Efficacy of voluntary HIV-1 counselling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomised trial

Multi-centred mixed-methods PEPFAR HIV care & support public health evaluation: study protocol

BACKGROUND

A public health response is essential to meet the multidimensional needs of patients and families affected by HIV disease in sub-Saharan Africa. In order to appraise current provision of HIV care and support in East Africa, and to provide evidence-based direction to future care programming, and Public Health Evaluation was commissioned by the PEPFAR programme of the US Government.

METHODS/DESIGN

This paper described the 2-Phase international mixed methods study protocol utilising longitudinal outcome measurement, surveys, patient and family qualitative interviews and focus groups, staff qualitative interviews, health economics and document analysis. Aim 1) To describe the nature and scope of HIV care and support in two African countries, including the types of facilities available, clients seen, and availability of specific components of care [Study Phase 1]. Aim 2) To determine patient health outcomes over time and principle cost drivers [Study Phase 2]. The study objectives are as follows. 1) To undertake a cross-sectional survey of service configuration and activity by sampling 10% of the facilities being funded by PEPFAR to provide HIV care and support in Kenya and Uganda (Phase 1) in order to describe care currently provided, including pharmacy drug reviews to determine availability and supply of essential drugs in HIV management. 2) To conduct patient focus group discussions at each of these (Phase 1) to determine care received. 3) To undertake a longitudinal prospective study of 1200 patients who are newly diagnosed with HIV or patients with HIV who present with a new problem attending PEPFAR care and support services. Data collection includes self-reported quality of life, core palliative outcomes and components of care received (Phase 2). 4) To conduct qualitative interviews with staff, patients and carers in order to explore and understand service issues and care provision in more depth (Phase 2). 5) To undertake document analysis to appraise the clinical care procedures at each facility (Phase 2). 6) To determine principle cost drivers including staff, overhead and laboratory costs (Phase 2).

DISCUSSION

This novel mixed methods protocol will permit transparent presentation of subsequent dataset results publication, and offers a substantive model of protocol design to measure and integrate key activities and outcomes that underpin a public health approach to disease management in a low-income setting.

Factors associated with self-reported HIV testing among men in Uganda

This study examined rates and predictors of self-reported HIV testing and willingness to test among married men aged 15-59 in Uganda. The data are nationally representative and drawn from the 2000-01 Uganda Demographic and Health Survey. The results of multiple regression analyses indicate that knowledge about AIDS, a history of paying for sex, spousal communication about HIV prevention, secondary or higher education, household wealth, and neighbourhood knowledge of a test site are associated with an increased likelihood of HIV testing. The higher the frequency of injection use in the past 3 months and the greater the level of interest in learning how to help one's partner have a safe pregnancy, the higher was the likelihood of willingness to test for HIV. Findings suggest that voluntary counselling and testing programmes need to target older married men aged 30-59 and expand services to the Northern region, where previously untested men indicated significantly higher desires of HIV testing.

‘What I've noticed what they need is the stats’: Lay HIV counsellors’ reports of working in a task-orientated health care system

Counselling has been recognized as an important component of HIV and AIDS care, and an essential part of HIV testing. In South Africa, a commonly used model is for lay counsellors to be trained by non-governmental organizations and then to work alongside professionals in public health clinics. In studies of counselling in health care settings in the context of HIV, there has been a relative lack of attention to the organizational and systemic issues faced by counsellors and counselling programmes. Counsellors are involved in a dynamic interrelationship not only with their clients but also with the organizations in which they work. In this paper we report on counsellors' accounts of the impact of their unclear position on their work. Twenty-nine counsellors were interviewed using individual interviews and focus group discussions. The findings reveal a clash between an holistic counselling approach and a task-oriented health system. The results provide some indication of the need to consider workplace issues in planning and researching VCT.

Cost-effectiveness of HIV testing referral strategies among tuberculosis patients in India

Background

Indian guidelines recommend routine referral for HIV testing of all tuberculosis (TB) patients in the nine states with the highest HIV prevalence, and selective referral for testing elsewhere. We assessed the clinical impact and cost-effectiveness of alternative HIV testing referral strategies among TB patients in India.

Methods and Findings

We utilized a computer model of HIV and TB disease to project outcomes for patients with active TB in India. We compared life expectancy, cost, and cost-effectiveness for three HIV testing referral strategies: 1) selective referral for HIV testing of those with increased HIV risk, 2) routine referral of patients in the nine highest HIV prevalence states with selective referral elsewhere (current standard), and 3) routine referral of all patients for HIV testing. TB-related data were from the World Health Organization. HIV prevalence among TB patients was 9.0% in the highest prevalence states, 2.9% in the other states, and 4.9% overall. The selective referral strategy, beginning from age 33.50 years, had a projected discounted life expectancy of 16.88 years and a mean lifetime HIV/TB treatment cost of US$100. The current standard increased mean life expectancy to 16.90 years with additional per-person cost of US$10; the incremental cost-effectiveness ratio was US$650/year of life saved (YLS) compared to selective referral. Routine referral of all patients for HIV testing increased life expectancy to 16.91 years, with an incremental cost-effectiveness ratio of US$730/YLS compared to the current standard. For HIV-infected patients cured of TB, receiving antiretroviral therapy increased survival from 4.71 to 13.87 years. Results were most sensitive to the HIV prevalence and the cost of second-line antiretroviral therapy.

Conclusions

Referral of all patients with active TB in India for HIV testing will be both effective and cost-effective. While effective implementation of this strategy would require investment, routine, voluntary HIV testing of TB patients in India should be recommended.

Preparing for highly active antiretroviral therapy rollout in rural South Africa: an assessment using the information, motivation, and behavioral skills model

Following a controversial history and before South Africa started the world's largest highly active antiretroviral therapy (HAART) rollout, little was known about community-level information, motivation, and behavioral skills (IMB) regarding HAART in high-HIV-prevalence rural communities. The IMB model has been shown to predict behaviors that are associated with desirable HAART outcomes. We conducted an anonymous, cross-sectional "HAART-Felt Prospects" survey among HIV-serostatus-unknown young adults in Tugela Ferry, KwaZulu-Natal. We aimed to identify behavioral aspects of HAART preparedness that could be targeted by local interventions to enhance HAART outcomes. Data analysis included: percent correct, thematic means based on a four-point Likert-scale, and composite quotients. Subjects (N=176) were Zulu (99%), young (mean 19 years), and severely impoverished (55%). Relatively high levels of information were reported: overall correct score was 46%, secondary-transmission-of-resistance information was highest (81%), and only 15% reported traditional or government-advocated folk remedies cure or treat HIV/AIDS. Motivation quotient was "consistent" with favorable HAART behaviors; attitudes toward medication-taking behaviors (3.48) and condom use during HAART (3.43) ranked the highest. Desire for HIV testing (71%) was associated with HIV treatment optimism [adjusted odds ratio (AOR)=4.0, p=0.0004] and previous experience with good treatment outcome [AOR=3.2, p=0.01]. Acceptance of HAART (93%) was associated with HIV optimism [AOR=18.0, p=0.001] and not believing government-advocated folk remedies cure or treat HIV/AIDS [AOR=10.0, p=0.04]. Behavioral skills quotient was "neutral" for favorable HAART behaviors; side effects self-efficacy was the highest (3.16); and medication-taking self-efficacy the lowest (2.51). Only 47% believed disclosing HIV-serostatus would be easy. Despite controversy surrounding HAART initiation, these results suggest that local South African at-risk youth were relatively well-poised for HAART rollout. This conclusion is supported by subsequent successful HAART rollout locally. Community-based assessments are urgently needed as HAART rollouts continue. Adaptation of this IMB-based survey may better inform efforts to enhance HAART-program implementation in resource-limited settings globally.

