Anxiety levels in women attending colposcopy clinics for treatment for cervical intraepithelial neoplasia: a randomised trial of written and video information

OBJECTIVE

To assess the effectiveness of video information in reducing the level of anxiety in women attending Colposcopy clinics.

DESIGN

An observational study followed by a randomised trial.

SETTING

Colposcopy Clinic, Royal Free Hospital, London.

PARTICIPANTS

Between April and December 1999, all new referrals to the clinic with a cervical smear showing moderate or severe dyskaryosis.

MAIN OUTCOME MEASURE

The level of anxiety measured by the Spielberger State Anxiety Inventory.

CONCLUSION

Women attending colposcopy clinics for either diagnosis or treatment, experience a high level of anxiety. The highest levels occur in women attending a one-stop see and treat clinic. The introduction of visual information in the form of an explanatory video prior to attendance significantly reduced anxiety.

Cost effectiveness of expanded antenatal HIV testing in London

BACKGROUND

Recently the Department of Health announced the introduction in England of voluntary universal HIV screening in early pregnancy to prevent vertical transmission. New data have shown the importance of HIV infection in infants born to mothers who were HIV-negative in early pregnancy and who acquired HIV later in pregnancy or during lactation. This requires consideration of repeat testing in late pregnancy and testing of partners of pregnant women (expanded antenatal HIV testing).

OBJECTIVE

To estimate cost effectiveness of expanded antenatal HIV testing in London (England) within the framework of universal voluntary HIV screening in early pregnancy.

DESIGN

Incremental cost-effectiveness analysis.

METHODS

Cost estimates of service provision for HIV-positive children and adults by stage of HIV infection were combined with estimates of health benefits for infants and parents and with costs of counselling and testing (testing costs). In a pharmacoeconomic model cost effectiveness was estimated for expanded antenatal HIV testing in London for universal and selective strategies.

RESULTS

Testing costs in the plausible range of pounds sterling 4 to pounds sterling 40 translate into favourable incremental cost-effectiveness estimates for expanded antenatal HIV testing in London which is already at low numbers of vertical transmissions averted per 100000 pregnant women who test HIV-negative in early pregnancy. Favourable cost effectiveness for universal expanded testing would require testing costs in the lower range, whereas selective expanded testing may produce favourable cost effectiveness at testing costs close to pounds sterling 40.

CONCLUSION

Based on pharmaco-economic considerations, the authors believe that implementation of expanded HIV testing in London should be considered.

Do gay men discuss HIV risk reduction with their GP?

In September/October 1997, 1,004 gay men using one of five gyms in central London completed a confidential anonymous questionnaire which included items on sexual as well as steroid-related injecting behaviour and whether they had ever discussed these behaviours with friends, sexual partners or a general practitioner (GP). Nearly all the men reported having had sex with another man in the previous six months, while a quarter had had unprotected anal intercourse in the previous three months. Less than one-third of the men (30%) had discussed safer sex with their GP, compared with 92% who had talked about it with friends and 87% with lovers (p < 0.001). Of those who had discussed safer sex with their GP, one in six (17%) had not found it easy--this was significantly higher than the proportion who had not found it easy to discuss safer sex with friends, lovers or casual partners (3-9%, p < 0.01). More than 10% of the men had ever injected anabolic steroids. Of those who had injected anabolic steroids, just over one-third (36%) had ever discussed this with their GP. It appears that the majority of gay men in this study had not discussed HIV risk reduction with their GP. Until obstacles to discussing risk reduction and HIV prevention are overcome, the routine consultation in general practice will not be able to fulfill its potential for health promotion.

Adherence to HIV combination therapy

The emergence of drug-resistant strains of HIV virus and treatment failure can result from non-adherence to antiretroviral therapy. While non-adherence to therapy is not a new issue or specific to HIV/AIDS, it has received renewed attention because of the complicated combination treatment regimens being prescribed. This paper reviews the relevant background literature on the contributions of social and behavioural science to non-adherence to HIV medications. Data indicating problems with adherence prior to combination therapy are reported. Despite limitations, even self-report assessments have already succeeded in showing that adherence to combination therapy is significantly related to HIV viral load. Recent research data are discussed. Implications of findings for counselling patients to increase their adherence are presented.

