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

Preventing HIV transmission to children: quality of counselling of mothers in South Africa

AIM

To assess the quality of counselling provided to mothers through the programme to prevent mother-to-child transmission (PMTCT) of HIV in South Africa.

METHODS

Structured observations of consultations and exit interviews with 60 mothers attending clinics at three purposively selected PMTCT sites across South Africa were conducted.

RESULTS

Twenty-two counsellors were observed. The general quality of communication skills was very good, and 73% of HIV-negative mothers were informed of the advantages of exclusive breastfeeding (EBF). However, only one of 34 HIV-positive mothers was informed about the possible side effects of nevirapine, and none was told what to do when it occurred. Only two HIV-positive mothers were asked about essential conditions for safe formula feeding before a decision about an infant feeding option was made. None of the 12 mothers choosing to breastfeed was shown how to position the baby correctly on the breast or asked whether they thought EBF was feasible. Fewer than a quarter of mothers expressed confidence in performing the actions required, and 85% could not define the term EBF.

CONCLUSION

The poor quality of counselling in the PMTCT programme will reduce the effectiveness of these programmes. As they are being scaled up, there needs to be far more attention paid towards the counselling of mothers, especially with regards to optimal infant feeding.

Predictors of substance use frequency and reductions in seriousness of use among persons living with HIV

AIMS

To examine predictors of the current level of substance use and reductions in seriousness of substance use among adults living with HIV.

DESIGN

Cross-sectional survey.

SETTING

Four major metropolitan areas of the United States.

PARTICIPANTS

Three thousand eight hundred six adults living with HIV.

MEASUREMENT

Self-reported substance use, depression, and quality of life from audio computer assisted self-interviewing and computer assisted personal interviewing structured assessments.

FINDINGS

Recent substance use of persons living with HIV was classified as frequent (40%), occasional (32%), or abstinent (28%). Participants using drugs at a frequent level identified as heterosexual, had public insurance, and had higher levels of depression. Participants who reduced from a lifetime high seriousness in substance use were female, older, and knew their HIV status for a longer period of time.

CONCLUSIONS

Screening and identification of substance use should be included in all treatment settings and community-based organizations serving adults living with HIV.

Influences of social power and normative support on condom use decisions: a research synthesis

A meta-analysis of 58 studies involving 30,270 participants examined how study population and methodological characteristics influence the associations among norms, control perceptions, attitudes, intentions and behaviour in the area of condom use. Findings indicated that control perceptions generally correlated more strongly among members of societal groups that lack power, including female, younger individuals, ethnic-minorities and people with lower educational levels. Furthermore, norms generally had stronger influences among younger individuals and among people who have greater access to informational social support, including males, ethnic majorities and people with higher levels of education. These findings are discussed in the context of HIV prevention efforts.

HIV Testing Among Men Who Have Sex With Men

HIV counseling and testing has been a cornerstone of AIDS prevention strategies, with men who have sex with men being specifically targeted for the counseling and testing. Unfortunately, it appears that exposure to HIV counseling and testing has little effect on the behaviors of those who test negative. The Centers for Disease Control and Prevention recently altered its recommendations on when and how often men who have sex with men should undergo testing for HIV and other sexually transmitted diseases, now recommending annual testing for sexually active men who have sex with men, with even more frequent testing for men who have sex with men who engage in highest risk behaviors. Using data from our study, we evaluated the new recommendations with respect to HIV testing. Overall, 81% of the men who have sex with men in our sample reported never having tested positive for HIV. Among these men who have sex with men in South Beach nearly 8% tested positive on their current test. Slightly more than half of the men who tested positive on their current test had not been tested in the past 12 months; slightly fewer than half reported they had tested negative within the prior 9 months. Reporting multiple (4 or more) anal sexual partners during the past 12 months was significantly associated with a positive test result. Our results support the new CDC guidelines regarding more frequent testing for sexually active men who have sex with men, with having a high number of anal partners being a significant indicator of need for testing more often than annually in our population.

The efficacy of an integrated risk reduction intervention for HIV-positive women with child sexual abuse histories

Child sexual abuse (CSA) is associated with HIV risk behaviors [Bensley, L., Van Eenwyk, J., and Simmons, K. W., 2003.] and more prevalent among women living with HIV than in the general population [Koenig, L. J., and Clark, H., 2004]. This randomized Phase~I clinical trial tested the impact of a culturally congruent psychoeducational intervention designed to reduce sexual risks and increase HIV medication adherence for HIV-positive women with CSA histories. An ethnically diverse sample of 147 women were randomized to two conditions: an 11-session Enhanced Sexual Health Intervention (ESHI) or an attention control. Results based on "intent to treat'' analyses of pre-post changes are reported here. Additional analyses explored whether the observed effects might depend on "intervention dose,'' i.e., number of sessions attended. Women in the ESHI condition reported greater sexual risk reduction than women in the control condition. Although there were no differences between women in the ESHI and control groups on medication adherence, women in the ESHI condition who attended 8 or more sessions reported greater medication adherence at posttest than control women. The findings provide initial support for this culturally and gender-congruent psychoeducational intervention for HIV-positive women with CSA, and highlight the importance of addressing the effects of CSA on sexual risk reduction and medication adherence in preventive interventions for women.

[Women who are partners of a man infected by HIV: description of their characteristics and appraisal of risk]

OBJECTIVE

To describe the situations of risk and the prevalence of HIV in women with a heterosexual partner infected by HIV.

DESIGN

Cross-sectional descriptive study.

SETTING

Out-patient HIV diagnosis centre in Madrid.

PATIENTS

229 women seen for the first time between 1993 and 2002 because they had a stable heterosexual partner diagnosed with HIV, and who were exposed to no other risk.

MAIN MEASUREMENTS

Social and personal details, reproduction history, sexual conduct, clinical, and analytic data of both partners.

