a barrier to patient care. These results indicated a direct relation between state HIV law, provider attitudes, and counseling procedures for mandatory disclosure.

Occurrence of new sexually transmitted diseases in males after HIV diagnosis

Risk reduction following an HIV diagnosis is important for controlling the epidemic. The objective of this retrospective cohort study of 6,965 HIV-positive males was to evaluate the joint risk of new reportable STDs in males after HIV diagnosis by race/ethnicity and risk behavior. This investigation linked HIV case reports with STD surveillance, clinical care and laboratory datasets to determine new STD acquisition in HIV positive individuals.Compared to White MSM with high care engagement,Black MSM had a significantly higher rate of new reportable STDs for the full time period after HIV diagnosis, B1 year after diagnosis, and[1 year after diagnosis. High HIV care engagement was not as protective against new STD acquisition for Black MSM as it was for White MSM and reasons for this health disparity should be explored.

Patient characteristics and availability of onsite non-rapid and rapid HIV testing in US substance use disorder treatment programs

Racial and ethnic minorities and injection drug users (IDUs) are at increased risk of HIV infection. However, the associations between these caseload characteristics and the availability of onsite HIV testing in substance use disorder treatment programs are unknown. This study uses data collected in 2008-2009 from 198 program administrators of treatment programs participating in the National Institute on Drug Abuse's Clinical Trials Network to address this gap in the literature. Results show positive associations between the percentages of African American, Hispanic, and IDU patients and the odds of offering non-rapid onsite HIV testing versus no onsite testing. The associations between racial/ethnic composition and the availability of rapid HIV testing were more complicated. These findings suggest that many programs are responding to the needs of at-risk populations. However, programs and their patients may benefit from greater adoption of rapid testing which is less costly and better ensures that patients receive their results.

Factors associated with history of HIV testing among pregnant women and their partners in Cameroon: baseline data from a Behavioral Intervention Trial (ANRS 12127 Prenahtest)

BACKGROUND

We investigated HIV testing practices at baseline among pregnant women and their partners within a multicountry randomized trial aiming to evaluate the effect of enhanced prenatal posttest HIV counseling on men's involvement.

METHODS

In Yaoundé, Cameroon, 484 pregnant women with stable partners were recruited on their first antenatal care visit. We analyzed the coverage of previous HIV testing among women and their partners and looked for the factors associated with previous HIV testing, using multivariable logistic regression.

RESULTS

Among 476 pregnant women who completed the baseline questionnaire, 408 (85.7%) reported having been tested for HIV already once in their life, 48.3% of them during a previous pregnancy. Women previously tested for HIV were more likely to be in a stable relationship for >5 years than those never tested (P < 0.001). In multivariable analysis, tested women were more likely to be aged between 25 and 30 years compared with women <20 years [odds ratio (OR) 5.5, 95% confidence interval (CI): 1.4 to 22.1], to be able to say whether they felt at risk for HIV infection (OR 2.1, CI: 1.1 to 3.9), and to have ever discussed about HIV with their partner (OR 2.7, CI: 1.1 to 6.4). Most women (85.1%) reported that their partner had already been tested for HIV. Reasons for partner HIV testing were related to self-motivation (30.0%) and clinical symptoms (12.7%).

CONCLUSIONS

Strategies aiming at improving knowledge and couple communication about HIV risks need to be considered to address the remaining barriers to HIV testing and contribute to a couple approach to HIV prevention.

A single-blind randomized controlled trial to evaluate the effect of extended counseling on uptake of pre-antiretroviral care in Eastern Uganda

Background

Many newly screened people living with HIV (PLHIV) in Sub-Saharan Africa do not understand the importance of regular pre-antiretroviral (ARV) care because most of them have been counseled by staff who lack basic counseling skills. This results in low uptake of pre-ARV care and late treatment initiation in resource-poor settings. The effect of providing post-test counseling by staff equipped with basic counseling skills, combined with home visits by community support agents on uptake of pre-ARV care for newly diagnosed PLHIV was evaluated through a randomized intervention trial in Uganda.

Methods

An intervention trial was performed consisting of post-test counseling by trained counselors, combined with monthly home visits by community support agents for continued counseling to newly screened PLHIV in Iganga district, Uganda between July 2009 and June 2010, Participants (N = 400) from three public recruitment centres were randomized to receive either the intervention, or the standard care (the existing post-test counseling by ARV clinic staff who lack basic training in counseling skills), the control arm. The outcome measure was the proportion of newly screened and counseled PLHIV in either arm who had been to their nearest health center for clinical check-up in the subsequent three months +2 months. Treatment was randomly assigned using computer-generated random numbers. The statistical significance of differences between the two study arms was assessed using chi-square and t-tests for categorical and quantitative data respectively. Risk ratios and 95% confidence intervals were used to assess the effect of the intervention.

Results

Participants in the intervention arm were 80% more likely to accept (take up) pre-ARV care compared to those in the control arm (RR 1.8, 95% CI 1.4-2.1). No adverse events were reported.

Conclusions

Provision of post-test counseling by staff trained in basic counseling skills, combined with home visits by community support agents had a significant effect on uptake of pre-ARV care and appears to be a cost-effective way to increase the prerequisites for timely ARV initiation.

Trial registration

The trial was registered by Current Controlled Trials Ltd C/OBioMed Central Ltd as ISRCTN94133652 and received financial support from Sida and logistical support from the European Commission.

Routine screening for chronic human immunodeficiency virus infection: why don't the guidelines agree?

