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

Delayed entry into and failure to remain in HIV care among HIV-infected adolescents

Prompt entry into care and retention in care are critical for improving outcomes among HIV-infected individuals. This study identified factors associated with HIV-infected adolescents who delayed entry into HIV care (DEC) after diagnosis of HIV or who fail to remain in care afterward (FRC). We reviewed clinical, demographic, and social data from the records of 202 HIV-positive adolescents (13-21 years old) infected via high-risk behaviors. Strength of association between clinical and social factors and DEC or FRC were estimated with log-linear regression models. DEC occurred in 38% (76/202) of adolescents. Factors independently associated with DEC were unstable residence (RR 1.5; CI: 1.0-2.1) and, compared with less education, college attendance (RR 2.1; CI: 1.5-3.2). FRC occurred in 29% (52/177) of adolescents established in care. Compared with college attendees, high school students (RR: 4.5; CI: 1.2-17.3) and those who dropped out of high school (RR: 4.0; CI: 1.1-15) were more likely to FRC. Compared with adolescents with private insurance, adolescents without insurance (despite access to free care) were more likely to FRC (RR: 2.8; CI: 1.1-6.9). Controlling for sex, adolescents with children were more likely to FRC (RR: 1.8; CI: 1.0-3.1). Interventions to avoid DEC that target HIV-infected adolescents with unstable residences or those diagnosed while attending college are warranted. Among patients engaged in care, those with only high school education or without insurance-which may be markers for socioeconomic status-need additional attention to keep them in care.

O aconselhamento e a testagem anti-HIV como estratégia preventiva: uma revisão da literatura internacional, 1999-2011

Com base em revisão bibliográfica discute-se a literatura produzida nos anos de 1999 a 2011, no campo da saúde coletiva, sobre uma importante estratégia de prevenção da transmissão do HIV: o aconselhamento e testagem anti-HIV. O artigo realiza um balanço da literatura internacional, analisando criticamente os aspectos mais assinalados pela comunidade científica, apontando divergências e convergências entre os estudos e identificando lacunas que possam estimular o desenvolvimento de novas pesquisas neste campo temático. Como resultado, evidenciou-se que os processos de decisão de realizar um teste e a experiência da testagem são discutidos na literatura com abordagens fragmentadas, sejam de ordem individual ou institucional. Para compreender diversas dimensões implicadas na adoção de uma prática preventiva como o teste HIV, é preciso contemplar indicadores sociais tais como gênero, religião, identidade sexual, raça/cor, e relacioná-los às políticas públicas e à operacionalização dos serviços de saúde. O uso expressivo do conceito de risco (aliado às categorias de grupo, comportamento, percepção) e de escalas quantitativas para aferir a percepção individual do risco como uma barreira para a realização do teste ilustra o foco excessivo sobre uma dimensão individual e parcial do problema.

HIV voluntary counselling and testing among recently initiated and traditionally circumcised men in the Eastern Cape Province of South Africa

HIV voluntary counselling and testing (VCT) is a cornerstone of the national strategic plan for HIV/AIDS treatment, care and support in South Africa. However, research shows that the utilisation of VCT services is disappointingly low, particular among males. This article focuses on the factors associated with the intention to test for HIV-infection among recently initiated and traditionally circumcised men in the rural areas of Eastern Cape Province, South Africa. Individual face-to-face interviews were conducted among 1656 sexually active men. Logistic regression analyses were used to explore the association between intention to test for HIV and psychosocial factors. Overall, 35.1% of the participants reported ever having tested for HIV. Intention to test for HIV was positively associated with perceived probability of getting an STI, positive attitudes towards gender-based violence, received general teachings about being a responsible man and highest grade passed. These findings provide specific information that can be used in the development of a focused cultural sensitive STI/HIV prevention programme aimed to increase VCT uptake among sexually active young men, which can be integrated into initiation and health education practices.

Marketing the HIV test to MSM: ethnic differences in preferred venues and sources

Lack of awareness of HIV status is associated with an increased likelihood of HIV transmission. We surveyed 633 men who have sex with men (MSM) from diverse ethnic groups recruited from a variety of community venues in a U.S. Midwestern city with rising HIV infection rates. Our first aim was to describe patterns of sexual risk, annual HIV testing frequency, and venues where information about HIV and HIV testing could be disseminated to inner-city MSM. Our second aim was to identify preferred sources to receive information about HIV testing and determine whether these preferences differed by ethnic background. Results indicated that despite similar proportions of high-sexual risk behaviors, compared with African American and Latino MSM, smaller proportions of non-Hispanic White MSM had received an HIV test in the last 12 months. Despite ethnic differences in health care access, a physician's office was the most common HIV testing site. Overall, a majority conveyed a preference to see advertisements in mainstream media outlets. However, when preferences were stratified by ethnicity, African American MSM were the least likely to prefer receiving information from mainstream media and conveyed a stronger preference to receive information from authority figures than non-Hispanic White and Hispanic MSM.