RESULTS

66% of couples had maintained sexual relations for over a year. Women were on average younger (29.6 years old) than the men. 29% of the women had children and 5.2% were pregnant. 82% of men had injected drugs, but only 13% still did. 73% had been diagnosed with HIV for over 6 months, 16% had AIDS criteria, and 35% were taking retroviral treatment. 60% of the men who knew of their infection had systematically avoided sex without condoms, against 33% of those who did not know they were infected (P<.001). 19% had had accidents in use of the condom. HIV seroprevalence in the women was 6.1% (95% CI, 3.5%-10.3%).

CONCLUSIONS

Health care of people with HIV must include care of their sexual partner, involving information, psychological support, preventive and reproductive advice, as well as diagnosis of HIV or other sexually transmitted diseases.

Comparing the Cost-Effectiveness of HIV Prevention Interventions

OBJECTIVE

Communities need to identify cost-effective interventions for HIV prevention to optimize limited resources.

METHODS

The authors developed a spreadsheet tool using Bernoulli and proportionate change models to estimate the relative cost-effectiveness for 26 HIV prevention interventions including biomedical interventions, structural interventions, and interventions designed to change risk behaviors of individuals. They also conducted sensitivity analyses to assess patterns of the cost-effectiveness across different populations using various assumptions.

RESULTS

The 2 factors most strongly determining the cost-effectiveness of the different interventions were the HIV prevalence of the population at risk and the cost per person reached. In low-prevalence populations (eg, heterosexuals) the most cost-effective interventions were structural interventions (eg, mass media, condom distribution), whereas in high-prevalence populations (eg, men who have sex with men) individually focused interventions to change risk behavior were also relatively cost-effective. Among the most cost-effective interventions overall were showing videos in STD clinics and raising alcohol taxes. School-based HIV prevention programs appeared to be the least cost-effective. Needle exchange and needle deregulation programs were relatively cost-effective only when injection drug users have a high HIV prevalence.

CONCLUSIONS

Comparing estimates of the cost-effectiveness of HIV interventions provides insight that can help local communities maximize the impact of their HIV prevention resources.

Self-testing for HIV: a new option for HIV prevention?

Self-testing has the potential to be an innovative component to community-wide HIV-prevention strategies. This testing method could serve populations who do not have access to standard voluntary counselling and testing services or because of privacy concerns, stigma, transport costs, or other barriers do not use facility-based, standard HIV testing. This paper reviews recent research on the acceptability, feasibility, and cost of rapid testing and home-specimen collection for HIV, and suggests that self-testing may be another important strategy for diagnosing HIV infection. Several research questions are posed that should be answered before self-testing is realised.

Interventions for Seropositive Injectors—Research and Evaluation

BACKGROUND

Behavioral interventions to address the complex medical and HIV risk reduction needs of HIV-seropositive (HIV-positive) injection drug users (IDUs) are urgently needed. We describe the development of Interventions for Seropositive Injectors-Research and Evaluation (INSPIRE), a randomized controlled trial of an integrated intervention for HIV-positive IDUs, and the characteristics of the baseline sample.

METHODS

HIV-positive IDUs were recruited from community settings in 4 US cities. After completing a baseline assessment, participants who attended the first session were randomly assigned to (1) a 10-session peer mentoring intervention designed to improve utilization of HIV care, to improve adherence to HIV medications, and to reduce sexual and injection risk or (2) an 8-session videotape control. Periodic follow-up for 12 months is ongoing.

RESULTS

A total of 1161 HIV-positive IDUs completed the baseline assessment, and 966 (83%) were randomized. Retention rates are greater than 80% for all follow-up periods. Approximately 79% of baseline participants reported a recent medical visit, 49% were taking highly active antiretroviral therapy, and 19% had an undetectable viral load. Use of injection and noninjection substances was prevalent, and sexual and injection risks were each reported by more than 25% of participants.

CONCLUSION

There is a need for an integrated intervention for HIV-positive IDUs, and these data show the acceptability of such an approach.

Quality of study methods in individual- and group-level HIV intervention research: critical reporting elements

To facilitate research synthesis and the identification of effective interventions, we reviewed and summarized critical reporting elements related to quality of study methods (QSM) specifically for individual- and group-level HIV intervention research. In developing these elements, we considered three sources of information: threats to validity, criteria and recommendations from review projects, and criteria and recommendations from published reviews relevant to HIV intervention research. Suggested QSM elements include, thoroughly describing intervention activities, using comparable outcome measures at preintervention and postintervention assessments, reporting data in detail for each study group, reporting participant refusal rates, including a comparison group, demonstrating study group comparability, clearly describing assignment to study groups, using appropriate statistical controls, collecting follow-up data from at least a 3-month postintervention period, reporting attrition in detail, and describing in detail whether the study sample size is adequate for detecting the expected effect size. Reporting on these QSM elements will assist in identifying effective behavioral interventions.

Inability to Access Addiction Treatment and Risk of HIV Infection Among Injection Drug Users

It was recently found that 94% of the nearly $500 million allocated annually to Canada's illicit drug strategy has been spent on enforcement-based interventions. As a result, lack of funds for addiction treatment has meant demand for substance abuse treatment among illicit drug users has exceeded availability. This study evaluated whether injection drug users (IDUs) who reported being unable to access addiction treatment were at elevated risk of HIV infection. A prospective analysis was done of factors associated with syringe borrowing by baseline HIV-negative IDUs among participants enrolled in the Vancouver Injecting Drug Users Study (VIDUS). Since serial measures for each individual were available, variables potentially associated with syringe borrowing were evaluated using generalized estimating equations (GEEs) with logit link for binary outcomes. Overall, 1157 HIV-negative IDUs were enrolled into the VIDUS cohort between May 1996 and May 2002. Unsuccessful attempts to access addiction treatment were associated with reporting syringe borrowing during follow-up in both univariate (odds ratio 1.72; 95% CI 1.47-2.00; P<0.001) and in multivariate GEE analyses (adjusted odds ratio 1.29; 95% CI 1.09-1.53; P=0.003). Inability to access addiction treatment was independently associated with syringe borrowing among HIV-negative IDUs at risk for HIV infection. These findings suggest that the limited provision of addiction treatment may result in a major missed opportunity to reduce HIV transmission behavior among IDUs and that the expansion of addiction treatment services has major potential to reduce the substantial human and fiscal costs of HIV infection.