Infection with human immunodeficiency virus remains a major public health problem in the United States. Prominent guidelines from the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention differ in their recommendations on whether and how to screen adults and adolescents not known to be at higher risk. These discrepancies have led to controversy and debate as well as confusion among clinicians. This article reviews principles of screening, explains specific issues related to screening for human immunodeficiency virus, reviews the discrepancies between the US Preventive Services Task Force and the Centers for Disease Control and Prevention guidelines and the methods used in each guideline, and describes potential reasons for the discrepancies. The case of screening for human immunodeficiency virus illustrates how discrepancies between guidelines may be related to different guideline development methods as well as the different perspectives of the guideline development groups.

Recreating kinship: Coping options of HIV+ AIDS widows in Vietnam

In this retrospective study we explore the life trajectory of Vietnamese HIV-positive AIDS widows over a period 2 years after their husbands' deaths in a patrilinear and patrilocal setting where HIV is stigmatized. Some options, such as widows living with their eldest son, are not available to young HIV-positive widows, but the women in our study furthered their own interest by joining support groups, looking for new partners, and strengthening relations with their own family. Most women who returned to live with their family found a new intimate relationship through support groups for HIV-positive persons.

Egocentric network data provide additional information for characterizing an individual's HIV risk profile

OBJECTIVE

We investigated the hypothesis that partner-specific characteristics are important to improve an individual's risk characterization.

DESIGN

It has been shown that the egocentric network structure is important to establish a person's risk for infection.

METHODS

The study was cross-sectional in its design and enrolled 1231 volunteers at one HIV testing site in Rio de Janeiro, Brazil, and applied an adapted ego-network questionnaire. Each individual was interviewed about their own risk factors and those related to up to 10 sex partners. We used the dyadic data analysis method in which each relationship forms a record. Two receiver operator characteristic curves were generated, and the ability to correctly predict volunteers' HIV serostatus based on a model with characteristics of volunteers and sex partners and another with only volunteers' characteristics was evaluated.

RESULTS

Partner-related variables were associated with HIV serostatus both for men and women. The model with volunteer/sex partners' characteristics performed better in discriminating between HIV-positive and negative volunteers only for men but not for women. The c statistic for men volunteers was 0.82 [95% confidence interval (CI) 0.77-0.87] for the volunteer alone model and 0.88 (95% CI 0.86-0.91) for the combined model (P = 0.03). The values for women were 0.75 (95% CI 0.65-0.86) and 0.78 (95% CI 0.71-0.85), respectively (P = 0.71).

CONCLUSION

Ego-network theory-based approaches provide additional information for characterizing risk for HIV infection among men.

Knowledge, attitudes, and practices of voluntary HIV counseling and testing among rural migrants in Shanghai, China

A study of knowledge, attitudes and practices (KAP) of voluntary HIV counseling and testing (VCT) among rural migrants was conducted in Shanghai, China. An anonymous questionnaire was administered face-to-face. Among 2,690 participants, 78% reported having had lifetime sexual intercourse with 41.3% of singles reporting sexual intercourse, 9.2% having had multiple sex partners in the past year, only 19% of the participants always using condoms whereas 61.6% did not use in their sexual acts in the past month, 80% knew HIV infection was diagnosed through a blood test, 46.5% had heard of VCT ever before, but only 3.5% felt that they were likely to be HIV-infected now or in the future and only 62 (2.3%) had ever had HIV testing with 19 of them getting tested at a VCT site. Gender, working venue, multiple sex partnerships and knowledge of VCT were independently correlated with having had HIV testing. This study suggests that a much greater effort is needed to promote safer sex and to improve VCT knowledge and services among rural migrants particularly those who are engaging in risky behaviors.

Trends in evaluation for sexually transmitted infections among HIV-infected people, King County, Washington

OBJECTIVE

To assess clinician sexual risk assessment and sexually transmitted infection (STI) screening rates in a large cohort of human immunodeficiency virus (HIV)-infected patients in King County, Washington.

METHODS

We abstracted data from medical records of HIV-infected patients seen in diverse clinical settings during 2000-2003 and used [chi]2 and logistic regression to identify factors associated with higher rates of sexual risk assessment and STI testing. We defined patients as having had a sexual risk or STI assessment if the medical record included any information about the patient's recent sexual behavior or included laboratory test results for gonorrhea, chlamydial infection, syphilis, or trichomoniasis.

RESULTS

The proportion of patients with any recorded risk assessment or STI testing increased from 16% in 2000 to 46% in 2001, and thereafter remained stable. On multivariate analysis, having a sexual risk or STI evaluation was significantly associated with later time period of evaluation, receiving care in a HIV specialty clinic, higher number of outpatient visits, being men who have sex with men, Seattle residence (vs. residence outside Seattle), female gender, higher CD4 count, white race, and having never received antiretroviral therapy.

CONCLUSION

Although sexual risk and STI evaluation rates increased from 2000 to 2001, they now appear to be stable and many patients, particularly those seen outside of HIV specialty clinics, are not routinely evaluated for ongoing risks or STI. Clinicians and public health authorities need to develop better mechanisms to assure recommended risk assessments and STI testing among persons with HIV.

Ongoing risk behavior among persons with HIV in medical care

We surveyed randomly selected patients in the largest HIV clinic in Seattle, WA in 2005 and 2006. A total of 397 patients completed usable surveys. Twenty-seven percent of men who have sex with men (MSM) and 22% of women or heterosexual men reported having non-concordant unprotected anal or vaginal intercourse in the preceding year. Compared to 2005, more MSM in 2006 reported meeting a sex partner via the Internet (15% vs. 33%), and fewer met partners in bathhouses (23% vs. 13%). Twenty-four percent of MSM reported deciding not to have sex with a potential partner because he was HIV negative, and 31% of MSM reported that another man had decided not to have sex with them because they were HIV positive. Among all participants, 22% had told a sex partner they were HIV negative since their HIV diagnosis. These findings demonstrate the persistence of high-risk behavior among persons with HIV, a rapid increase in the use of the Internet among MSM to find sex partners, and provide direct evidence for serosorting among MSM.

Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA

BACKGROUND

New HIV infections stem from people who are aware they are HIV positive (approximately 75% of infected persons in the USA) and those who are unaware of their HIV-positive status (approximately 25%).

OBJECTIVE

We estimated the relative contribution of these two groups in sexually transmitting new HIV infections to at-risk (HIV-negative or unknown serostatus) partners in the USA.

METHODS

The parameters in the estimation included: number of people aware and unaware they are infected with HIV; 33% of the aware group are at low risk of transmitting HIV because of low/undetectable viral load; 57% relative reduction in the prevalence of unprotected anal and vaginal intercourse (UAV) with at-risk partners in persons aware (compared to unaware) they have HIV; and assumed differences in the average number of at-risk UAV partners in each awareness group (ranging from equal to twice as many in the unaware group).

RESULTS

The proportion of sexually transmitted HIV from the HIV-positive unaware group was estimated to range from 0.54 (assuming no difference in average number of at-risk UAV partners between groups) to 0.70 (assuming twice as many at-risk UAV partners in the unaware group). Using the lower bounds, the transmission rate from the unaware group was 3.5 times that of the aware group after adjusting for population size differences between groups.

CONCLUSION

The results indicate that the HIV/AIDS epidemic can be lessened substantially by increasing the number of HIV-positive persons who are aware of their status.

Routine, rapid HIV testing

HIV testing identifies HIV-positive persons, allowing for reduced future HIV transmission while simultaneously providing policy makers with surveillance data to inform policy planning. If current costs of HIV testing were reduced, these funds could be redirected to increase testing rates or to expand treatment. The cost of testing is lowered and impact increased if noninvasive (oral and urine), rapid-testing modalities are utilized, pretest counseling uses cost-efficient counseling methods (e.g., video, pamphlets, small group discussions), and opt-out consent strategies are implemented while posttest counseling is more narrowly targeted to HIV-positive persons. Rather than relying on one international standard, customizing HIV testing procedures to local environments may be more efficient and effective. In the United States, laboratories with substantial HIV testing revenues are likely to be most resistant to altering current practices. However, AIDS researchers, policy makers, and advocates may dramatically influence the epidemic's course by encouraging flexibility and innovation in HIV-testing guidelines.

Integrating routine HIV testing into a public health STD clinic

OBJECTIVE

To integrate routine HIV testing into the services offered at a public health department STD clinic and document the rate of acceptance and rate of test positivity during the first 18 months.

METHODS

Testing for HIV was added to the array of tests offered to all patients at the Maricopa County STD clinic. Patients were informed of this new option at registration and were provided with a consent form and instructions to read the form and sign it, unless they did not desire testing. STD clinicians were responsible for insuring that questions regarding testing were answered and that consent forms were signed. HIV prevention was integrated into the general STD preventive messages during the clinical encounter.

RESULTS

Sixty-eight percent of patients accepted testing (12,176 of 17,875). Of these, 68 were HIV-positive, for a rate of 5.6 per 1,000. The positive rate for men was 8.6/1000 and for women 1.2/1,000. The rate for men who reported having sex with men (MSM) was 63.8/1,000. Fourteen of the HIV-positive MSM were co-infected with syphilis. Of the 68 who were HIV-positive, 58 (85.3%) were successfully located, informed of their test results, and referred for HIV treatment and support services.

CONCLUSIONS

HIV testing can be included in the routine battery of tests offered at an STD clinic with high patient acceptance. Routine testing can discover those who are unaware of their HIV-positive status, providing an opportunity for early referral for treatment, counseling to avoid disease transmission, and notification of sexual contacts.

Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs

OBJECTIVES

To compare the prevalence of high-risk sexual behaviors in HIV persons aware of their serostatus with that in HIV persons unaware of their status in the United States and to discuss implications for HIV prevention programs.

METHODS

A meta-analysis was conducted on 11 independent findings. Six findings compared HIV(+) aware persons with independent groups of HIV(+) unaware persons (between-group comparisons), and 5 findings compared seroconverting individuals before and after being notified of their HIV status (within-subject comparisons). Outcomes were self-reported unprotected anal or vaginal intercourse (UAV) during specified recall periods.

RESULTS

The analysis integrating all 11 findings indicated that the prevalence of UAV with any partner was an average of 53% (95% confidence interval [CI]: 45%-60%) lower in HIV persons aware of their status relative to HIV(+) persons unaware of their status. There was a 68% reduction (95% CI: 59%-76%) after adjusting the data of the primary studies to focus on UAV with partners who were not already HIV(+). The reductions were larger in between-group comparisons than in within-subject comparisons. Findings for men and women were highly similar.

CONCLUSIONS

The prevalence of high-risk sexual behavior is reduced substantially after people become aware they are HIV(+). Increased emphasis on HIV testing and counseling is needed to reduce exposure to HIV(+) from persons unaware they are infected. Ongoing prevention services are needed for persons who know they are HIV(+) and continue to engage in high-risk behavior.

Relative Efficacy of Prevention Counseling With Rapid and Standard HIV Testing: A Randomized, Controlled Trial (RESPECT-2)

BACKGROUND

Two risk-reduction counseling sessions can prevent sexually transmitted diseases (STDs); however, return rates for test results are low.