Consent and antenatal HIV testing: the limits of choice and issues of consent in HIV and AIDS

The mood of nihilism that affected HIV is now changing. The availability of new therapies allows for cautious optimism--especially in relation to mother-to-child transmission of HIV and preventative interventions. This has prompted a widespread policy shift towards HIV testing in pregnancy. In this context, informed consent is an ethical issue which needs to be addressed. This study reports on two sets of data exploring consent policy and practices in UK antenatal clinics. The first is derived from an audit of obstetric clinics in the UK and Eire (n = 288), with a 91% response rate. The second provided the views on consent and testing of a cohort of pregnant women attending four London antenatal clinics (n = 697). It was found that written consent was more likely to be obtained in units with a universal HIV testing offer (p = 0.0005); 77.8% of women believed consent would be requested, but 17.7% believed they could not refuse an HIV test. Their views were contrasted with those held about other antenatal screening tests. The data show that the generally haphazard method of giving information and obtaining consent in antenatal HIV provision is probably counterproductive in terms of test uptake and the ultimate goal of minimizing maternal-fetal HIV transmission.

A review of HIV testing policies and procedures for pregnant women in public maternity units of Porto Alegre, Rio Grande do Sul, Brazil

HIV/AIDS is considered one of the major public health issues in Brazil, with 120,399 notified AIDS cases by 1998 (Aristedes Barbosa et al., 1998). Rio Grande do Sul (RS) reports the highest HIV prevalence in women in the country (Louireiro et al., 1998) and local sero-surveillance studies note an increase in HIV prevalence in pregnancy from 2.6% in 1996 (Buchalter et al., 1996) to 3.3% in 1997 (Ferreira & Valente, 1997). As a result, the Ministry of Health has recommended that all pregnant women are offered an HIV test. This study reviewed HIV testing policies and procedures, reported by obstetric staff in public health care centres in Porto Alegre. The beliefs and practices of obstetric health care professionals towards HIV testing and prevention for pregnant women were also examined, given the crucial role of obstetric staff in the implementation of successful antenatal HIV testing procedures. In total, 106 (69.3%) of eligible obstetric health care professionals responded to a postal questionnaire during April and June 1998. Eighty-six (83.5%) of respondents reported a policy of universal offer of HIV testing. A few reported selective offer (n = 9, 8.7%) and eight (7.8%) reported a policy of testing on request only. When selection was operational, respondents reported aiming at women who disclosed intravenous drug use (88.9%), women whose partner had a history of injecting drugs (77.8%), recipients of blood products prior to 1985 (66.7%), women who reported one or more sexually transmitted diseases (STDs) (88.9%) and women whose current or previous partner ever had sex with a man (77.8%). Respondents reported that consent for an HIV test was acquired 'verbally' by the majority (n = 90, 88.2%), whilst ten (9.8%) acquired consent in writing. Two (2.0%) reported that women's consent for an HIV test was not asked for. Units with universal antenatal HIV testing policy were significantly more likely to have had pregnant women test HIV-positive compared with non-universal policy units (U = 13.500, p = 0.050). It appears that whilst the majority of the public health centres were offering an HIV test to all pregnant women in Porto Alegre by 1998, a lack of structured auditing of the actual uptake of HIV testing by pregnant women still remains. Local HIV testing strategy would greatly benefit from such data.

Repeat HIV testing: high-risk behaviour or risk reduction strategy?

OBJECTIVE

To examine the characteristics of repeat and first-time HIV testers and consider their implications for HIV test counselling.

METHODS

An anonymous questionnaire was completed by nearly 1500 people seeking an HIV test between September 1997 and July 1998 at a same-day HIV testing clinic in London, United Kingdom. Repeat testers were those people who had previously tested HIV negative and were returning for another test. Information was collected on self-reported unprotected penetrative sex (UPS) in the previous 3 months and reasons for seeking the present test.

RESULTS

Overall, 50.6% (721/1446) of all clinic attenders were repeat testers: gay men 71.7% (337/470), heterosexual men 42.1% (208/494) and heterosexual women 38.6% (186/482). No significant differences were found between repeat and first time testers in the frequency of UPS (P > or = 0.06). However, gay men (but not heterosexual men and women) reporting three or more previous HIV tests were significantly more likely to report higher-risk UPS (i.e. with a partner whose HIV status was either positive or unknown) (42.2%) than those who had had one-two or no previous tests (25.3 and 25.4%, respectively; P = 0.002). Over half the heterosexual men and women, and one third of gay men said they were seeking the current HIV test in preparation for a new relationship; these proportions did not differ significantly between repeat and first-time testers (P > 0.1).