Acceptability and challenges of implementing voluntary counselling and testing (VCT) in rural Zimbabwe: evidence from the Regai Dzive Shiri Project

Voluntary counselling and testing (VCT) is an important component of HIV prevention and care. Little research exists on its acceptability and feasibility in rural settings. This paper examines the acceptability and feasibility of providing VCT using data from two sub-studies: (1) client-initiated VCT provided in rural health centres (RHCs) and (2) researcher-initiated VCT provided in a non-clinic community setting. Nurses provided client-initiated VCT in 39 RHCs in three Zimbabwean provinces (2004-2007). Demographic data and HIV status were collected. Qualitative data were also collected to assess rural communities' impressions of services. In a second study in 2007, VCT was offered to participants in a population-based HIV prevalence survey. Quantitative data from clinic-based VCT show that of 3585 clients aged > or =18, 79.4% (95% CI: 78.0-80.7%) were female; young people (aged 18-24) comprised 21.1%. Overall, 32.9% (95% CI: 31.4-34.5%) tested HIV positive. Young people were less likely to be HIV positive 13.5% (95% CI: 11.1-16.1%) vs. 38.1% (95% CI: 36.3-39.9%). In the second study conducted in a non-clinic setting, 27.0% (n=1368/5052) of participants opted to test. Young people were as likely to test as adults (27.3% vs. 26.9%) and an equal proportion of men and women tested. Overall during the second survey, 18.8% (95% CI: 16.7-21.0%) of participants tested positive (youth = 8.4% (95% CI: 6.4-10.7%); adults = 29.1% (95% CI: 25.7-32.7%)). Qualitative data, unique to clinics only, suggested that adults identify RHCs as acceptable VCT sites, whereas young people expressed reservations around these venues. Males reported considering VCT only after becoming ill. While VCT offered through RHCs is acceptable to women, it seems that men and youth are less comfortable with this venue. When VCT was offered in a non-clinic setting, numbers of men and women testing were similar. These data suggest that it may be possible to improve testing uptake in rural communities using non-clinic settings.

Factors associated with HIV testing among public sector clinic attendees in Johannesburg, South Africa

Uptake of VCT remains low in many sub-Saharan African countries. Men and women aged 15 and older were recruited from a family planning, STI, and VCT clinic in inner-city Johannesburg between 2004 and 2005 to take part in a cross-sectional survey on HIV testing (n = 198). Fourty-eight percent of participants reported previously testing for HIV and, of these, 86.9% reported disclosing their status to their sex partner. In multivariable analyses, individuals whose partners had been tested for HIV were more likely to have tested (AOR 2.92; 95% CI: 1.38-6.20). In addition, those who reported greater blame/shame attitudes towards people living with HIV/AIDS were less likely to have tested (AOR 0.35; 95% CI: 0.16-0.77) while those reporting more equitable attitudes towards people living with HIV/AIDS were more likely to have tested (AOR 2.87; 95% CI: 1.20-6.86). Promotion of and increased access to couples HIV testing should be made available within the South African context.

The associations of voluntary counseling and testing acceptance and the perceived likelihood of being HIV-infected among men with multiple sex partners in a South African township

This paper examines the socio-demographic factors and sexual risk behaviors (condom use, number of sexual partners, STI symptoms) associated with voluntary counselling and testing (VCT) acceptance and self-perceived risk of being HIV-infected among black men with multiple and younger sex partners in a South African township outside of Cape Town. Using respondent driven sampling, we interviewed 421 men, of whom 409 (97.3%) consented to provide a dried blood spot, 12.3% were HIVinfected (95% confidence intervals [CI.] 8.3, 16.9) and 47.2% (CI. 41.1, 53.6) accepted on site VCT. Twenty six percent (CI. 20.2, 30.7) reported having an HIV test in the past year. Few men perceived themselves as very likely to be infected with HIV (15.6%; CI. 10.4, 20.5). VCT acceptance was significantly associated with being older, married or living with a partner, having higher education, having four to six partners in the past three months and testing HIV positive. Self-perceived likelihood of being HIV infected was significantly associated with low condom use and having seven or more partners in the past three months, and testing HIV positive. These findings indicate that men correctly understand that engaging in certain HIV risk behaviors increases the likelihood of HIV-infection. However, those who perceive themselves at high risk of having HIV do not seek testing. Further investigation into the psychological and cultural barriers to reducing risky sexual behaviors and accessing VCT and other HIV services is recommended.

The limited effect of knowing they are HIV-positive on the sexual and reproductive experiences and intentions of infected adolescents in Uganda

This paper compares the sexual and reproductive experiences and intentions of those adolescents aged 15-19 years in Uganda who are perinatally infected with HIV and know their sero-status with those of adolescents who do not know their sero-status. The analysis comprises a simple comparison of means and proportions, together with the relevant tests of significance, as well as estimation of Cox proportional hazards and random-effects logit models. The findings show that the two groups of adolescents do not differ significantly in terms of timing of sexual debut and whether they intend to have children in the future. However, adolescents who are HIV-positive and know their status are significantly more likely to use a modern method of contraception, including condoms. Nonetheless, the level of condom use among these adolescents is still limited (less than half of those sexually active) and inconsistent (less than half of those in relationships reported always using a condom).

Home-based HIV voluntary counselling and testing (VCT) for improving uptake of HIV testing

BACKGROUND

The low uptake of HIV voluntary counselling and testing (VCT) has hindered global attempts to prevent new HIV infections and has limited scale-up of HIV care and treatment. Globally, only 10% of HIV-infected individuals are aware of their HIV status. One approach to increase uptake is home-based HIV VCT, which may be effective in increasing the number of patients on treatment and preventing new infections.

OBJECTIVES

To establish the effect of home-based HIV VCT on uptake of HIV testing

SEARCH STRATEGY

We searched MEDLINE (February 2007), EMBASE (February 2007), CENTRAL (February 2007), AIDSearch (February 2007), LILACS, CINAHL and Sociofile. We also contacted relevant researchers. The original review search strategy was updated in 2008.

SELECTION CRITERIA

Randomised controlled trials comparing home-based HIV VCT with other testing models

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed methodological quality, and extracted data. We planned to conduct statistical analysis using the Review Manager software and calculate summary statistics (relative risks (RRs) with 95% confidence intervals (CI)) for primary outcomes.

MAIN RESULTS

Only one study from developing countries met the inclusion criteria and was included in the review. The study, a cluster randomised trial (10 clusters, n=849) compared VCT uptake between an optional location (including home-based) and a local clinic location in a population-based HIV survey. The study showed a higher uptake of VCT among participants in the optional-location group. Uptake was significantly greater in the optional-location group in those who were pre-test counselled only (RR=4.6; 95% CI 3.58 to 5.91); pretest counselled and tested (RR=4.6; 95% CI 3.51 to 5.92); and post-test counselled and received the test result (RR=4.8; 95% CI 3.62 to 6.21). This study, however, had significant methodological problems limiting further analysis and interpretation.