Ambivalent tales of HIV disclosure in San Francisco

In light of rising levels of unprotected anal intercourse (UAI) among men who have sex with men (MSM) in San Francisco, we sought to understand disclosure practices, the calculus of risk and attitudes about HIV seroconversion. In 2000, 150 MSM participated in interviews pivoting around a detailed narrative of a recent incident of UAI. In order to understand the relationship between individual and community norms, we analyzed the narratives as accounts situated within the respondents' experience of the HIV epidemic and the gay community in San Francisco. In justifying their risky sexual practices, MSM cited a community-wide shift toward non-disclosure and barebacking since the advent of highly active anti-retroviral therapy (HAART). Fearing rejection by HIV-positive partners who refuse to use condoms, HIV-negative men saw little advantage in disclosing to casual partners whom they perceived as overwhelmingly HIV-positive. By contrast, HIV-positive men appeared eager to disclose their positive status to release themselves from responsibility for transmission and facilitate "bareback" or unprotected sex. Disavowal of individual responsibility for safer sex in deference to community norms may contribute to the recent spiraling of risk behavior and HIV incidence. Implications for prevention policy are discussed.

Update and projection on HIV/AIDS in Taiwan

The HIV/AIDS epidemic in Taiwan started in 1986, with 5,221 cases of HIV infections, 1,596 cases of AIDS, and 911 deaths reported through 2003. National surveillance data indicate that men who have sex with men accounted for 48.2% of HIV infections, followed by heterosexual men (33.8%) and heterosexual women (6.1%). Only 353 (6.8%) of all HIV cases are females. The average age of HIV-infected persons, AIDS cases, and deaths was 31.2, 36.2, and 39.0 years, respectively. The incidence of HIV infection has increased by approximately 15% every year since 1997. The continuing epidemic will likely burden the national health care system and may result in an estimated socioeconomic loss of U.S. dollars 1.6 billion in 2010, as 15,125 HIV infections and 1,420 deaths from AIDS are projected. To respond to the HIV/AIDS epidemic in Taiwan, the government has been working with nongovernmental organizations to promote HIV testing, conduct various education programs, and reach out to high-risk groups. HIV/AIDS patients are linked to medical care and provided with free highly active antiretroviral treatment. The main challenge is to reduce HIV-related stigma. Prevention focused on preventing further transmission of HIV by seropositive persons to others is urgently needed in fighting the HIV/AIDS epidemic.

Vulnerability to malaria, tuberculosis, and HIV/AIDS infection and disease. Part 1: determinants operating at individual and household level

A high burden of malaria, tuberculosis, and HIV infection contributes to national and individual poverty. We have reviewed a broad range of evidence detailing factors at individual, household, and community levels that influence vulnerability to malaria, tuberculosis, and HIV infection and used this evidence to identify strategies that could improve resilience to these diseases. This first part of the review explores the concept of vulnerability to infectious diseases and examines how age, sex, and genetics can influence the biological response to malaria, tuberculosis, and HIV infection. We highlight factors that influence processes such as poverty, livelihoods, gender discrepancies, and knowledge acquisition and provide examples of how approaches to altering these processes may have a simultaneous effect on all three diseases.

The high cost of medical care for patients who present late (CD4<200 cells/muL) with HIV infection

OBJECTIVE

To compare the direct costs of medical care in the year following HIV diagnosis for patients who present with a CD4 count <200 cells/microL ('late presenters') and those who present with a CD4 count >200 cells/microL ('early presenters').

METHODS

Direct costs (i.e. drugs, laboratory tests, outpatient care, in-patient care, and home care) for the 12 months following HIV diagnosis, sociodemographic data and clinical data were collected for all patients presenting for HIV care in Southern Alberta, Canada between April 1996 and April 2001. Mean costs are presented as costs in 2001 Canadian dollars.

RESULTS

Thirty-nine per cent of 241 patients presented with a CD4 count <200 cells/microL. The mean costs for late presenters were more than twice as high as those for early presenters (i.e. $18,448 vs. $8455, respectively). Late presenters were more likely to be older, male and black, and to have a risk activity of men having sex with men (MSM) or heterosexual contact (P<0.05). However, the large difference in mean costs cannot be attributed to differences in characteristics. When characteristics were statistically held constant, the estimated excess cost of late presentation was almost unaffected, at $9723 (z=5.6). Repeating the analysis using disaggregated costing categories suggested that the difference in total costs was largely attributable to differences in HIV-related hospital care costs, which were 15 times higher for late presenters.

CONCLUSIONS

Direct care costs in the year following HIV diagnosis were more than 200% higher for patients who presented late. This difference could not be attributed to differences in patient characteristics. Most costs were attributable to HIV-related hospital care costs and the immediate initiation of antiretroviral therapy. While early diagnosis in those at risk for HIV remains medically important, the short-term economic impact is also substantial.

HIV and STD testing in prisons: perspectives of in-prison service providers

Because individuals at risk for HIV and STDs are concentrated in prisons and jails, incarceration is an opportunity to provide HIV and STD testing. We interviewed 72 service providers working in U.S. prisons in four states about their experiences with and perceptions regarding HIV and STD testing in prison. Providers' job duties represented administration, education, security, counseling, and medical care. Providers' knowledge of prison procedures and programs related to HIV and STD testing was narrowly limited to their specific job duties, resulting in many missed opportunities for prevention counseling and referral. Suggestions include increasing health care and counseling staff so posttest counseling can be provided for those with negative as well as positive test results, providing additional prevention programs for incarcerated persons, improving staff training about HIV and STD testing, and improving communication among in-prison providers as well as between corrections and public health staff.