CONCLUSION

In this London HIV testing clinic, no significant differences were found in the frequency of UPS between repeat and first-time testers with the exception of gay men with a history of three or more previous HIV tests, who reported elevated levels of high-risk sexual behaviour. For many people, repeat HIV testing has become part of a risk reduction strategy to establish seroconcordance with a regular partner. HIV test counselling provides the opportunity both to address high-risk behaviour and to reinforce personal risk-reduction strategies.

Combination therapies for HIV and sexual risk behavior among gay men

OBJECTIVE

To examine optimism in the light of recent advances in HIV treatment among gay men and its association with sexual risk behavior.

METHODS

An anonymous questionnaire was completed by gay men who visited gyms in central London in March and April 1998 regarding their HIV status, unprotected anal intercourse (UAI) in the previous 3 months, and their response on a five-point linear scale to two measures of optimism: "I am less worried about HIV now that treatments have improved," and "I believe that new drug therapies make people with HIV less infectious."

RESULTS

Two thirds of the men (67.5%, 522 of 773) did not agree with the statement, "I am less worried about HIV now that treatments have improved," and only 42 (5.4%) said they agreed quite a lot or a lot. HIV-positive men were more likely to agree with this statement than HIV-negative men (p = .001) and men who had never been tested (p < .001). There was no association between agreement with this statement and frequency of UAI among HIV-positive or never-tested men (p > .3); there was, however, a positive association among HIV-negative men who reported UAI with a partner of unknown or discordant status (p = .003). The vast majority of men (81.4%; 634 of 779) did not agree with the statement, "I believe that new drug therapies make people with HIV less infectious." Regardless of HIV status, no significant association was seen between agreement with this statement and frequency of UAI (p > .1 for all comparisons).

CONCLUSION

Most gay men surveyed in central London gyms did not endorse the optimism statements concerning improved treatments or reduced infectivity. Although HIV-positive gay men were more likely to be optimistic than other men, there was no association between their optimism and sexual risk behavior. Among HIV-negative men, optimism around improved treatments (but not around reduced infectivity) was associated with UAI with a partner of unknown or discordant HIV status. For some HIV-negative men in London, optimism in the light of recent advances in HIV treatment may have triggered, or have been used as a justification for, sexual risk-taking.

HIV risk behaviours among gay men who use anabolic steroids

AIMS

To examine the injecting and sexual risk behaviours of gay men in London who use anabolic steroids or other fitness-enhancing substances (referred to as AS).

DESIGN

Cross-sectional survey using self-administered questionnaire.

SETTING

Five gyms in central London.

PARTICIPANTS

1004 gay men using the gyms during September-October 1997.

MEASUREMENTS

Proportion of men who report (i) injecting AS, (ii) sharing needles and (iii) HIV status-unknown unprotected and intercourse (UAI).

FINDINGS

Of 1004 men, 136 (13.5%) were current users of AS (range across the five gyms, 2.7-21.2%, p < 0.001), and 81 (8.1%) injected AS (range 0.4-17.5%, p < 0.001). None said they shared a needle with other users and more than 90% said they always used disposable units from sealed packets. Among current AS users, 20.9% (28/136) reported status-unknown UAI compared with 12.9% (107/827) of never-users (p = 0.02), a differential which remained significant after adjusting for confounding factors (adjusted odds ratio = 1.75, 95% CI 1.05, 2.91, p = 0.03).

CONCLUSIONS

While nearly one in 10 gay men in this study injected anabolic steroids or other fitness-enhancing substances, none reported sharing needles. Steroid users were, however, more likely to report status-unknown UAI than other men, a differential that remained after adjusting for confounding factors. Since any change in injecting practice could dramatically increase the risk of HIV transmission in this population, behavioural surveillance to monitor risk behaviours among gay men using anabolic steroids is recommended, as are targeted HIV prevention programmes.

Are researchers bound by child abuse reporting laws?

OBJECTIVE

To discuss issues concerning mandatory reporting of child abuse in research settings.