AUTHORS' CONCLUSIONS

Although home-based HIV VCT has the potential to enhance VCT uptake in developing countries, insufficient data exist to recommend large-scale implementation of home-based HIV testing. Further studies are needed to determine if home-based VCT is better than facility-based VCT in improving VCT uptake.

Rethinking HIV exceptionalism: the ethics of opt-out HIV testing in sub-Saharan Africa

Opt-out testing for the human immunodeficiency virus (HIV) incorporates testing as a routine part of health care for all patients unless they refuse. The ethics of this approach to testing in sub-Saharan Africa is a source of controversy. Opt-out HIV testing is expected to improve survival by increasing case detection and thus linking more HIV-infected people to earlier treatment, provided there is effective patient follow-up and programme sustainability. At the population level, these benefits will likely outweigh the potential negative consequences of individuals experiencing HIV-related stigma. These justifications appeal to consequentialist moral theories that the acceptability of an action depends upon its outcomes. On the other hand, liberal moral theories state that the autonomy of individuals should always be protected unless restricting autonomy is necessary to protect the welfare of others. Opt-out consent may restrict autonomy and it is unclear whether it would benefit people other than those being tested. Yet, the doctrine of libertarian paternalism proposes that it is justifiable and desirable to use unobtrusive mechanisms to help individuals make choices to maximize their own welfare. Central to this idea are the premises featured by supporters of opt-out consent that individuals will not always make the best choices for their own welfare but they may be influenced to do so in ways that will not compromise their freedom of choice. Also important is the premise that all policies inevitably exert some such influence: opt-in consent encourages test refusal just as opt-out consent encourages acceptance. Based on these premises, opt-out testing may be an effective and ethically acceptable policy response to Africa's HIV epidemic.

Randomized controlled trials of interventions to prevent sexually transmitted infections: learning from the past to plan for the future

Globally, sexually transmitted infections (STIs) represent a significant source of morbidity and disproportionately impact the health of women and children. The number of randomized controlled trials testing interventions to prevent STIs has dramatically increased over time. To assess their impact, the authors conducted a systematic review of interventions to prevent sexual transmission or acquisition of STIs other than human immunodeficiency virus, published in the English-language, peer-reviewed literature through December 2009. Ninety-three papers reporting data from 74 randomized controlled trials evaluating 75 STI prevention interventions were identified. Eight intervention modalities were used: behavioral interventions (36% of interventions), vaginal microbicides (16%), vaccines (16%), treatment (11%), partner services (9%), physical barriers (5%), male circumcision (5%), and multicomponent (1%). Overall, 59% of interventions demonstrated efficacy in preventing infection with at least 1 STI. Treatment interventions and vaccines for viral STIs showed the most consistently positive effects. Male circumcision protected against viral STIs and possibly trichomoniasis. Almost two-thirds of behavioral interventions were effective, but the magnitude of effects ranged broadly. Partner services yielded similarly mixed results. In contrast, vaginal microbicides and physical barrier methods demonstrated few positive effects. Future STI prevention efforts should focus on enhancing adherence within interventions, integrating new technologies, ensuring sustainable behavior change, and conducting implementation research.

Comparing couples' and individual voluntary counseling and testing for HIV at antenatal clinics in Tanzania: a randomized trial

Voluntary counseling and testing (VCT) for couples (CVCT) is an important HIV-prevention effort in sub-Saharan Africa where a substantial proportion of HIV transmission occurs within stable partnerships. This study aimed to determine the acceptance and effectiveness of CVCT as compared to individual VCT (IVCT). 1,521 women attending three antenatal clinics in Dar es Salaam were randomized to receive IVCT during that visit or CVCT with their husbands at a subsequent visit. The proportion of women receiving test results in the CVCT arm was significantly lower than in the IVCT arm (39 vs. 71%). HIV prevalence overall was 10%. In a subgroup analysis of HIV-positive women, those who received CVCT were more likely to use preventive measures against transmission (90 vs. 60%) and to receive nevirapine for themselves (55 vs. 24%) and their infants (55 vs. 22%) as compared to women randomized to IVCT. Uptake of CVCT is low in the antenatal clinic setting. Community mobilization and couple-friendly clinics are needed to promote CVCT.

Behavior change interventions to prevent HIV infection among women living in low and middle income countries: a systematic review

We conducted a systematic review of behavioral change interventions to prevent the sexual transmission of HIV among women and girls living in low- and middle-income countries. PubMed/MEDLINE, Web of Science, the Cochrane Library, and other databases and bibliographies were systematically searched for trials using randomized or quasi-experimental designs to evaluate behavioral interventions with HIV infection as an outcome. We identified 11 analyses for inclusion reporting on eight unique interventions. Interventions varied widely in intensity, duration, and delivery as well as by target population. Only two analyses showed a significant protective effect on HIV incidence among women and only three of ten analyses that measured behavioral outcomes reduced any measure of HIV-related risk behavior. Ongoing research is needed to determine whether behavior change interventions can be incorporated as independent efficacious components in HIV prevention packages for women or simply as complements to biomedical prevention strategies.

Patterns of self-reported behaviour change associated with receiving voluntary counselling and testing in a longitudinal study from Manicaland, Zimbabwe

Voluntary counselling and testing (VCT) is promoted as a potential HIV prevention measure. We describe trends in uptake of VCT for HIV, and patterns of subsequent behaviour change associated with receiving VCT in a population-based open cohort in Manicaland, Zimbabwe. The relationship between receipt of VCT and subsequent reported behaviour was analysed using generalized linear models with random effects. At the third survey, 8.6% of participants (1,079/12,533), had previously received VCT. Women who received VCT, both those positive and negative, reduced their reported number of new partners. Among those testing positive, this risk reduction was enhanced with time since testing. Among men, no behavioural risk reduction associated with VCT was observed. Significant increases in consistent condom use, with regular or non-regular partners, following VCT, were not observed. This study suggests that, among women, particularly those who are infected, behavioural risk reduction does occur following VCT.

Behavioural interventions for HIV positive prevention in developing countries: a systematic review and meta-analysis

OBJECTIVE

To assess the evidence for a differential effect of positive prevention interventions among individuals infected and not infected with human immunodeficiency virus (HIV) in developing countries, and to assess the effectiveness of interventions targeted specifically at people living with HIV.

METHODS

We conducted a systematic review and meta-analysis of papers on positive prevention behavioural interventions in developing countries published between January 1990 and December 2006. Standardized methods of searching and data abstraction were used. Pooled effect sizes were calculated using random effects models.

FINDINGS

Nineteen studies met the inclusion criteria. In meta-analysis, behavioural interventions had a stronger impact on condom use among HIV-positive (HIV+) individuals (odds ratio, OR: 3.61; 95% confidence interval, CI: 2.61-4.99) than among HIV-negative individuals (OR: 1.32; 95% CI: 0.77-2.26). Interventions specifically targeting HIV+ individuals also showed a positive effect on condom use (OR: 7.84; 95% CI: 2.82-21.79), which was particularly strong among HIV-serodiscordant couples (OR: 67.38; 95% CI: 36.17-125.52). Interventions included in this review were limited both in scope (most were HIV counselling and testing interventions) and in target populations (most were conducted among heterosexual adults or HIV-serodiscordant couples).