STUDY

A randomized, controlled trial compared rapid HIV testing and counseling in 1 visit with standard HIV testing and counseling in 2 visits. Main outcomes were STDs (gonorrhea, chlamydia, trichomoniasis, syphilis, HIV) within 12 months. Participants were 15- to 39-year-old STD clinic patients in Denver, Long Beach, and Newark. STD screening and questionnaires were administered every 3 months.

RESULTS

Counseling was completed by 1632 of 1648 (99.0%) of the rapid-test group and 1144 of 1649 (69.4%) of the standard-test group. By 12 months, STD was acquired by 19.1% of the rapid group and 17.1% of the standard group (relative risk [RR], 1.11; confidence interval [CI], 0.96-1.29). STD incidence was higher in the rapid-test group than in the standard-test group among men (RR, 1.34; CI, 1.06-1.70), men who had sex with men (RR, 1.86; 95% CI, 0.92-3.76), and persons with no STDs at enrollment (RR, 1.21; 95% CI, 0.99-1.48). Behavior was similar in both groups.

CONCLUSIONS

Counseling with either test had similar effects on STD incidence. For some persons, counseling with standard testing may be more effective than counseling with rapid testing.

Having a regular physician and attempted weight loss after screening for hypertension or hypercholesterolemia

OBJECTIVE

To examine the relationship between having a regular physician, results of screening tests for cardiovascular risk (hypertension, hypercholesterolemia) and efforts to lose weight among obese adults.

DESIGN

Analysis of a population-based telephone survey (2002 Behavioral Risk Factor Surveillance System).

SETTING

Four states (Iowa, South Carolina, South Dakota, Virginia) in the US.

PARTICIPANTS

Adults (> or =18 y old) who were obese (body mass index > or =30 kg/m(2)) (unweighted n=1735).

MAIN OUTCOME MEASURES

Currently attempting to lose weight; changes in diet or exercise as strategies to lose weight.

RESULTS

Obese individuals with a personal physician were more likely to report attempts to lose weight in the face of screening normal for hypertension or hypercholesterolemia than those without a personal physician (75.6 vs 60.5% for hypercholesterolemia, P=0.03; 74.6 vs 57.7% for hypertension, P=0.01). In adjusted models, obese individuals screening normal for hypertension but having a personal physician were significantly more likely to attempt to lose weight than individuals without a personal physician (OR 1.71, 95% CI 1.12-2.60).

CONCLUSIONS

Having a regular physician is associated with a higher likelihood of attempted weight loss among obese individuals who believe that they do not have hypertension or hypercholesterolemia, than their counterparts with no regular physician. This suggests a previously unrecognized benefit of having a personal physician.

Importance of Sex Partner HIV Status in HIV Risk Assessment Among Men Who have Sex With Men

Clinical HIV risk assessments have not typically integrated questions about sex partners' HIV status with questions about condom use and type of sex. Since 2001, we have asked all men who have sex with men (MSM) evaluated in an urban sexually transmitted disease (STD) clinic how often in the preceding 12 months they used condoms for anal sex with partners who were HIV-positive, HIV-negative, and of unknown HIV status. Overall, MSM displayed a pattern of assortative mixing by HIV status, particularly for unprotected anal intercourse (UAI). Nevertheless, 433 (27%) of 1580 MSM who denied knowing they were HIV-positive and 93 (43%) of 217 HIV-positive MSM reported having UAI with a partner of opposite or unknown HIV status. Among men who denied previously knowing they were HIV-positive, 24 (9.6%) of 251 MSM who reported having UAI with an HIV-positive partner or partner of unknown HIV status compared with 11 (1.7%) of 620 MSM who denied such exposure tested HIV-positive (odds ratio=5.8, 95% confidence interval: 2.8-12.1). UAI with an HIV-positive partner or partner with unknown HIV status was 69% sensitive and 73% specific in identifying men with previously undiagnosed HIV infection; UAI regardless of partner HIV status was 80% sensitive but only 45% specific. The positive predictive value was highest for risk assessments that included partner HIV status. Integrating questions about anal sex partner HIV status and condom use identifies MSM at greatest risk for HIV acquisition and transmission. These risk criteria might be effectively used to triage MSM into more intensive prevention interventions.

Reducing the sexual risk behaviors of HIV+ individuals: outcome of a randomized controlled trial

Testing behavioral interventions to increase safer sex practices of HIV+ individuals has the potential to significantly reduce the number of new infections. This study evaluated a behavioral intervention designed to reduce the sexual risk behaviors of HIV+individuals. HIV+individuals (N = 387) who reported engaging in unprotected sex with HIV- or partners of unknown serostatus were randomly assigned to (a) a single counseling session targeting problem areas identified by the participant in 3 possible intervention domains (i.e., condom use, negotiation, disclosure); (b) a single-session comprehensive intervention that covered all 3 intervention domains; (c) the same comprehensive intervention, plus 2 monthly booster sessions; or (d) a 3-session diet and exercise attention-control condition. The median number of unprotected sex acts decreased from 14 at baseline to 6, 6, and 4 at 4-, 8-, and 12-month follow-ups, respectively. A repeated measures analysis of variance revealed a significant decrease in unprotected sex acts across all groups across time. A significant Group x Time interaction revealed that the comprehensive-with-boosters group had the most unprotected sex at 8-month follow-up as compared to the other 3 groups. These findings suggest that a brief intervention can result in large reductions in HIV transmission risks among HIV+individuals, but the relative benefit of one intervention approach over another remains unclear.