METHOD

An overview of existing Federal and State statutes regarding mandatory reporting of child abuse is presented. A critical review of the literature addresses the following issues: (1) whether researchers have a moral duty to place the health and safety of children above concerns about confidentiality and the benefits of obtaining new knowledge; (2) whether the Certificate of Confidentiality preempts reporting requirements; (3) whether researchers who are not health professionals (such as child developmentalists, psychobiologists, neuroscientists) should be required to report; and (4) whether researchers should be required to expand their protocols to include more in-depth investigation of potential abuse.

RESULTS

Existing child abuse reporting laws do not specifically designate researchers as among the category of individuals mandated to report suspected child abuse. Currently, Human Subject Protection Committees and Federal funding agencies are tending to interpret reporting laws as applying to researchers, including requiring that research subjects are informed of this responsibility in consenting procedures. It is unclear whether the Certificate of Confidentiality preempts child abuse reporting laws.

CONCLUSION

The authors recommend that legislatures specifically designate researchers as mandated reporters to ensure more uniform reporting practices in research settings. For both investigators and Human Subject Protection Committees, inclusion of researchers among the categories of those mandated to report would also help address issues of immunity from civil and criminal liability for "good faith" reports that turn out to be false and injurious.

Sexual risk behaviour among gay men in a relationship

OBJECTIVE

To examine whether gay men in a relationship have adopted negotiated safety as an HIV risk reduction strategy.

METHODS

A confidential, anonymous questionnaire was completed by 1004 gay men attending gyms in central London in September-October 1997. Information was sought on sociodemographic characteristics, HIV testing and sexual risk behaviour. Men reporting unprotected anal intercourse (UAI) in the previous 3 months were classified as 'status-unknown' if they did not know their own HIV status, that of their UAI partner(s) or both. Men who knew their own and their UAI partner's HIV status were classified as 'status-known'.

RESULTS

Of the 1004 men surveyed, 986 provided complete information on relationship, personal HIV test history and HIV status of UAI partner. Over half (539) said they were currently in a relationship with another man, of whom 173 reported UAI in the previous 3 months; 140 (80.9%) with their main partner only, 18 (10.4%) with a casual partner only and 15 (8.7%) with both their main and casual partners. Of the 140 men reporting UAI only with their main partner, 62 (44.3%) did not know their own HIV status or that of their partner. Overall, a quarter (26.0%) of the men in a relationship reported UAI only with their main partner in the previous 3 months; 11.5% status-unknown UAI, 14.5% status-known UAI. In a multivariate logistic model, both age and being in a relationship were significantly associated with UAI (status-unknown and status-known).

CONCLUSION

Gay men in a relationship, surveyed in central London gyms, have for the most part adopted the first principle of negotiated safety: only to have UAI with their main partner. However, not all have embraced the second principle: to establish HIV seroconcordance. Nearly half the men reporting UAI only with their main partner were unaware of their own HIV status, their partner's or both. As a consequence, more than one in 10 men in a relationship reported high-risk (i.e. status-unknown) UAI with their main partner. Because the study population, from central London gyms, was not randomly selected, these findings may not be generalizable to all gay men in London. Nonetheless, HIV prevention programmes should continue to encourage gay men in a relationship to seek an HIV test and establish seroconcordance if they wish to have UAI with each other.

Universal HIV screening of pregnant women in England: cost effectiveness analysis

OBJECTIVE

To estimate the cost effectiveness of universal, voluntary HIV screening of pregnant women in England.

DESIGN

Cost effectiveness analysis. Cost estimates of caring for HIV positive children were based on the stage of HIV infection and calculated using data obtained from a London hospital between 1986 and 1996. These were combined with estimates of the health benefits and costs of antenatal screening so that the cost effectiveness of universal, voluntary antenatal screening for HIV infection in England could be estimated.

MAIN OUTCOME MEASURES

Lifetime, direct costs of medical care of childhood HIV infection; life years gained as a result of the screening programme; net cost per life year gained for different pretest counselling costs; and different prevalence rates of pregnant women who were unaware that they were HIV positive.

RESULTS

Estimated direct lifetime medical and social care costs of childhood HIV infection were pound178 300 using a 5% discount rate for time preference (1995-6 prices). In high prevalence areas screening pregnant women for HIV is estimated to be a cost effective intervention with a net cost of less than pound4000 for each life year gained. For areas with comparatively low prevalence rates, cost effectiveness could be less than pound20 000 per life year gained, depending on the number of pregnant women who are unaware that they are infected and local screening costs.