CONCLUSION

Current evidence suggests that interventions targeting people living with HIV in developing countries increase condom use, especially among HIV-serodiscordant couples. Comprehensive positive prevention interventions targeting diverse populations and covering a range of intervention modalities are needed to keep HIV+ individuals physically and mentally healthy, prevent transmission of HIV infection and increase the agency and involvement of people living with HIV.

Couples' voluntary counselling and testing and nevirapine use in antenatal clinics in two African capitals: a prospective cohort study

Background

With the accessibility of prevention of mother to child transmission (PMTCT) services in sub-Saharan Africa, more women are being tested for HIV in antenatal care settings. Involving partners in the counselling and testing process could help prevent horizontal and vertical transmission of HIV. This study was conducted to assess the feasibility of couples' voluntary counseling and testing (CVCT) in antenatal care and to measure compliance with PMTCT.

Methods

A prospective cohort study was conducted over eight months at two public antenatal clinics in Kigali, Rwanda, and Lusaka, Zambia. A convenience sample of 3625 pregnant women was enrolled. Of these, 1054 women were lost to follow up. The intervention consisted of same-day individual voluntary counselling and testing (VCT) and weekend CVCT; HIV-positive participants received nevirapine tablets. In Kigali, nevirapine syrup was provided in the labour and delivery ward; in Lusaka, nevirapine syrup was supplied in pre-measured single-dose syringes. The main outcome measures were nurse midwife-recorded deliveries and reported nevirapine use.

Results

In eight months, 1940 women enrolled in Kigali (984 VCT, 956 CVCT) and 1685 women enrolled in Lusaka (1022 VCT, 663 CVCT). HIV prevalence was 14% in Kigali, and 27% in Lusaka. Loss to follow up was more common in Kigali than Lusaka (33% vs. 24%, p = 0.000). In Lusaka, HIV-positive and HIV-negative women had significantly different loss-to-follow-up rates (30% vs. 22%, p = 0.002). CVCT was associated with reduced loss to follow up: in Kigali, 31% of couples versus 36% of women testing alone (p = 0.011); and in Lusaka, 22% of couples versus 25% of women testing alone (p = 0.137). Among HIV-positive women with follow up, CVCT had no impact on nevirapine use (86-89% in Kigali; 78-79% in Lusaka).

Conclusions

Weekend CVCT, though new, was feasible in both capital cities. The beneficial impact of CVCT on loss to follow up was significant, while nevirapine compliance was similar in women tested alone or with their partners. Pre-measured nevirapine syrup syringes provided flexibility to HIV-positive mothers in Lusaka, but may have contributed to study loss to follow up. These two prevention interventions remain a challenge, with CVCT still operating without supportive government policy in Zambia.

HIV voluntary counseling and testing: an experience from India

Despite proof of voluntary counseling and testing (VCT) effectiveness in HIV disease prevention and management, there are limited reports on experience with pre- and post-HIV-test counseling in developing countries. In view of this, we aimed to bring to the fore the voluntary counseling and testing experience at a tertiary healthcare center. The present study was conducted at the voluntary counseling and testing center of a tertiary healthcare center and the National HIV Reference Center. Participants were 1169 men and 581 females attending the VCT clinic from February 2005 to March 2006. Odds ratios were calculated for each of the variable to analyze the strength of association with HIV sero-status. Out of 1750 patients, 322 (27.5%) males and 156 females (26.9%) tested HIV-positive. HIV-sero-positivity was observed to be associated to participant age (approximately 1.5 for 25-44 yrs age group), marital status (2.3 times in married patients), primary or lower education level (1.5 times), citing spouse death/HIV-infected spouse as the reason for seeking VCT (2.2 times) and reporting a history of risk behavior as reason for getting tested. This study aims to evaluate the effectiveness of existing client initiated voluntary counseling and testing facility in the light of a recent recommendation by WHO/UNAIDS for the implementation of provider initiated voluntary counseling services. Through this study, we could also highlight socio-demographic factors, like education and age, and reasons stated by participants for seeking VCT, which were associated with HIV-positive status and put an individual at a higher risk of HIV infection.

The voluntary HIV counselling and testing service in Kenema District, Sierra Leone, 2004-2006: a descriptive study

Background

Voluntary counselling and testing (VCT) is an important component of national HIV programs, which are necessary to realize the right to health. VCT data also provide valuable information on regional HIV epidemiology.

Methods

The study examines data on the population that obtained HIV VCT in Kenema District, Sierra Leone, from 2004 to 2006, using descriptive statistics and exploring potential HIV risk factors using bivariate and multivariable logistic regression. Analysis was performed separately for two subpopulations: those accessing VCT routinely as part of antenatal care and those specifically seeking VCT.

Results

During this period, 2230 people accessed VCT: 1213 through antenatal testing and 1017 specifically seeking VCT. The HIV prevalence was 0.6% in women presenting for antenatal care, 12.6% in women specifically accessing VCT, and 6.7% in men specifically accessing VCT. In both bivariate and multivariable analyses, being female was statistically significantly associated with testing positive in people specifically seeking VCT.

Conclusions

These data from the VCT service in Kenema will be used to improve the accessibility of HIV testing. Questions raised by the analysis will be used to enhance data collection and to inform further research on risk factors.

HIV coping self-efficacy: a key to understanding stigma and HIV test acceptance among incarcerated men in Jamaica

Although prisons have been noted as important venues for HIV testing, few studies have explored the factors within this context that may influence HIV test acceptance. Moreover, there is a dearth of research related to HIV and incarcerated populations in middle and low-income countries, where both the burden of HIV and the number of people incarcerated is higher compared to high-income countries. This study explores the relationship between HIV coping self-efficacy, HIV-related stigma, and HIV test acceptance in the largest prisons in Jamaica. A random sample of inmates (n=298) recruited from an HIV testing demonstration project were asked to complete a cross-sectional quantitative survey. Participants who reported high HIV coping self-efficacy (adjusted odds ratio (AOR) 1.86: 95% confidence interval CI 1.24-2.78, p-value=0.003), some perceived risk of HIV (AOR 2.51: 95% (CI) 1.57-4.01, p-value=0.000), and low HIV testing stigma (AOR 1.71: 95% CI 1.05-2.79, p-value=0.032) were more likely to test for HIV. Correlates of HIV coping self-efficacy included external and internal HIV stigma (AOR 1.28: 95% CI 1.25-1.32, p-value=0.000 and AOR 1.76: 95% CI 1.34-2.30, p-value=0.000, respectively), social support (AOR 2.09: 95% CI 1.19-3.68, p-value=0.010), and HIV knowledge (AOR 2.33: 95% CI 1.04-5.22, p-value=0.040). Policy and programs should focus on the interrelationships of these constructs to increase participation in HIV testing in prison.

Reducing sexual risk behavior among steady heterosexual serodiscordant couples in a testing and counseling program

OBJECTIVE

To assess the effect of an HIV counseling and testing program targeting steady heterosexual serodiscordant couples.