HIV Prevention Among High-Risk and Hard-to-Reach Rural Residents

HIV infection and HIV risk behaviors are primarily considered to be urban problems. However, rural areas are also experiencing HIV. Because the criminal justice system has a disproportionate number of persons at high risk for HIV, rural probationers were targeted. This article (1) describes an intervention designed to change the high-risk drug use and sexual behaviors of rural residents on probation; and (2) presents information on 200 rural probationers who entered a project to reduce drug use and risky sex. After informed consent was obtained, participants were randomly assigned to either the NIDA standard HIV intervention or a "rural-focused" HIV intervention that incorporates the NIDA intervention as well as thought mapping and structured stories. The rural focused intervention is grounded in the Stages of Change theory and motivational interviewing. Initial findings indicate that participants reported high levels of lifetime illicit drug use and risky sexual behaviors. Participants also reported limited knowledge about protection from HIV and hepatitis. These findings suggest that the project is reaching a group of rural residents who engage in high-risk drug and sexual behaviors.

Effective methods to change sex-risk among drug users: a review of psychosocial interventions

This review examines the current state of knowledge on the effectiveness of HIV prevention interventions with respect to sexual behavior among the population of drug users. The review focuses specifically on the relation between intervention methods found to be effective and the underlying theory. Electronic searches were conducted and supplemented by publications gathered through other channels. The studies were reviewed for (1) study design, (2) evident use of theory in intervention development, (3) clear targeting of determinants, (4) description of the study or studies, and (5) evaluation of the behavioral goals and targeted determinants. For each study, a description is given of: (1) the size and nature of the sample; (2) the retention rate; (3) the study design; (4) the nature of the intervention programs, including theoretical methods, practical strategies and theoretical background; (4) the measures of variability. The results show that a limited number of interventions were effective in changing sexual risk behavior among drug users. More successful programs featured several of the following elements: use of multiple theories and methods, inclusion of peers and rehearsal of skills. Moreover, the community-level interventions showed the importance of sustainability. The most successful intervention methods were modeling, skill building and social support enhancement. These methods are generally derived from the Social-Cognitive Theory or the Diffusion of Innovations Theory. Future HIV/AIDS interventions should build on the strengths discussed. Evaluations of interventions should be designed to facilitate comparison, using standardized and specific behavioral outcomes as well as standardized and preferably long-term follow-up levels, and should also evaluate the impact of programs at a psychosocial level to examine whether or not the theoretical methods on which a program was based were actually effective in changing the psychosocial factors targeted and why.

Risk behavior and social-cognitive determinants of condom use among ethnic minority communities in Amsterdam

This study assessed sexual risk behavior and determinants of condom use among migrants in Amsterdam, The Netherlands. We tested the predictive utility of constructs derived from the health belief model and the theory of planned behavior. Data were collected by means of a cross-sectional study in a community sample of 537 Surinamese, Antillean, and sub-Saharan African heterosexual men and women randomly recruited from participants in an epidemiological study. Participants donated saliva for HIV testing and were interviewed using two structured questionnaires. Inconsistent condom use occurred in 82% of the primary partnerships and in 25% of the casual partnerships. Multivariate analyses, controlling for sociodemographic and behavioral factors, showed that perceived behavioral control and subjective norm regarding condom use were main social-cognitive determinants of consistent condom use. However, contrary to predictions, the relation between consistent condom use and sociodemographic and behavioral factors was not entirely mediated by these social-cognitive factors.

If HIV prevention works, why are rates of high-risk sexual behavior increasing among MSM?

Systematic reviews of HIV prevention research provide clear evidence that behavioral interventions can influence the sexual behavior of men who have sex with men (MSM). However, if HIV prevention works, why are rates of high-risk sexual behavior increasing among MSM in major European, Australian, Canadian, and U.S. cities? The evidence generated by systematic reviews alone may not provide a clear answer to this question. This is because (a) it is uncertain whether experimental interventions shown to be effective in one setting, place, or moment in time can be repeated successfully in another; (b) we have limited understanding of the processes that underlie the interventions; (c) interventions shown to work in an experimental study may not necessarily be effective in everyday life. To answer the question, we need to be alert to the changing risk environment in which men have sex with other men. We also need to develop a new program of research addressing the transferability, sustainability, and effectiveness of sexual health promotion among MSM. Randomized controlled trials will remain one of the optimal means of evaluating behavioral interventions in such a program. By further strengthening the evidence base, we may identify opportunities for innovative as well as effective HIV prevention initiatives.

HIV testing and counseling: test providers' experiences of best practices

Although education is central to HIV testing and counseling, little is known about the educational processes within the testing experience. This study investigated test providers' understandings of testing and counseling best practices. Interviews with a purposive sample of 24 test providers were thematically analyzed. Analysis revealed five best practices specific to HIV education and public health--ensuring information and education for HIV risk reduction, individualization of risk assessment, ensuring test results are given in person, providing information and referrals, and facilitating partner notification--and six practices not specific to HIV counseling relationship building. The latter were building trust and rapport; maintaining professional boundaries; ensuring a comfortable, safe environment; ensuring confidentiality; imparting nonjudgmntal attitude; and self-determination. The identified best practices demonstrated remarkable consistency across respondent subgroups. Although counseling was seen as largely educational and with a preventive focus, it included individualized messages based on assessments of risk, knowledge, and social and cultural characteristics.

Persuasive communications to change actions: an analysis of behavioral and cognitive impact in HIV prevention

This meta-analysis examined the validity of various theoretical assumptions about cognitive and behavioral change following a communication recommending condom use. The synthesis comprised 82 treatment and 29 control groups included in 46 longitudinal reports with measures of perceived severity and susceptibility, attitudes and expectancies, norms, perceptions of control, intentions, knowledge, behavioral skills, or condom use. Results indicated that across the sample of studies, communications taught recipients about facts related to HIV and also induced favorable attitudes and expectancies, greater control perceptions, and stronger intentions to use condoms in the future. Moreover, messages that presented attitudinal information and modeled behavioral skills led to increased condom use. Results are discussed in the context of theories of human behavior and change and in reference to HIV-prevention interventions.