CONCLUSIONS

Our results confirm recent recommendations that universal, voluntary antenatal HIV screening should be implemented in the London area. Serious consideration of the policy should be given for other areas in England depending on local prevalence and screening costs.

HIV testing and prevention issues for women attending termination assessment clinics

The prevalence of HIV infection in London is nearly threefold in women who seek terminations compared to women who carry to term. Despite the higher prevalence, HIV testing is not systematically offered to women attending termination of pregnancy assessment clinics (TOPCs). The Department of Health has given clear guidance on HIV testing in antenatal clinics and most London antenatal clinics have implemented policies on HIV testing. No similar guidance exists for TOP clinics. This paper describes the results from a study examining HIV testing and prevention issues for women attending five TOPCs in North London. Data on risk disclosure, HIV testing intentions and awareness of HIV infection and testing were analysed for 141 women who completed a self-administered questionnaire. Women who expressed an intention to have an HIV test were more likely to be from ethnic minority origin, to report that their partner intends to have an HIV test and to perceive it as easier to talk to their partner about HIV testing, compared to women who did not report an intention to test for HIV The former group also were more likely to have had a previous HIV test and perceived their personal control for staying HIV negative as greater compared to others. Fifty six (39.8 per cent) women disclosed one or more potential risk factors for HIV Women with risks were more knowledgeable about HIV infection, perceived their personal chances of being HIV positive as greater and experienced greater worry about past risks, compared to women who disclosed no risks. However, women who disclosed risk factors were no more likely to intend to have an HIV test. Knowledge on HIV infection, testing and potential interventions to reduce mother-to-baby transmission was low, with fewer than one in four women being aware that transmission may be reduced by AZT, Caesarean section and bottle feeding. Given the findings about the level of risk disclosed and women's positive attitude towards information on HIV infection and testing, this client group should no longer be overlooked in the planning of future policies on HIV testing for populations at risk.

Performance of antenatal HIV screening strategies in the United Kingdom

BACKGROUND

In 1996 only 13.5% of previously undiagnosed HIV infected women were detected in pregnancy. In this study, all 265 maternity units in the United Kingdom were surveyed to determine the relation between screening strategy, uptake of testing, and detection rate.

METHODS

Data on HIV screening strategy and uptake of testing were collected in 1997 by postal questionnaire. The proportion of women with previously undiagnosed HIV infection identified during pregnancy (detection rate) was calculated using data from national obstetric HIV surveillance and unlinked anonymous seroprevalence studies.

RESULTS

239 (90%) units responded; 25 of these (10%) had a universal offer strategy, 89 (37%) a selective offer, and 125 (52%) tested only women who requested it. All selective units offered testing to injecting drug users, but only 26% to women who had lived abroad in high prevalence areas. Uptake was over 10% in only eight units, all with a universal strategy, and in 76% of selective units it was below 0.1%. The detection rate was 14.7% in universal units, 7.8% in selective units, and 7.7% in on request units. In universal units, detection increased by 6.3% (95% confidence interval 3.7% to 8.8%) for every 10% increase in uptake of testing. There was evidence of both selective presentation for testing and avoidance of testing among infected women.

CONCLUSIONS

All current antenatal HIV testing strategies fail to identify most infected women. Universal offer strategies achieve a very low uptake and a poor detection rate. Units with selective strategies tend to test only a minority of women at high risk and do not target all the main high risk groups.

Temporal trends in reasons for and result of HIV-testing among women in Rome, Italy

To describe the trend in the reasons for and result of women's HIV testing, systematic data was gathered for 11,523 consecutive women during pre-and post-test visits at a major counseling and testing (CT) site of Rome, Italy, June 1985-July 1996. The number of tested women and the proportion of female clients attending the CT site significantly increased during the study period (p < 0.001), mostly because of reported sexual risk or when triggered by pregnancy. A significant increasing trend in the proportion of women who had one prior test (30% overall) was observed in all groups, apart from IDU. Newly diagnosed HIV infections were 319 (2.8%). The HIV prevalence was 27% in 1985-1987, when 66.7% of cases were IDUs, and decreased to 1.3% in 1994-1996, when 53.7% of cases were women reporting HIV infected partners. The findings suggest that information on the potential risk of HIV transmission has permeated the female population. The shift of newly diagnosed infections from IDUs towards women reporting sexual exposure, suggests the need for targeting preventive efforts to these population groups. Underlying reasons for multiple testing need further analysis.