METHODS

We studied 564 couples who attended a sexually transmitted infections/HIV clinic in Madrid in the period 1989 to 2007 and participated in couples counseling and testing. Sociodemographic, epidemiologic, clinical, and behavioral information of both partners was obtained before testing the nonindex partner. Sexual practices reported in the first (preintervention) and second visit were compared, as well those reported in 4 additional visits.

RESULTS

Among the 399 couples who returned for a second visit (71%), the median number of sexual risk practices in the previous 6 months decreased (26.9-0; P <0.001) and the percentage of couples who had not engaged in sexual risk behavior increased (46.1-66.7; P <0.001). This reduction was maintained by the 143 couples who had 4 return visits. The diagnosis of HIV-infection in the index case previous to entering the program was associated with a lower frequency of sexual risk behavior. Independent predictors of postintervention risky sexual behavior included preintervention sexual risk behavior (odds ratio [OR]: 2.8, 95% confidence interval: 1.7-4.4), index case aged over 35 (OR: 2.0, 1.2-3.3), and a recent pregnancy (OR: 3.1, 1.6-6.3). The incidence of HIV seroconversion was 3.9 per 1000 couple-years (1.4-9.7).

CONCLUSION

The diagnosis of HIV-infection and counseling appears to provide complementary reductions in sexual risk behaviors among serodiscordant steady heterosexual couples at follow-up, but the risk of transmission was not totally eliminated.

Characteristics of HIV voluntary counseling and testing clients before and during care and treatment scale-up in Moshi, Tanzania

OBJECTIVES

We evaluated changes in characteristics of clients presenting for voluntary counseling and testing (VCT) before and during care and treatment center (CTC) scale-up activities in Moshi, Tanzania, between November 2003 and December 2007.

METHODS

Consecutive clients were surveyed after pretest counseling, and rapid HIV antibody testing was performed. Trend tests were used to assess changes in seroprevalence and client characteristics over time. Multivariable logistic regression models were used to estimate the contribution of changes in sociodemographic and behavioral risk characteristics, and symptoms, to changes in seroprevalence before and during CTC scale-up.

RESULTS

Data from 4391 first-time VCT clients were analyzed. HIV seroprevalence decreased from 26.2% to 18.9% after the availability of free antiretroviral therapy and expansion of CTCs beyond regional and referral hospitals. Seroprevalence decreased by 27 % for females (P = 0.0002) and 34% for males (P = 0.0125). Declines in seropositivity coincided with decreases in symptoms among males and females (P < 0.0001) and a more favorable distribution of sociodemographic risks among females (P = 0.002). No changes in behavioral risk characteristics were observed.

CONCLUSIONS

Concurrent with the scale-up of CTCs, HIV seroprevalence and rates of symptoms declined sharply at an established freestanding VCT site in Moshi, Tanzania. If more HIV-infected persons access VCT at sites where antiretrovirals are offered, freestanding VCT sites may become a less cost-effective means for HIV case finding.

Are the investments in national HIV monitoring and evaluation systems paying off?

BACKGROUND

Concerted efforts and substantial financial resources have gone toward strengthening national monitoring and evaluation (M&E) systems for HIV programs. This article explores whether those investments have made a difference in terms of data availability, quality and use for assessing whether national programs are on track to achieve the 2015 Millennium Development Goal (MDG) of halting and reversing the HIV epidemic.

METHODS

Descriptive analyses, including trends, of the National Composite Policy Index data and M&E expenditures were conducted. Global Fund funding continuation assessments were reviewed for concerns related to M&E. Availability of population-based survey data was assessed.

RESULTS

There has been a marked increase in the number of countries where the prerequisites for a national HIV M&E system are in place and in human resources devoted to M&E at the national level. However, crucial gaps remain in M&E capacity, available M&E data, and data quality assurance. The extent to which data are used for program improvement is difficult to ascertain. There is a potential threat to sustaining the current momentum in M&E as governments have not committed long-term funding and current M&E-related expenditures are below the minimum needed to make M&E systems fully functional.

CONCLUSIONS

There is evidence of rapid scale-up of basic HIV M&E systems, but if M&E is to fulfil its role in guiding optimal use of resources, ensuring effective HIV programs and providing evidence of progress toward the Millennium Development Goal of halting and reversing the HIV epidemic, essential data gaps will need to be filled urgently and those data will need to be used to guide decision making.

Keep talking about it: HIV/AIDS-related communication and prior HIV testing in Tanzania, Zimbabwe, South Africa, and Thailand

Informal, interpersonal communication within a community about HIV and AIDS, or lack of such communication, may influence community members' uptake of voluntary counseling and testing. Drawing from Noelle-Neumann's spiral of silence theory, this study examined the association between communication about HIV/AIDS and prior HIV testing in communities in Tanzania, Zimbabwe, South Africa, and Thailand. Participants (N = 14,818) in 48 communities across five sites throughout the four countries completed a behavioral survey assessing communication, prior voluntary counseling and testing (VCT) uptake, social norms, stigma, and sexual risk. Site-specific logistic regression models demonstrated that frequent conversations about HIV were significantly associated with prior HIV testing at every site. Odds ratios for each site ranged from 1.885 to 3.085, indicating a roughly doubled or tripled chance of past VCT uptake. Results indicate that verbal communication may be an important mechanism for increasing health behaviors and inclusion in future interventions should be considered.

HIV risk behaviours and determinants among people living with HIV/AIDS in Vietnam

There is a potentially high risk of HIV spreading from people living with HIV/AIDS. We conducted a cross-sectional study to examine HIV risk behaviours and their determinants among people living with HIV/AIDS. Eighty-two percent had been sexually active. Sex with multiple partners was reported by 20% and consistent condom use by about one third. More than half of the participants (52%) reported having injected drugs during the previous month, and 35% of those had shared needles and syringes. Voluntary HIV testing and having received condoms or injection equipment from the local HIV prevention program, were found to be significantly associated with fewer HIV risk behaviours. Having learned recently about personal HIV status, multiple sex partners, low educational attainment and young age were found to be associated with higher HIV risk behaviours. Giving high priority to targeted preventive and support programmes is likely to be a highly cost-effective strategy.

"It's better not to know": perceived barriers to HIV voluntary counseling and testing among sub-Saharan African migrants in Belgium

This study explored perceptions, needs, and barriers of sub-Saharan African migrants in relation to HIV voluntary counseling and testing (VCT). Using an inductive qualitative methodological approach, data were obtained from focus group discussions. Results showed that participants were in principle in favor of VCT. However, they indicated that barriers outweighed advantages. Such barriers included fear of positive test results and its related personal and social consequences, lack of information, lack of preventive health behavior, denial of HIV risk, and missed opportunities. Limited financial resources were only a concern for some subgroups like young people, asylum seekers, and recent migrants. This study identified multiple and intertwined barriers to VCT from a community perspective. In order to promote VCT, interventions such as raising awareness through culturally sensitive education should be adopted at community level. At level of service provision, provider initiated HIV testing including target group tailored counseling should be promoted.

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.