HIV counselling and testing in rural Uganda: communities' attitudes and perceptions towards an HIV counselling and testing programme

Study results on the assessment of a community-wide HIV counselling and testing programme are presented. The aim of this qualitative study was to elucidate whether HIV counselling and testing (HIV CT) was acceptable to a rural community and whether they expressed a need for it. From a total of 2,267 persons of Kigoyera Parish, western Uganda, who were HIV tested and counselled, 171 persons participated in 17 focus group discussions. Most participants expressed a strong need for HIV counselling and testing services. The counsellors were seen as competent and confidential. Community health workers were favoured as the preferred provider of HIV CT services. However, participants stressed that they should not come from the same community. Most participants felt that a HIV CT programme available only once is not enough and did not induce a change in sexual behaviour, e.g. increased condom use. They requested counselling services that are continuously offered. The study results also showed that there is a demand for HIV counselling services without being HIV tested.

Voluntary HIV counseling and testing: experience among the sexually active population in Bangui, Central African Republic

OBJECTIVES

In July 1997, the National Reference Center for Sexually Transmitted Diseases of Bangui, Central African Republic (CAR), was expanded by the creation of an anonymous and voluntary counseling and testing (VCT) unit for HIV infection, the Anonymous Surveillance Unit (Unité de Dépistage Anonyme [UDA]). The goal of the UDA was to initiate and promote voluntary HIV testing in the general adult population of Bangui. We carried out an observational and comprehensive survey over a 4-year period to document and analyze the experience of VCT in the UDA, with special attention to risk factors associated with HIV infection.

METHODS

All clients for VCT were given adequate pretest counseling by trained counselors focused on knowledge about HIV infection and sexually transmitted infections, individual risks of acquiring HIV, and anticipation of the client's attitude about test results. After consent was obtained, a blood sample was drawn and tested for HIV by two ELISAs in parallel. The client paid a standard cost of $1.20 at the initial visit. After a week, test results were given to the client during the posttest visit, at which time HIV-seropositive individuals received emotional support and were referred to specific social or medical structures. Seronegative clients received reinforcement of prevention messages and were asked to come back for serologic follow-up free of charge after 3 (M3) and 12 (M12) months.

RESULTS

From July 1997 to March 2001, 5686 individuals aged 14 to 65 years (mean age, 27 years) had an initial visit for VCT (V1). Peaks of UDA visitation (250-450 clients) were observed on the annual AIDS Day in the CAR, at which time HIV serologic testing was offered free of charge. A total of 5060 (89%) clients came back for a second visit (V2) to receive test results. Among those, 18.3% were infected with HIV type 1. Multivariate analysis of risk factors demonstrated marked association of HIV seropositivity with age, female gender, widowed/divorced women, poor or low education level, occupations such as civil servants or merchants, presence of symptoms of sexually transmitted infections, and lack of systematic condom use. Single young women were at higher risk for HIV infection compared with men of the same age (OR = 7.7 for women aged 15-24 years, 95% CI: 4.0-14.0; OR = 2.8 for women aged 25-34 years, 95% CI: 1.7-4.5). Widowed women older than 44 years of age were more likely to be HIV-seropositive than men (OR = 10.0; 95% CI: 1.7-83.6). A total of 885 (21%) HIV-seronegative individuals returned for follow-up at 3 months (M3; 0.45% rate of seroconversion). Seventy-nine (9%) individuals returned at 12 months (M12), without any new cases of HIV infection. HIV-negative clients consulting at M3 and M12 showed a significant reduction in unprotected intercourse with occasional sexual partners.

CONCLUSION

This experience demonstrates that VCT for HIV infection is feasible in Central Africa.

Using sexually transmitted disease incidence as a surrogate marker for HIV incidence in prevention trials: a modeling study

BACKGROUND

Because many of the sexual behaviors that place individuals at risk of acquiring HIV are the same as those that place them at risk for other sexually transmitted diseases (STDs), researchers and policymakers have called for the use of non-HIV STDs as surrogate markers for HIV infection.

GOALS

This study examined the epidemiologic conditions under which changes in STD incidence are associated with changes in HIV incidence.

STUDY DESIGN

A mathematical model of HIV/STD transmission was applied to empirical data from a large HIV prevention intervention. The association between participants' HIV infection risk reduction scores and their STD risk reduction scores was measured with use of the Pearson product-moment correlation. The authors examined how the strength of association varied across different epidemiologic parameters and heterosexual behaviors.

RESULTS

Moderate to strong associations were noted when the infectivity of the STD was similar to the infectivity of HIV. The association was attenuated for larger STD infectivity values. The prevalence of STD infection was a less important determinant of the strength of association. Stronger associations were obtained when the number of sex partners was large or the number of sex acts was small.

CONCLUSIONS

Easily transmitted STDs, such as gonorrhea, are unsuitable for general use as surrogate markers for HIV infection. Hepatitis B, syphilis, and chlamydial infection have more promising epidemiologic profiles. Careful studies of STD infectivity are needed to aid in the identification of potential marker STDs.

Low impact of a community-wide HIV testing and counseling program on sexual behavior in rural Uganda

Study results on the assessment of a community-wide HIV counseling and testing program are presented. The aim of this study was to elucidate whether HIV counseling and testing was effective in reducing high risk sexual behavior of a rural population in Uganda. From a total of 2,267 persons of Kigoyera Parish, western Uganda, who were HIV tested and counseled, 495 persons were selected and interviewed about their sexual behavior. Persons who were HIV tested showed no difference in sexual behavior compared to those who were not tested (condom use 4.3% vs. 5.5%, mean number of sexual partner in the past three months 1.8 vs. 2.0). The conclusion is that only knowing the HIV serostatus is not enough to reduce high risk behavior. The study results also showed that there is a demand for HIV counseling services without being HIV tested.