Universal sex differences in the desire for sexual variety: tests from 52 nations, 6 continents, and 13 islands

Evolutionary psychologists have hypothesized that men and women possess both long-term and short-term mating strategies, with men's short-term strategy differentially rooted in the desire for sexual variety. In this article, findings from a cross-cultural survey of 16,288 people across 10 major world regions (including North America, South America, Western Europe, Eastern Europe, Southern Europe, Middle East, Africa, Oceania, South/Southeast Asia, and East Asia) demonstrate that sex differences in the desire for sexual variety are culturally universal throughout these world regions. Sex differences were evident regardless of whether mean, median, distributional, or categorical indexes of sexual differentiation were evaluated. Sex differences were evident regardless of the measures used to evaluate them. Among contemporary theories of human mating, pluralistic approaches that hypothesize sex differences in the evolved design of short-term mating provide the most compelling account of these robust empirical findings.

New sexually transmitted diseases in HIV-infected patients: markers for ongoing HIV transmission behavior

OBJECTIVE

The objective of this study was to describe the rate of new sexually transmitted diseases (STDs) among HIV-infected patients and to define the behavioral and clinical characteristics of HIV-infected patients who return with a new STD in follow-up.

DESIGN

The study design was a record-based clinical cohort study focusing on patients testing HIV-seropositive in the STD clinics of Baltimore, Maryland from 1993 to 1998.

METHODS

The authors identified those HIV-infected patients later diagnosed with an STD in follow-up and compared their demographic, behavioral, and clinical characteristics with those who were not diagnosed with an STD in follow-up.

RESULTS

Of 796 men and 354 women with HIV infection, 13.9% of men and 11.9% of women were diagnosed with an STD after their initial HIV diagnosis. HIV-infected men returned with a new STD at a rate of 7 cases per 100 person-years; HIV-infected women returned at a rate of 5.6 cases per 100 person-years. In men, multiple sex partners and sex worker contact were associated with a subsequent STD diagnosis (OR = 1.67, p =.037; OR = 1.82, p =.015, respectively). In women, age younger than 30 years was associated with the diagnosis of an STD after the diagnosis of HIV infection (OR = 2.94, p =.0009).

CONCLUSIONS

Patients diagnosed with HIV in an STD clinic setting commonly return with new STDs in follow-up, suggesting continued exposure of HIV to others. More intensive screening and counseling interventions focused on STD prevention in those with HIV infection is a necessary HIV prevention strategy.

“What is the Point of Knowing?”: Psychosocial Barriers to HIV/AIDS Voluntary Counselling and Testing Programmes in South Africa

Voluntary Counselling and Testing (VCT) programmes are regarded as an important strategy in the management of the HIV/AIDS pandemic worldwide. Such programmes, however, often have limited success due to various problems such as the existence of attitudes and beliefs that act as psychosocial barriers. This article, which presents a study of attitudes towards VCT in South Africa, attempts to ascertain the reasons for people's continued resistance to VCT programmes. A semi-structured questionnaire was used to survey the views of 1422 people. The results indicate that while the research participants, in principle, were not opposed to VCT, they professed a deep mistrust of health-care professionals, and feared discrimination and rejection by the latter, their sexual partners, and their communities. Participants did not know how to disclose their HIV-positive status, and were concerned about testing that did not include treatment and/or follow-up support, as well as their ability to deal with the ensuing psychological turmoil in the event of testing HIV-positive. The authors proposed various suggestions concerning how to improve VCT services in South Africa.

Sexual behavior of HIV discordant couples after HIV counseling and testing

BACKGROUND AND OBJECTIVES

Sexual behavior following voluntary HIV counseling and testing (VCT) is described in 963 cohabiting heterosexual couples with one HIV positive and one HIV negative partner ('discordant couples'). Biological markers were used to assess the validity of self-report.

METHODS

Couples were recruited from a same-day VCT center in Lusaka, Zambia. Sexual exposures with and without condoms were recorded at 3-monthly intervals. Sperm detected on vaginal smears, pregnancy, and sexually transmitted diseases (STD) including HIV, gonorrhea, syphilis, and Trichomonas vaginalis were assessed.

RESULTS

Less than 3% of couples reported current condom use prior to VCT. In the year after VCT, > 80% of reported acts of intercourse in discordant couples included condom use. Reporting 100% condom use was associated with 39-70% reductions in biological markers; however most intervals with reported unprotected sex were negative for all biological markers. Under-reporting was common: 50% of sperm and 32% of pregnancies and HIV transmissions were detected when couples had reported always using condoms. Positive laboratory tests for STD and reported extramarital sex were relatively infrequent. DNA sequencing confirmed that 87% of new HIV infections were acquired from the spouse.

CONCLUSIONS

Joint VCT prompted sustained but imperfect condom use in HIV discordant couples. Biological markers were insensitive but provided evidence for a significant under-reporting of unprotected sex. Strategies that encourage truthful reporting of sexual behavior and sensitive biological markers of exposure are urgently needed. The impact of prevention programs should be assessed with both behavioral and biological measures.

Persuasive communications to change actions: an analysis of behavioral and cognitive impact in HIV prevention

This meta-analysis examined the validity of various theoretical assumptions about cognitive and behavioral change following a communication recommending condom use. The synthesis comprised 82 treatment and 29 control groups included in 46 longitudinal reports with measures of perceived severity and susceptibility, attitudes and expectancies, norms, perceptions of control, intentions, knowledge, behavioral skills, or condom use. Results indicated that across the sample of studies, communications taught recipients about facts related to HIV and also induced favorable attitudes and expectancies, greater control perceptions, and stronger intentions to use condoms in the future. Moreover, messages that presented attitudinal information and modeled behavioral skills led to increased condom use. Results are discussed in the context of theories of human behavior and change and in reference to HIV-prevention interventions.

Continued high risk behaviors in HIV infected drug abusers

To characterize current risk behaviors of HIV drug abusers in the highly active antiretroviral therapy (HAART) era, socio-demographic, medical and behavioral information were obtained and immune measurements determined. High-risk sexual practices were prevalent. Participants diagnosed before 1995 were 6 times more likely to have unprotected sex with HIV+ partners (p = 0.05) and 11 times more likely to use contaminated needles (p = 0.05) than participants with later diagnosis. Consistent condom use was reported by only 7% of the cohort. Many (43%) of the participants reported multiple HIV+ and HIV- concurrent partners. Most (65%), particularly women (OR = 3, p = 0.02), did so for drugs or money. Despite detectable viral loads, 36% reported unprotected anal sex. Antiretroviral-treated men, compared to non-treated, tended to have unprotected anal sex (OR = 2, p = 0.07). The continued high-risk behaviors of HIV drug users, particularly those diagnosed before 1995 and/or on antiretroviral therapy, indicates an urgent need for new public health strategies.