Quality of life, psychosocial health, and antiretroviral therapy among HIV-positive women in Zimbabwe

Little is known about the psychosocial impact of antiretroviral therapy (ART) among women in sub-Saharan Africa. Therefore, we conducted a cross-sectional study in Zimbabwe to assess the impact of ART on HIV-positive women's health-related quality of life, using the Medical Outcomes Study-HIV Quality of Life (QOL) questionnaire. Additionally, we assessed socio-demographics, reproductive and sexual health, HIV-related history, disclosure, social stigma, self-esteem, and depression. Structured interviews were conducted with 200 HIV-positive women and categorized into three groups by treatment: (1) Group 1 (n=31) did not meet clinical or laboratory criteria to begin treatment; (2) Group 2 (n=73) was eligible to begin treatment but awaiting initiation of treatment; and (3) Group 3 (n=96) was on ART for a median of 13 months. The women had similar socio-demographic characteristics but varied significantly in clinical characteristics. Women on ART reported fewer AIDS-related symptoms in the last week and year and had higher current and lower baseline CD4 counts compared to women not on ART. On most QOL domains women on ART reported higher mean scores as compared to women not on ART (p<0.01). Additionally, women on ART reported less depression compared to women not on ART (p<0.001). Between the two groups of women not on ART, unexpectedly, there were no significant differences in their scores for QOL or depression. Thus, Zimbabwean women living with HIV experience better overall QOL and lower depression on ART. Altogether, our findings suggest that ART delivery in resource-poor communities can enhance overall QOL as well as psychosocial functioning, which has wide-ranging public health implications.

HIV prevention cost-effectiveness: a systematic review

BACKGROUND

After more than 25 years, public health programs have not been able to sufficiently reduce the number of new HIV infections. Over 7,000 people become infected with HIV every day. Lack of convincing evidence of cost-effectiveness (CE) may be one of the reasons why implementation of effective programs is not occurring at sufficient scale. This paper identifies, summarizes and critiques the CE literature related to HIV-prevention interventions in low- and middle-income countries during 2005-2008.

METHODS

Systematic identification of publications was conducted through several methods: electronic databases, internet search of international organizations and major funding/implementing agencies, and journal browsing. Inclusion criteria included: HIV prevention intervention, year for publication (2005-2008), setting (low- and middle-income countries), and CE estimation (empirical or modeling) using outcomes in terms of cost per HIV infection averted and/or cost per disability-adjusted life year (DALY) or quality-adjusted life year (QALY).

RESULTS

We found 21 distinct studies analyzing the CE of HIV-prevention interventions published in the past four years (2005-2008). Seventeen CE studies analyzed biomedical interventions; only a few dealt with behavioral and environmental/structural interventions. Sixteen studies focused on sub-Saharan Africa, and only a handful on Asia, Latin America and Eastern Europe. Many HIV-prevention interventions are very cost effective in absolute terms (using costs per DALY averted), and also in country-specific relative terms (in cost per DALY measured as percentage of GDP per capita).

CONCLUSION

There are several types of interventions for which CE studies are still not available or insufficient, including surveillance, abstinence, school-based education, universal precautions, prevention for positives and most structural interventions. The sparse CE evidence available is not easily comparable; thus, not very useful for decision making. More than 25 years into the AIDS epidemic and billions of dollars of spending later, there is still much work to be done both on costs and effectiveness to adequately inform HIV prevention planning.

The Tanzania HIV/AIDS nursing education (THANE) preservice curriculum

The Schools of Nursing at Muhimbili University of Health and Allied Sciences and the University of California, San Francisco (UCSF) have been collaborating on a twinning partnership to develop an HIV nursing education preservice curriculum. The Tanzania HIV/AIDS Nursing Education (THANE) project was designed to increase the HIV education capacity of Tanzanian nursing schools by strengthening the knowledge and skills of the nurse educators. The THANE project includes three components: (a) development of 12 curriculum modules, (b) training of trainers, and (c) roll-out to all nurse educators in the eight zones of Tanzania and Zanzibar. The evaluation plan focuses on three main areas: (a) HIV knowledge, confidence in teaching, and thoughts about HIV, (b) participant satisfaction with the workshops, and (c) monitoring educators to assess implementation and dissemination of the THANE curriculum into existing curricula. To date, 300 nurse educators have been trained.

Factors related to female sex workers' willingness to utilize VCT service: a qualitative study in Jinan city, northern China

While national HIV prevalence remains low in China, female sex workers (FSWs) have become infected at high rates. Free voluntary HIV counseling and testing (VCT) has been offered in recent years; however, its utilization rate is low. This study explored factors related to FSWs' willingness to utilize a VCT clinic. Qualitative interviews informed by the Ecological Perspective were conducted to interview 17 FSWs and 12 managers from 23 selected entertainment establishments in Jinan, the capital of Shandong province in northern China. While the majority of FSWs professed willingness to use VCT services, they described barriers to actual utilization of services which included: misunderstandings about HIV; low perceived risk and HIV prevalence; mistrust of the free VCT; and especially anxiety about the implications of possible test results. This research suggests that increasing FSWs' utilization of VCT will require increased knowledge of HIV and VCT, and acceptance of testing and on-site VCT services.

Couple-centred testing and counselling for HIV serodiscordant heterosexual couples in sub-Saharan Africa

In Africa, a large proportion of HIV infections occur within stable relationships, either because of prior infection of one of the partners or because of infidelity. In five African countries at least two-thirds of couples with at least one HIV-positive partner were HIV serodiscordant; in half of them, the woman was the HIV-positive partner. Hence, there is an urgent need to define strategies to prevent HIV transmission within couple relationships. HIV counselling and testing have largely been organised on an individual and sex-specific basis, for pregnant women in programmes for prevention of mother-to-child transmission of HIV and in STI consultations and recently male circumcision for men. A couple-centred approach to HIV counselling and testing would facilitate communication about HIV status and adoption of preventive behaviours within couples. This paper reviews what is known about HIV serodiscordance in heterosexual couples in sub-Saharan Africa and what has been published about couple-centred initiatives for HIV counselling and testing since the early 1990s. Despite positive outcomes, couple-oriented programmes have not been implemented on a large scale. In order to stimulate and strengthen HIV prevention efforts, increased attention is required to promote prevention and testing and counselling for couples in stable relationships.

Factors associated with HIV testing among sexually active South African youth aged 15-24 years

HIV infection is high among South African youth but most report being unaware of their HIV status. We explored the correlates of HIV testing using data from youth aged 15-24 years old who reported being sexually experienced during a national survey conducted in South Africa in 2003 (N=7665). Among sexually experienced youth, 32.7% of females and 17.7% of males reported having been tested for HIV. In multivariable analysis, ever being pregnant (OR = 2.97; 95% CI 2.36-3.73), ever starting a conversation about HIV/AIDS (OR = 1.29; 95% CI 1.0-1.65) and urban residence (OR = 2.0; 95% CI 1.58-2.52) were independent correlates of HIV testing among sexually experienced females. Among sexually experienced males, HIV-positive status (OR = 1.76; 95% CI 1.14-2.73), personally knowing someone that died of AIDS (OR = 1.68; 95% CI 1.14-2.47), being aged 20-24 years (OR = 1.56; 95% CI 1.10-2.22) and having completed high school (OR = 1.58; 95% CI 1.17-2.12) were independent correlates of HIV testing. The following factors were significantly associated with HIV testing among both men and women; ever talking to parents about HIV/AIDS, ever participating in a loveLife programme, a higher frequency of visits to a clinic in the past 12 months and non-black race (p<0.05). There is a need to better understand the correlates of HIV testing to ensure that adolescent HIV prevention programmes actively promote HIV testing among this group. Specific attention needs to be paid to young women who do not access antenatal care and young men who are less regular users of routine clinical care. Communication is a significant predictor of having tested for HIV and should be encouraged with parents and through intervention programmes for adolescents. Finally, specific attention must be paid to increasing access to HIV testing for at-risk adolescents in rural communities.