Effective detection of HIV

Biomedical advances, new HIV testing technologies, and policy shifts in the last 15 years have created substantial new challenges and opportunities for service providers, policy makers, and researchers regarding broad scale identification of HIV-seropositive persons. Effective HIV testing will be achieved when we: (1) increase the number of high-risk persons tested; (2) decrease the time from HIV infection to detection; (3) increase testing acceptability; (4) increase the proportion of individuals tested who receive their results; and (5) increase the proportion of individuals tested seropositive who are linked to care. Strategies to enhance effectiveness include implementing new testing technologies and delivery modalities; expanding access to client-controlled testing; targeting providers' knowledge, attitudes, and behaviors regarding HIV testing; mainstreaming HIV testing as routine clinical care; targeting persons who engage in high-risk behaviors and those in high-risk groups; and implementing a national behavioral surveillance system. Addressing these challenges will improve HIV detection in the United States, which is vital to both HIV prevention and treatment.

Regional differences in HIV testing among European patients with sexually transmitted diseases: trends in the history of HIV testing and knowledge of current serostatus

OBJECTIVES

To determine trends in (1) HIV testing and knowledge of current serostatus and (2) clinic-visits of aware HIV-infected patients and (3) to determine associates of incident HIV infection among patients with sexually transmitted disease (STD) in 15 countries participating in a European Community anonymous HIV seroprevalence survey.

METHODS

Demographics, STD diagnosis, self-reported history of HIV tests and current HIV test results were collected for patients diagnosed with one of 12 pre-selected STDs. Incident HIV infections were determined among patients who reported prior HIV-negative test results.

RESULTS

Between June 1990 and December 1996, 66560 STD patients were tested for HIV. Of these, 1581 (2.4%) reported a prior HIV-positive test. Of 41727 (62%) patients who reported no previous HIV test, 611 (1.4%) were HIV infected. Of 20785 (31%) patients who reported a prior HIV-negative test, 213 (1.0%) were HIV infected. Of 2467 (4%) patients without prior HIV test data available 123 (4.9%) were HIV infected. Overall, 63% of HIV-seropositive patients was aware of their HIV infection. Over time, the proportion of aware HIV-seropositive patients increased in some exposure categories in south and central Europe. Among the 11684 patients who reported dates of prior HIV-negative tests, 108 HIV infections were found. Compared with the north, HIV incidence was higher in the central region [odds ratio (OR), 1.23; 95% confidence interval (CI), 0.71-2.12] and in the south (OR, 4,39; 95% CI, 2.80-6.88) in all exposure categories except homosexual men.

CONCLUSIONS

Two-thirds of patients with an STD had never been tested for HIV. Of all HIV infections found, 32% were undiagnosed, indicating missed opportunities for counselling, safe sex education and referral for treatment. HIV testing should be routinely offered to all STD patients.

Personal, cognitive, behavioral, and demographic predictors of HIV testing and STDs in homeless women

Using a multiracial sample of 621 homeless women, we tested a latent variable causal model of personal, cognitive, behavioral, and demographic predictors of two coping mediators and the outcome variables of HIV testing and return for test results and a recent STD infection. HIV testing and return were predicted by more social support, greater AIDS knowledge, greater perceived risk for AIDS, and more problem-focused coping strategies. Recent STDs were predicted by more AIDS knowledge, emotion-focused coping strategies, and risky sexual behavior and one measured variable, crack cocaine use. Emotion-focused coping strategies were predicted by drug use, less self-esteem, more social support, and greater perceived risk for AIDS. Hispanics reported less emotion-focused coping strategies than African-Americans. Predictors of problem-focused coping strategies included less drug use, more self-esteem, more social support, more AIDS knowledge, and less risky sexual behavior. African-Americans reported less problem-focused coping strategies than Latinas. Indirect effects on the outcomes mediated through coping styles are also reported. Theoretical and practical implications of results for community outreach are discussed.

The resurgence of tuberculosis in the tropics. Improving tuberculosis control--social science inputs

Public health has for long been dominated by the notion of 'control'. However, social science research on tuberculosis in the tropics indicates that policies and programmes that take 'control' as their primary focus may fail to meet the health needs of patients and their communities. It is proposed that research and programmes meet the public health goal of lowering the prevalence of disease in populations by forging and cementing partnerships which take the support and care of patients as their focus. These will be partnerships between researchers in the North and the South, between research and programmes/policy, between outside 'experts' and communities themselves and between (public) health and other social service sectors. Social science approaches to operations research in tuberculosis are outlined, and data from a recent project in New Delhi are introduced.

An STD/HIV prevention intervention framework

Historically, interventions to prevent STD/HIV transmission have been categorized by program methodology rather than defining the content and nature of the intervention. A new taxonomy is needed to help expand the scope of interventions that can be used to prevent STD and HIV transmission. The taxonomy defines two major types of interventions, individual-level and structural level. The former targets risk factors attributable to individuals. Structural interventions target conditions outside the control of the individual. Individual-level interventions focus on counseling, screening, and treatment. They include psychological and biological interventions. Structural-level interventions address accessibility of relevant consumer products (condoms, needles), physical structures (e.g. blighted and abandoned housing, lighting, design of social facilities), social structures (policies that facilitate or constrain behaviors such as supervision of youth, and enforcement of alcohol beverage laws); and media messages (messages and images in the broadcast and print media that portray high-risk behaviors as positive and without serious consequences). A new taxonomy not only clarifies the content of preventive interventions but highlights neglected strategies involving individual biological interventions and structural interventions to prevent STD/HIV transmission.