New Centers for Disease Control and Prevention's guidelines on HIV counseling and testing for the general population and pregnant women

We review two new HIV counseling and testing guidelines by the U.S. Centers for Disease Control and Prevention. The guidelines, which address the general population and pregnant women, reflect an important shift in the goals and methods of counseling and testing that has widespread implications. The guidelines' defining characteristic is the greater emphasis on increasing the numbers of people knowing their HIV status while maintaining the historical focus on extensive pretest counseling and consent procedures. We discuss the policy and practice implications by evaluating five factors: 1) Will the guidelines be adopted? 2) Will at-risk and infected individuals be identified for counseling and testing? 3) Will health care providers offer counseling and testing and patients accept counseling and testing, obtain their test results, seek treatment, and change risky behaviors? 4) Will the guidelines be relatively cost-effective? 5) Will the guidelines be compatible with ethical standards?

HIV testing policy and serious mental illness

OBJECTIVES

Using opinion data from experts, we examined the context of the argument for mandatory testing of psychiatric patients.

METHODS

Vignettes were distributed to experts on HIV and mental illness. Respondents were asked to provide appropriateness ratings for different hypothetical clinical decisions regarding HIV management.

RESULTS

Respondents were reluctant to impose testing without informed consent in most circumstances. The presence of risk factors or danger to another increased appropriateness ratings modestly.

CONCLUSIONS

Despite experts' tendency to emphasize individual rights, public reluctance to mandate testing is unlikely to extend to people with serious mental illness. No argument for mandatory testing can be persuasive if improved voluntary testing can achieve adequate detection rates. Voluntary testing protocols should be studied to determine which successfully identify infected individuals.

Screening for HIV infection in high-risk communities by urine antibody testing

OBJECTIVES

To evaluate the effectiveness of urine screening to detect HIV-infected individuals in high-prevalence communities.

METHODS

Urine HIV testing was performed at 16 discrete events and four ongoing testing sites in Baltimore communities with a high incidence of HIV infection. When possible, positive urine test results were confirmed by blood testing. In addition, we attempted to obtain blood samples from subjects who reported a possible exposure to HIV but did not have a positive urine test.

RESULTS

From February 1998 to August 2001, we screened 1718 persons. Overall, 210 persons (12%) were HIV-positive, of whom 169 (80%) had never previously tested positive; 87% of those who tested positive received their results, and most were referred for medical care.

CONCLUSIONS

Urine-based screening for HIV infection in high-prevalence inner city communities can be an effective tool for identifying and treating infected persons who are unaware of their infection.

Introduction of voluntary counselling and rapid testing for HIV in rural South Africa: from theory to practice

Expanding access to voluntary counselling and testing (VCT) for HIV is an important first step in the development of a comprehensive package of HIV services. This article describes the introduction of VCT among five primary health care (PHC) facilities in a rural South African setting, alongside a multidimensional impact assessment as part of a national pilot programme. A baseline review of services demonstrated low levels of VCT, which were predominantly hospital-based. Twenty health workers in five PHC facilities were trained to provide VCT using rapid-testing assays. The feasibility of VCT introduction and its overall acceptability to clients and providers were evaluated using clinic testing registers, semi-structured interviews with counsellors and mock client encounters. One year after its introduction, a major increase in the quantity of HIV testing, the proportion of clients who receive their results, and the proportion who present voluntarily was observed. The majority of those presenting were women, and 20-40 year olds predominated. There was a high level of acceptance among health workers, and the quality of VCT was rated very good in mock client encounters. This work demonstrates one effective model for improving access to VCT through existing primary health care services in a rural South African context.

Desired elements of HIV testing services: test recipient perspectives

Thematic analysis of transcripts from interviews with a purposive sample of 39 voluntary human immunodeficiency virus (HIV) test recipients in Ontario (selected on the basis of HIV serostatus, risk behaviors, region of residence, gender, and testing format) was used to identify elements of HIV testing services of concern to test recipients. Colleague review was used to ensure dependability of findings, and emergent themes were compared with the existing literature on patient satisfaction. Data analysis identified a comprehensive set of 28 service elements, including components related to access and availability (convenience, physical accessibility, familiarity), structure of the service (privacy, and characteristics of the venue, session, and test provider), technical and medical aspects of the testing process (including blood-taking, file maintenance, obtaining informed consent, waiting period, and manner of result provision), and both cognitive and socioemotional aspects of the interpersonal process (including decision-making support, personalized risk information, receipt of appropriate emotional support, and service referrals). Results suggest that information on, and training in, counseling skills for both physician and nonphysician test counselors is important in the provision of quality testing services. Results also suggest that test recipients would appreciate choice in testing service options, and within the test session, individualized information, and counseling.

HIV testing within at-risk populations in the United States and the reasons for seeking or avoiding HIV testing

OBJECTIVES

We determined proportions of high-risk persons tested for HIV, the reasons for testing and not testing, and attitudes and perceptions regarding HIV testing, information that is critical for planning prevention programs.

METHODS

Cross-sectional interview study of persons at high risk for HIV infection (men who have sex with men [MSM]; injection drug users [IDUs]; and heterosexual persons recruited from gay bars, street outreach, and sexually transmitted disease clinics) among six states participating in the HIV Testing Survey (HITS) in 1995 to 1996 (HITS-I) and 1998 to 1999 (HITS-II).

RESULTS

Overall testing rates were lower in the HITS-I (1226/1599 [77%]) than in the HITS-II (1375/1711 [80%]) (p =.01). Persons <25 years old tested less frequently than those >or=25 years old (HITS-I: 71% vs. 78%, respectively, p=.007; HITS-II: 63% vs. 85%, respectively, p<.001). The main reasons for testing and not testing were the same in both surveys, but the proportions of reasons for not testing differed (e.g., "unlikely exposed to HIV" [HITS-I (17%) vs. HITS-II (30%), p<.0001], "afraid of finding out HIV-positive" [HITS-I (27%) vs. HITS-II (18%), p<.0001]). Attitudes regarding HIV testing differed among tested and untested respondents, especially among MSM.