Feasibility, acceptability and cost of home-based HIV testing in rural Kenya

OBJECTIVE

To demonstrate the feasibility, acceptability and cost of home-based HIV testing and to examine the applicability of the model to high HIV prevalence settings.

METHODS

Quantitative, qualitative and cost data were collected during a home-based HIV testing program in a high-prevalence rural area of Kenya; data on age, gender and marital status along with HIV test results were collected. This was complemented with qualitative research including key informant interviews with counselors and program managers to highlight experiences and challenges. Direct costs of the interventions were estimated through the review of budgets and monthly expenditure sheets.

RESULTS

Of 3180 15-49-year olds exposed to a community awareness campaign, 2033 (63.9%) agreed to be visited by counselors, of whom 1984 (97.6%) agreed to be tested and receive the results. Adult HIV prevalence was 8.2% and married women were 4.8 times more likely to be HIV-positive than those never married. Counselors reported feeling welcomed and noted the enthusiasm of the community towards testing. The total cost of the exercise was $17,569. The program cost was $2.60 for each of the 6750 community members, $5.88 for each person tested, and $84 per positive case detected.

CONCLUSION

This study suggests that home-based HIV testing is feasible with high uptake, and has the potential to substantially expand access to HIV testing services. There is a strong economic case for the extension of such a screening program to other communities.

The context of HIV risk behaviours among HIV-positive injection drug users in Viet Nam: moving toward effective harm reduction

Background

Injection drug users represent the largest proportion of all HIV reported cases in Viet Nam. This study aimed to explore the perceptions of risk and risk behaviours among HIV-positive injection drug users, and their experiences related to safe injection and safe sex practices.

Methods

This study used multiple qualitative methods in data collection including in-depth interviews, focus group discussions and participant observation with HIV-positive injection drug users.

Results

The informants described a change in the sharing practices among injection drug users towards more precautions and what was considered 'low risk sharing', like sharing among seroconcordant partners and borrowing rather than lending. However risky practices like re-use of injection equipment and 'syringe pulling' i.e. the use of left-over drugs in particular, were frequently described and observed. Needle and syringe distribution programmes were in place but carrying needles and syringes and particularly drugs could result in being arrested and fined. Fear of rejection and of loss of intimacy made disclosure difficult and was perceived as a major obstacle for condom use among recently diagnosed HIV infected individuals.

Conclusion

HIV-positive injection drug users continue to practice HIV risk behaviours. The anti-drug law and the police crack-down policy appeared as critical factors hampering ongoing prevention efforts with needle and syringe distribution programmes in Viet Nam. Drastic policy measures are needed to reduce the very high HIV prevalence among injection drug users.

Social and cognitive variables predicting voluntary HIV counseling and testing among Tanzanian medical students

OBJECTIVE

The present study aimed to predict Tanzanian medical students' Voluntary Counseling and Testing (VCT) participation intention using the Health Belief Model (HBM) as a theoretical framework. Further, differences between respondents who had previously participated in VCT and respondents who had not were assessed.

METHODS

Cross-sectional data were gathered from 186 Tanzanian medical students using a self-administered questionnaire.

RESULTS

Almost half of the respondents (43.3%) reported having been tested for HIV. A prediction model containing HBM and demographic variables explained 31% of the variance in VCT-participation intention. Self-efficacy, fear of being HIV-positive, and perceived susceptibility contributed significantly to the final regression model. In addition, respondents who had previously participated in VCT expressed less fear of being stigmatized and being HIV-positive than respondents who had not.

CONCLUSION

Fear of being HIV-positive, self-efficacy, perceived susceptibility and fear of being stigmatized were associated with either VCT-participation intention or previous participation. Further, the HBM accounted for a limited proportion of the explained variance in Tanzanian students' intention to participate in VCT. This suggests that the validity of the HBM in explaining HIV-preventive behavior in Sub-Saharan Africa should be questioned.

PRACTICE IMPLICATIONS

Interventions promoting VCT should incorporate program elements targeting self-efficacy, fear of being HIV-positive, perceived susceptibility and fear of being stigmatized.

Prevalence and predictors of failure to return for HIV-1 post-test counseling in the era of antiretroviral therapy in rural Kilimanjaro, Tanzania: challenges and opportunities

In this era of antiretroviral therapy (ART) a limited number of population-based studies have investigated the extent of voluntary counseling and testing acceptance and completion in Africa. The aim of this study was to assess the prevalence and predictors of failure to return for HIV post-test counseling (PTC) among adults in rural Kilimanjaro, Tanzania. Following a cross-sectional survey, people aged 15-44 years living in Oria village were interviewed and offered individual HIV-1 pre-test counseling. They were asked to return for PTC two weeks after blood sample collection. HIV-1 testing was accepted by 1491 (97.6%) of participants with 98.9% expressing desire to know their results. The proportion of individuals who did not return for PTC was 50.9%. These proportions did not differ by sex. Seropositive HIV result (AOR: 2.2; 95%CI: 1.3-4.3 for women and AOR: 2.1, 95%CI: 1.2-5.7 for men), low HIV/AIDS-transmission and ART availability knowledge, perceived low risk of HIV infection, not accepting to share results (men only) and inability to self-prevent HIV infection (women only) predicted failure to return for PTC. Additionally, participants were more likely not to return for PTC if they had no-formal education or reported recent sexual-risk behaviors, for both sexes. Age, prior HIV testing or AIDS-related clinical symptoms were not associated with return for PTC in this population. These findings suggest that low returns for PTC, especially for HIV-seropositive individuals, result in a substantial missed opportunity for prevention and care. Knowledge of ART accessibility is necessary but not sufficient to promote adequate return for PTC. The high attendance for pre-test counseling should be utilized to identify potential individuals who may not return for PTC and to promote risk reduction and care.

Correlates of HIV testing among South African women with high sexual and substance-use risk behaviours

Despite its importance in raising awareness of HIV risk behaviour and in linking HIV-positive individuals to care and treatment, research findings indicate that the HIV antibody testing rate in the general South African population remains relatively low, although knowledge of HIV testing services is high. The identification of important correlates of testing behaviour can be used to improve HIV testing campaigns by refining messages that target individuals at highest risk for infection. This study uses data from an ongoing prevention intervention study in Pretoria, South Africa to identify factors that may have a greater influence on facilitating or hindering HIV testing among South African women who face a high risk for infection. The data for this study (n=425) are derived from the baseline interviews and HIV test results collected between June 2004 and January 2007. HIV testing for this study was significantly associated with education level, alcohol and cannabis use, sex trading, number of STI symptoms, physical abuse and number of visits to a clinic for medical treatment. Results suggest that more focused efforts need to be made to provide HIV testing to women who report substance use behaviour, experience violence and report high-risk sexual behaviour. Interventions also need to address denial of HIV infection and fear to test for HIV.

The role of testing and counselling for HIV prevention and care in the era of scaling-up antiretroviral therapy

OBJECTIVE

HIV Testing and Counselling (TC) programmes are being scaled-up as part of efforts to provide universal access to antiretroviral treatment (ART).