Sexual compulsivity and substance use in HIV-seropositive men who have sex with men: prevalence and predictors of high-risk behaviors

Most persons aware of their HIV-positive serostatus refrain from sexual behavior that could transmit HIV infection to others. However, a minority of men who test HIV-seropositive continue to engage in transmission risk behavior. One factor that may play a role in high-risk sexual activity involves sexual behavior self-management. The present study investigated the role of sexual compulsivity as a contributing factor to high-risk sexual behavior in HIV seropositive men who have sex with men (N = 112). Participants also completed measures of factors known to be related to risky sexual behavior including: personal substance use, sexual partner substance use, pleasure associated with high-risk activities, beliefs about transmission risks, intentions to avoid future instances of risky behavior, and self-esteem. Men scoring high on sexual compulsivity reported engaging in more frequent unprotected sexual acts with more partners, reported greater use of cocaine in conjunction with sexual activity, rated high-risk sexual acts as more pleasurable, and reported lower self-esteem. Mediational analyses indicated that the relationship between sexual compulsivity and high-risk sexual behavior was partially mediated by both personal cocaine use and partner cocaine use in conjunction with sexual activity. The results suggest a need to integrate HIV risk-reduction services and substance use treatment for those persons living with HIV who have difficulty avoiding transmission risk behavior.

Effects of HIV counseling and testing on sexual risk behavior: a meta-analytic review of published research, 1985-1997

OBJECTIVES

This study examined whether HIV counseling and testing leads to reductions in sexual risk behavior.

METHODS

The meta-analysis included 27 published studies that provided sexual behavior outcome data, assessed behavior before and after counseling and testing, and provided details sufficient for the calculation of effect sizes. The studies involved 19,597 participants.

RESULTS

After counseling and testing, HIV-positive participants and HIV-serodiscordant couples reduced unprotected intercourse and increased condom use more than HIV-negative and untested participants. HIV-negative participants did not modify their behavior more than untested participants. Participants' age, volition for testing, and injection drug use treatment status, as well as the sample seroprevalence and length of the follow-up, explained the variance in results.

CONCLUSIONS

HIV counseling and testing appears to provide an effective means of secondary prevention for HIV-positive individuals but, as conducted in the reviewed studies, is not an effective primary prevention strategy for uninfected participants. Theory-driven research with attention given to the context of testing is needed to further explicate the determinants of behavior change resulting from HIV counseling and testing, and the effectiveness of specific counseling approaches.

Use of stage of change (SOC) to develop an STD/HIV behavioral intervention: phase 1. A system to classify SOC for STD/HIV sexual risk behaviors--development and reliability in an STD clinic

This paper reports on the initial phase in the development, program implementation, and inter-rater reliability of an application of Stage of Change (SOC) behavioral theory for use in STD/HIV risk reduction. SOC was adapted to assess readiness for sexual behavior change in an urban STD clinic in Rochester, New York. A standardized staging grid and protocol were developed and implemented as part of HIV pre- and post-test counseling. A "client instructor" methodology was used to assess standardization and staff inter-rater reliability. Percent agreement for stage assessment for target behaviors was calculated. The Rochester STD/HIV Behavioral Counseling (RoSHBeC) Staging Grid and Protocol was used to train staff and this staging system was implemented in the STD clinic. After training, staff identified the correct behavioral target and stage 90% of the time. Inter-rater agreement for SOC classification was greater than 70%. Our experience demonstrates that it is possible to develop, implement, and sustain an integrated provider-delivered STD/HIV behavioral intervention in a busy urban STD Clinic. This staging system has the potential for use in other settings and for other health-related behaviors.

Linking clients from HIV antibody counseling and testing to prevention services

The effectiveness of HIV antibody counseling and testing as a prevention intervention is limited: persons testing seronegative do not usually change their risk behaviors, some actually increase their risk behaviors, and decreases in risk behaviors are usually short-lived. Referrals to additional prevention and other needed services are therefore recommended, although the extent and determinants of referral provision for persons testing seronegative are unknown. We assessed the prevalence of referrals and the association between risk behaviors and prevention referrals among seronegatives. We reviewed HIV testing and referral data on all persons receiving confidential seronegative test results in San Francisco (SF) in the first 10 months of 1995 (n = 5,595), and gathered more detailed referral information at the municipal STD clinic from November 1995 through May 1996 (n = 747). The overall prevalence of referrals was low: a referral was given to 19.1% of the SF sample and 10.6% of the STD clinic sample; 15.4% of the SF sample and 5.9% of the STD clinic sample received a prevention referral. Injection drug users (IDUs) were the most likely to receive a prevention referral (48.5% of SF IDUs, 36.4% of STD clinic IDUs); men having sex with men and women with high-risk partners were also more likely to get a prevention referral than others. For SF IDUs, unsafe sex and needle sharing were not associated with an increased likelihood of receiving a prevention referral. Opportunities to link high-risk clients from counseling and testing to HIV prevention services are being missed. The referral component of HIV counseling and testing should be improved.

Testing for HIV: current practices in the academic ED

The objective of this study was to determine common practices for testing for Human Immunodeficiency Virus (HIV), particularly in patients with other sexually transmitted diseases (STD) in emergency departments (ED) with residency training in Emergency Medicine. Via mail, 112 directors of academic emergency medicine programs in the United States were surveyed. Surveys from 95 academic institutions were completed, returned, and included in the analysis. Three EDs (3%) routinely tested for HIV in patients with suspected STD. HIV testing was performed in the ED in 54% of responding institutions under special circumstances such as employee testing after occupational exposures (54%), cases of rape (46%), and suspicion of HIV infection by clinical manifestations other than suspected STD (36%). Based on the results it was determined that academic EDs do not routinely test for HIV in patients suspected of having a STD and have variable testing practices and policies regarding other possible HIV exposures.