CONCLUSIONS

HIV testing rates were higher in the HITS-II, but testing rates decreased among the youngest respondents. Denial of HIV risk factors and fear of being HIV-positive were the principal reasons for not being tested. Availability of new HIV therapies may have contributed to decreased fear of finding out that one is HIV infected as a reason to avoid testing. The increased proportion of persons at risk who did not test because they believed they were unlikely to have been exposed highlights the need for prevention efforts to address risk perceptions.

Late diagnosis of HIV infection in the era of highly active antiretroviral therapy: consequences for AIDS incidence

OBJECTIVE

To assess the repercussion of late diagnosis of HIV infection on AIDS incidence in the era of highly active antiretroviral therapy.

DESIGN

Analysis of AIDS surveillance data.

SETTING

Spain.

PATIENTS

AIDS cases reported from 1994 though 2000.

MAIN OUTCOME MEASURES

Late testers were defined as persons who had a first positive HIV test in the month of or immediately preceding AIDS diagnosis. Their incidence trend was compared against that for the remaining cases, and the influence of demographic factors evaluated.

RESULTS

Of 30 778 AIDS cases, 8499 (28%) were late testers, and of these, 1061 (12%) died within 3 months of diagnosis of HIV infection. From 1995 to 2000, AIDS diagnoses declined by 36% among late testers versus 67% for the remainder (P < 0.001). The percentage of late testers increased from 24% in 1994-1996 to 35% in 1998-2000 (P < 0.001). Among the 7825 AIDS cases diagnosed in 1998-2000, late testing was independently associated (P < 0.01) with male sex, age over 44 years, residence in provinces with a lower AIDS incidence, foreign origin, and no record of injecting drug use or prison stay.

CONCLUSIONS

A growing proportion of AIDS cases involves late diagnosis of HIV infection. Persons who are unaware of their HIV infection cannot benefit from antiretroviral therapy and, hence, early diagnosis would strengthen the impact of such therapy and so reduce AIDS incidence.

Can targeted HIV testing campaigns alter health-seeking behaviour?

This paper describes the evaluation of 'gimme 5 minutes' a multimedia HIV testing campaign aimed at gay and bisexual men in London particularly targeting those of Black and South European Origin and those under the age of 25 years old using peer images. The text linked a summary of the key issues of a pre-test discussion with detailed information on how to access testing at a specified testing centre (campaign clinic). The number and demographics of men who reported sex with men (MSM) testing at the campaign clinic were monitored and compared with those testing at two other central London clinics. There was a 4.5-fold rise (p < 0.001) in MSM testing at the campaign clinic. Increases were proportionately greater in the sub-populations targeted with peer images: South European origin, 14-fold rise (p < 0.001), Black origin, 6.5-fold rise (p = 0.003), and MSM under 25 years old, 9.5-fold rise (p < 0.001). There were no significant changes in the number of MSM testing for HIV at the two other central London clinics studied. The results suggest that including detailed information about accessing testing services may be a vital ingredient in the success of media campaigns focusing on HIV testing.

Changing sexual behavior among gay male repeat testers for HIV: a randomized, controlled trial of a single-session intervention

CONTEXT

High-risk sexual behavior is increasingly prevalent among men who have sex with men (MSM) and among men with a history of repeat testing for HIV.

OBJECTIVES

The study assessed whether one counseling intervention session focusing on self-justifications (thoughts, attitudes, or beliefs that allow the participant to engage in high-risk sexual behaviors) at most recent unprotected anal intercourse (UAI) is effective in reducing future high-risk behaviors among HIV-negative men.

DESIGN, SETTING, AND PARTICIPANTS

A randomized, controlled, counseling intervention trial was conducted at an anonymous testing site in San Francisco, California, between May 1997 and January 2000. Participants were 248 MSM with a history of at least one previous negative HIV test result and self-reported UAI (receptive or insertive) in the previous 12 months with partners of unknown or discordant HIV status. Two intervention groups received standard HIV test counseling plus a cognitive-behavioral intervention, and two control groups received only standard HIV test counseling. Follow-up evaluation was at 6 and 12 months.

MAIN OUTCOME MEASURE

Number of episodes of UAI with nonprimary partners (of unknown or discordant HIV status) in the 90 days preceding the interview was measured via self-report during face-to-face interview.

RESULTS

A novel counseling intervention focusing on self-justifications significantly decreased the proportion of participants reporting UAI with nonprimary partners of unknown or discordant HIV status at 6 and 12 months (from 66% to 21% at 6 months and to 26% at 12 months, p =.002; p <.001) as compared with a control group when added to standard client-centered HIV counseling and testing.

CONCLUSIONS

A specific, single-session counseling intervention focusing on a reevaluation of a person's self-justifications operant during a recent occasion of high-risk behavior may prove useful in decreasing individual risk behavior and thus limiting community-level HIV transmission.

The effectiveness of HIV post-test counselling in determining healthcare-seeking behavior

To examine the relationship between HIV post-test counselling and healthcare-seeking behaviors among HIV-positive individuals, we conducted patient interviews and medical chart reviews on 100 HIV-positive patients at a public hospital. When performed, HIV post-test counselling effectively encourages HIV-positive individuals to seek medical care, especially when performed by trained personnel. The consistent use of post-test counselling may improve care for HIV-positive individuals and should be encouraged at all healthcare facilities that conduct HIV testing.

No evidence of an epidemic of locally acquired heterosexual HIV infection in Norway

BACKGROUND

An early sign of a major heterosexual human immunodeficiency virus (HIV) epidemic will be heterosexual infection acquired from persons who were themselves infected through heterosexual intercourse.

GOAL

To test the hypothesis that there is a growing heterosexual epidemic of HIV in Norway.

STUDY DESIGN

Data from the mandatory, comprehensive, anonymous HIV case reporting system were analyzed concerning Norwegian residents who had acquired HIV heterosexually and for whom such infections were diagnosed before the year 2001.