METHODS AND FINDINGS

Mathematical modelling of TC in Zimbabwe shows that if universal access is to be sustained, TC must include prevention counselling that enables behaviour change among infected and uninfected individuals. The predicted impact TC is modest, but improved programmes could generate substantial reductions in incidence, reducing need for ART in the long-term.

CONCLUSIONS

TC programmes that focus only on identifying those in need of treatment will not be sufficient to bring the epidemic under control.

The costs and effectiveness of four HIV counseling and testing strategies in Uganda

OBJECTIVE

HIV counseling and testing (HCT) is a key intervention for HIV/AIDS control, and new strategies have been developed for expanding coverage in developing countries. We compared costs and outcomes of four HCT strategies in Uganda.

DESIGN

A retrospective cohort of 84 323 individuals received HCT at one of four Ugandan HCT programs between June 2003 and September 2005. HCT strategies assessed were stand-alone HCT; hospital-based HCT; household-member HCT; and door-to-door HCT.

METHODS

We collected data on client volume, demographics, prior testing and HIV diagnosis from project monitoring systems, and cost data from project accounts and personnel interviews. Strategies were compared in terms of costs and effectiveness at reaching key population groups.

RESULTS

Household-member and door-to-door HCT strategies reached the largest proportion of previously untested individuals (>90% of all clients). Hospital-based HCT diagnosed the greatest proportion of HIV-infected individuals (27% prevalence), followed by stand-alone HCT (19%). Household-member HCT identified the highest percentage of discordant couples; however, this was a small fraction of total clients (<4%). Costs per client (2007 USD) were $19.26 for stand-alone HCT, $11.68 for hospital-based HCT, $13.85 for household-member HCT, and $8.29 for door-to-door-HCT.

CONCLUSION

All testing strategies had relatively low per client costs. Hospital-based HCT most readily identified HIV-infected individuals eligible for treatment, whereas home-based strategies more efficiently reached populations with low rates of prior testing and HIV-infected people with higher CD4 cell counts. Multiple HCT strategies with different costs and efficiencies can be used to meet the UNAIDS/WHO call for universal HCT access by 2010.

Overestimating HIV infection: The construction and accuracy of subjective probabilities of HIV infection in rural Malawi

In the absence of HIV testing, how do rural Malawians assess their HIV status? In this paper, we use a unique dataset that includes respondents' HIV status as well as their subjective likelihood of HIV infection. These data show that many rural Malawians overestimate their likelihood of current HIV infection. The discrepancy between actual and perceived status raises an important question: Why are so many wrong? We begin by identifying determinants of self-assessed HIV status, and then compare these assessments with HIV biomarker results. Finally, we ask what characteristics of individuals are associated with errors in self-assessments.

The Demand for, and Impact of, Learning HIV Status

This paper evaluates an experiment in which individuals in rural Malawi were randomly assigned monetary incentives to learn their HIV results after being tested. Distance to the HIV results centers was also randomly assigned. Without any incentive, 34 percent of the participants learned their HIV results. However, even the smallest incentive doubled that share. Using the randomly assigned incentives and distance from results centers as instruments for the knowledge of HIV status, sexually active HIV-positive individuals who learned their results are three times more likely to purchase condoms two months later than sexually active HIV-positive individuals who did not learn their results; however, HIV-positive individuals who learned their results purchase only two additional condoms than those who did not. There is no significant effect of learning HIV-negative status on the purchase of condoms.

HIV risk behaviors in sub-Saharan Africa and Northern Thailand: baseline behavioral data from Project Accept

BACKGROUND

Of 2.5 million new HIV infections worldwide in 2007, most occurred in sub-Saharan Africa and southeast Asia. We present the baseline data on HIV risk behaviors and HIV testing in sub-Saharan Africa and northern Thailand from Project Accept, a community-randomized controlled trial of community mobilization, mobile voluntary counseling and testing (VCT), and posttest support services.

METHODS

A random household probability sample of individuals aged 18-32 years yielded a sample of 14,657, with response rates ranging from 84%-94% across the 5 sites (Thailand, Zimbabwe, Tanzania, and 2 in South Africa). Individuals completed an interviewer-administered survey on demographic characteristics, HIV risk behaviors, and history of VCT.

RESULTS

In multivariate analysis, females, married individuals, less educated with 1 sexual partner in the past 6 months were more likely to have had unprotected intercourse in the previous 6 months. Rates of lifetime HIV testing ranged from 5.4% among males in Zimbabwe to 52.6% among females in Soweto.

CONCLUSIONS

Significant risk of HIV acquisition in Project Accept communities exists despite 2 decades of prevention efforts. Low levels of recent HIV testing suggest that increasing awareness of HIV status through accessible VCT services may reduce HIV transmission.

Sexual prevention of HIV within the couple after prenatal HIV-testing in West Africa

The resumption of sexual activity after delivery is a key moment in the management of the risk of sexual HIV transmission within the couple for women who have been prenatally tested for HIV. In this study, we have investigated consistent condom use during the resumption of sexual activity and its evolution over time among women tested for HIV infection during pregnancy. We tested for HIV during pregnancy 546 HIV-infected and 393 HIV-negative women within the Ditrame Plus ANRS project in Abidjan; these women were followed-up for two years after delivery. Most HIV-negative women (96.7%) disclosed their HIV-test result to their partners, whereas only 45.6% of HIV-infected women did so (p<0.001). Partners of HIV-infected women were more likely to be tested for HIV before resuming sexual activity than partners of HIV-negative women (11.7% vs. 7.4%, p=0.054). Less than one third of both HIV-infected and HIV-negative women reported having systematically used condoms during the resumption of sexual activity. The proportions of HIV-infected and HIV-negative women having consistently used condoms were respectively 26.2% and 19.8% (p=0.193) at 3 months post-partum, 12.1% and 15.9% (p=0.139) at 12 months post-partum, and 8.4% and 10.6% (p=0.302) at 18 months post-partum. In our study, although women had been prenatally tested for HIV and properly counselled on the sexual risk of HIV transmission, male partners were not tested for HIV before the resumption of sexual activity after delivery, very few couples were using condoms systematically and condom use was decreasing over time.

ZAMSTAR, The Zambia South Africa TB and HIV Reduction Study: design of a 2 x 2 factorial community randomized trial

BACKGROUND

TB and HIV form a deadly synergy in much of the developing world, especially Africa. Interventions to reduce the impact of these diseases at community level are urgently needed. This paper presents the design of a community randomised trial to evaluate the impact of two complex interventions on the prevalence of tuberculosis (TB) in high HIV prevalence settings in Zambia and South Africa.

METHODS

The interaction between TB and HIV is reviewed and possible interventions that could reduce the prevalence of TB in HIV-endemic populations are discussed. Two of these interventions are described in detail and the design of a 2 x 2 factorial community randomised trial to test these interventions is presented. The limitations and challenges of the design are identified and discussed.

CONCLUSION

There is an urgent need to reduce the prevalence of TB in communities highly affected by HIV. Potential interventions are complex and require innovative trial designs to provide the rigorous evidence needed to inform health policy makers and to ensure that resources are used optimally.

TRIAL REGISTRATION

Number: ISRCTN36729271.