Gonorrhea incidence and HIV testing and counseling among adolescents and young adults seen at a clinic for sexually transmitted diseases

OBJECTIVE

To determine whether HIV testing and posttest counseling may be associated with an increase in gonorrhea incidence among adolescents and young adults seen at a clinic for sexually transmitted diseases (STD).

DESIGN

A historical cohort study with the collection of longitudinal data on the patients' HIV testing and counseling experience.

SETTING

Delgado STD clinic of New Orleans, Louisiana, a public ambulatory primary care center that serves mainly the economically disadvantaged Black population.

PATIENTS

A record-based inception cohort of 4031 patients aged 15-25 years diagnosed at the clinic between June 1989 and May 1991 with a first lifetime gonorrhea infection.

INTERVENTION

Routine confidential HIV tests and posttest counseling sessions experienced at the clinic during follow-up.

OUTCOME MEASURE

Incidence rate of reported gonorrhea reinfection.

RESULTS

Of the patients, 51.5% were tested once for HIV antibodies and 25.9% twice or more. Formal posttest counseling occurred after 8.5% of the 4665 HIV-negative and 44.0% of the 49 HIV-positive tests. In the most pessimistic of several models controlling for history of gonorrhea, HIV testing and counseling history, and other potential confounding factors, a significantly lower rate of gonorrhea reinfection was observed after a first HIV-negative test than before [adjusted relative risk (RR), 0.66; 95% confidence interval (CI), 0.59-0.74; P < 0.00011. As compared with the pretest period, significantly higher rates of gonorrhea were observed after respectively a second (RR, 1.18; 95% CI, 1.01-1.37; P = 0.03) and a third (RR, 1.52; 95% CI, 1.22-1.88; P = 0.0001) HIV-negative test. No significant association was found between HIV-positive testing and any variation in gonorrhea rate (RR, 0.95; 95% CI, 0.56-1.62; P = 0.85). Posttest counseling for HIV-negative and HIV-positive results were followed respectively by a significantly higher rate of gonorrhea (RR; 1.27; 95% CI, 1.09-1.48; P = 0.002) and a non-significantly lower rate of gonorrhea (RR, 0.53; 95% CI, 0.17-1.60; P = 0.85).

CONCLUSION

Our results do not exclude the possibility of a modest increase in gonorrhea incidence after routine HIV testing and counseling in an STD clinic. Nevertheless, this conclusion holds only under the least favorable assumptions and applies solely to a minority of patients.

Predictors and risk-taking consequences of drug use among HIV-infected women

OBJECTIVE

To determine rates of drug use among women with HIV, and to examine associations between drug use, health, risk behavior, and sexually transmitted diseases (STD).

DESIGN

A longitudinal cohort study of 260 women with confirmed HIV-positive serostatus.

METHODS

Each participant contributed a self-report interview, a clinical examination, laboratory testing of cultures for Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoeae, and urinalysis for the presence of metabolites of cocaine and opiates. Data were examined on 140 women at 1-year follow-up. Women were defined as drug users if they reported crack, cocaine, or heroin use in the 6 months before the interview or if they had a positive toxicologic test result for cocaine or opiates.

RESULTS

34% of those in the sample were classified as positive for drug use. Drug use was associated with the number of sexual partners, age at first intercourse, prevalence of STDs, and lower quality of life. STDs were present at baseline in 33.7% and 15.5% of drug users and nonusers, respectively. Drug use among this population was also associated at both baseline and follow-up with the likelihood of having a Karnofsky score below 80, and with overall perceived general health.

CONCLUSIONS

Drug users in this cohort were more likely to engage in behaviors that place them at risk for STDs, to have elevated STD prevalence, and to have lower perceived health across several indices. Identification of drug use and treatment for it need to be a central component of HIV care for women.

Sexual, contraceptive, and drug use behaviors of women with HIV and those at high risk for infection: results from the Women's Interagency HIV Study

OBJECTIVE

To document the sexual and contraceptive practices of women with HIV infection or who are at risk for infection.

DESIGN

Data on the baseline behaviors of 561 HIV-negative and 2040 HIV-positive women were collected as part of the Women's Interagency HIV Study (WIHS). WIHS is a multisite, longitudinal study following the natural history of HIV infection among women in the United States.

METHODS

Each participant contributed an interviewer administered, self-report interview including questions on sexual and contraceptive behavior.

RESULTS

Women with HIV were less likely to report heterosexual activity in the previous 6 months (65% HIV-positive, 76% HIV-negative). Among sexually active women, there were no differences in the proportion of those reporting vaginal (97% HIV-positive, 98% HIV-negative) or anal sex (12% HIV-positive, 10% HIV-negative), although women with HIV were less likely to report cunnilingus (41% HIV-positive, 70% HIV-negative) and fellatio (48% HIV-positive, 57% HIV-negative). Of women with HIV, 63% always used condoms during vaginal sex (versus 28% HIV-negative), with lower rates reported during other sexual activities. Crack, cocaine, or injecting drug use, reported by 27% of HIV-positive and 35% of HIV-negative women, was associated with inconsistent condom use, independent of serostatus. HIV-positive women who reported using condoms and another contraception method were less consistent condom users (57% consistent versus 67%).

CONCLUSIONS

The prevalence of sexual risk behavior in this sample suggests that, although women with HIV exhibit lower levels of sexual risk behavior than uninfected women, many have not been successfully reached with regard to implementing safer behaviors. These findings have implications for more widespread and effective behavioral intervention efforts.