RESULTS

One hundred fifty-five (71%) of 221 men were infected abroad, whereas 107 (76%) of 140 women were infected in Norway (mainly by drug injectors and immigrants); 23 men and 55 women had been infected in Norway by partners who themselves acquired HIV through heterosexual intercourse (secondary heterosexual transmission). There was a slightly increasing incidence of all heterosexual cases and secondary cases.

CONCLUSIONS

Secondary heterosexual HIV transmission remains rare in Norway, and a sustainable epidemic of locally acquired infection seems unlikely in the foreseeable future. The magnitude of the heterosexual epidemic will be strongly influenced by infections acquired abroad.

Field evaluation of the Merlin immediate HIV-1 and -2 test for point-of-care detection of human immunodeficiency virus antibodies

The Merlin Immediate HIV-1 and -2 Test (Merlin point-of-care [POC] test; Merlin Biomedical & Pharmaceutical) is a nitrocellulose membrane flow immunoassay performed at the POC with the use of blood obtained from a fingerprick. The results of this test were compared with those of enzyme immunoassay (EIA) performed on venous blood samples in the laboratory. Positive results of both tests were confirmed by a Western blot (WB). The study included 553 adults with known HIV (human immunodeficiency virus) seropositivity (all of whom had positive Merlin POC test results) and 2659 adults with unknown HIV serostatus (20 of whom had positive EIA/WB results; 19 of the 20 also had positive Merlin-POC test results). The sensitivity of the Merlin POC test was 95.0% for patients with an unknown HIV serostatus and 99.83% for those with a positive serostatus. For previously untested subjects, the test's specificity and positive predictive value were 100%, its negative predictive value was 99.96%, and its overall accuracy was 99.96%. The Merlin POC test is highly accurate for the detection of HIV antibodies.

A survey of sexual activity in HIV-positive gay men

The aim of this study was to explore the sociopsychological influences that affect decision-making processes regarding sexual practice before and after becoming infected with the human immunodeficiency virus (HIV). It was hoped to identify and describe the factors that influence sexual practices using multiple regression methods and to explore in more detail, using qualitative methods, the issues for gay men.

The study randomised participants to complete a questionnaire which included the short General Health Questionnaire (GHQ-12) and the National Survey of Sexual Attitudes and Lifestyles (NASSAL) questionnaire; carried out in-depth semi-structured interviews and invited participants to take part in a focus group. The study was undertaken in an HIV clinic in South London, and completed data from 60 gay HIV seropositive men were included.

Contracting HIV results in a complex disease process, and multiple factors may influence behaviour in sexual practices. Using stepwise regression, the study indicated that the strongest predictor of present and intended future sexual behaviours was past sexual behaviour. The other variable measures were weakly correlated and therefore not significant.

These results indicate that innovative methods to increase condom use in men during their first sexual experiences have to be considered. Although this applies to all age ranges, from this study, younger men (under 20 years) who were experiencing their first exposures to homosexual lifestyle were considered more at risk for learning unsafe sexual behaviours from older sexual partners.

Concordance between HIV source partner identification and molecular confirmation in acute retroviral syndrome

Most HIV-1 transmission studies use self-reported history to define the source contact. To evaluate the reliability of epidemiologic source partner reporting, heteroduplex mobility assays (HMAs) were performed comparing the different viral strains present in the partners. Partners were typed for human leukocyte antigen (HLA) to evaluate the degree of shared alleles. Of 11 couples evaluated, HMA analysis confirmed nine transmissions (including 1 oral-genital transmission), indicated probable transmission in 1 couple, and suggested an alternative source partner in another. Nine source partners transmitted a major variant. Four source partners knew their HIV status. Previous HIV monitoring was reported by 5 of the 6 confirmed source partners who were unaware of their HIV status at the time of transmission. We also evaluated potential "sharing of HLA alleles" as a risk factor for HIV-1 acquisition; partners were not found to have a higher degree of shared HLA alleles. Lack of awareness about infection status as a consequence of infrequent testing plays a major role in the secondary transmission of HIV. These findings re-emphasize the importance of using safe sex practices at all times.

The effects of sponsorship in 12-step treatment of injection drug users

What contributes to sustained abstinence from injection drug use by those who participate in community-based Narcotics Anonymous (NA) and Alcoholics Anonymous (AA) is not well understood. We know that sponsorship is a central element in these programs. To investigate the relationship between sponsorship and abstinence, we evaluated NA/AA sponsorship over a 1-year period in a longitudinal study of 500 former and current injection drug users in inner-city Baltimore recruited from the community-at-large, independent of treatment center affiliation. The findings indicated that having a sponsor in NA/AA for this population was not associated with any improvement in 1-year sustained abstinence rates than a non-sponsored group. However, being a sponsor over the same time period was strongly associated with substantial improvements in sustained abstinence rates for the sponsors, controlling for involvement with community organizations, NA/AA meeting attendance, marital status, employment, participation in drug and alcohol treatment centers and HIV status. Involvement in community organizations was also strongly associated with successful abstinence, controlling for the same variables. Of those participants involved with community organizations, more than half reported involvement in church activities. Our investigation suggests that, for NA/AA sponsors in this study population, providing direction and support to other addicts is associated with improved success in sustained abstinence for the sponsors but does little to improve the short-term success of the persons being sponsored.

Clinic-based service programs for increasing responsible sexual behavior

Three general classes of clinic-based programs to increase responsible sexual behavior are considered: (a) clinic-based educational/counseling programs, (b) school clinic-based condom distribution programs, and (c) clinic-based STD/HIV screening programs. Consistent condom use may double in response to clinic-based counseling. However, consistent use seldom exceeds 50% of coital exposures. Extensive and personalized counseling interventions reduce incident sexually transmitted infections by 5% to 10%. Increases in responsible sexual behavior following school-based condom distribution programs is reported in some but not in all studies. Screening programs for sexually transmitted infections are associated with decreases in rates of some infections. STD/HIV screening should be considered an important aspect of healthy sexuality and an adjunct to other counseling efforts.