Self reported risk reduction behavior associated with HIV counseling and testing: a comparative analysis of facility- and home-based models in rural Uganda

Home-based human immunodeficiency virus (HIV) voluntary counseling and testing (VCT) in Uganda is being promoted to increase coverage, in addition to main stay approach of service provision through health facilities. The aim of this study was to compare self reported risk reduction behavior among clients receiving facility and home-based HIV VCT within a rural context. Pre-post intervention client surveys were conducted in November 2007 (baseline) and March 2008 (follow up) in southwestern Uganda. The facility-based VCT intervention was provided to 500 clients and home-based VCT to 494 clients at baseline, in 2 different sub-counties. A total of 76% (759/994) of these clients were interviewed at the follow up visit. The respondents who received facility-based VCT were more likely to report abstinence (adjusted Odds Ratio [aOR]=1.47, 95% CI 1.074, 2.02), reducing multi sexual relationships (aOR=3.23, 95% CI 2.02, 5.16) and more frequent use of condoms (aOR=3.14, 95% CI 1.60, 6.18). However, they were less likely to report, discussing HIV (aOR=0.63, 95% CI 0.46, 0.85) with their sexual partner/s and having sex with only one partner (aOR=0.72, 95% CI 0.519-0.99). While facility-based VCT appears to promote abstinence and condom use home-based VCT on the other hand promotes faithfulness and disclosure. VCT services should, therefore, be provided through both models in a complementary relationship and not as surrogates within given settings.

HIV testing behaviors of a cohort of HIV-positive racial/ethnic minority YMSM

The HIV epidemic in the United States has disproportionately affected young racial/ethnic minority men who have sex with men (YMSM). However, HIV testing rates among young men of color remain low. Within this sample of racial/ethnic minority YMSM (n = 363), the first HIV test was a median of 2 years after men who have sex with men sexual debut. Individuals with less than 1 year between their first negative and first positive HIV test were significantly more likely to identify the reason for their first negative test as being sick (OR = 2.99; 95 % CI 1.23-7.27). This may suggest that these YMSM may have experienced symptoms of acute HIV infection. Of major concern is that many YMSM in our study tested positive for HIV on their first HIV test. Given recommendations for at least annual HIV testing, our findings reveal that medical providers YMSM need to know the importance of regular testing.

Meta-analysis of single-session behavioral interventions to prevent sexually transmitted infections: implications for bundling prevention packages

Evidence-based, single-session behavioral interventions are urgently needed for preventing the spread of HIV and other sexually transmitted infections (STIs). To estimate the efficacy of single-session, behavioral interventions for STI prevention, we collected data from 29 single-session interventions (20 studies; n = 52 465) with an STI outcome. Infection with an STI was 35% less likely (odds ratio = 0.65; 95% confidence interval = 0.55-0.77) among intervention group participants than among control group participants. Single-session interventions offer considerable benefits in terms of disease prevention and create minimal burden for both the patient and the provider. Brief and effective STI prevention interventions are a valuable tool and can be readily adapted to bolster the benefits of biomedical technologies focusing on the prevention of HIV and other STIs.

The impact of HIV testing on subjective expectations and risky behavior in Malawi

We investigate the causal impact of learning HIV status on HIV/AIDS-related expectations and sexual behavior in the medium run. Our analyses document several unexpected results about the effect of learning one's own, or one's spouse's, HIV status. For example, receiving an HIV-negative test result implies higher subjective expectations about being HIV-positive after two years, and individuals tend to have larger prediction errors about their HIV status after learning their HIV status. If individuals in HIV-negative couples also learn the status of their spouse, these effects disappear. In terms of behavioral outcomes, our analyses document that HIV-positive individuals who learned their status reported having fewer partners and using condoms more often than those who did not learn their status. Among married respondents in HIV-negative couples, learning only one's own status increases risky behavior, while learning both statuses decreases risky behavior. In addition, individuals in sero-discordant couples who learned both statuses are more likely to report some condom use. Overall, our analyses suggest that ensuring that each spouse learns the HIV status of the other, either through couple's testing or through spousal communication, may be beneficial in high-prevalence environments.

Accuracy and user-acceptability of HIV self-testing using an oral fluid-based HIV rapid test

BACKGROUND

The United States FDA approved an over-the-counter HIV self-test, to facilitate increased HIV testing and earlier linkage to care. We assessed the accuracy of self-testing by untrained participants compared to healthcare worker (HCW) testing, participants' ability to interpret sample results and user-acceptability of self-tests in Singapore.

METHODOLOGY/PRINCIPAL FINDINGS

A cross-sectional study, involving 200 known HIV-positive patients and 794 unknown HIV status at-risk participants was conducted. Participants (all without prior self-test experience) performed self-testing guided solely by visual instructions, followed by HCW testing, both using the OraQuick ADVANCE Rapid HIV 1/2 Antibody Test, with both results interpreted by the HCW. To assess ability to interpret results, participants were provided 3 sample results (positive, negative, and invalid) to interpret. Of 192 participants who tested positive on HCW testing, self-testing was positive in 186 (96.9%), negative in 5 (2.6%), and invalid in 1 (0.5%). Of 794 participants who tested negative on HCW testing, self-testing was negative in 791 (99.6%), positive in 1 (0.1%), and invalid in 2 (0.3%). Excluding invalid tests, self-testing had sensitivity of 97.4% (95% CI 95.1% to 99.7%) and specificity of 99.9% (95% CI: 99.6% to 100%). When interpreting results, 96%, 93.1% and 95.2% correctly read the positive, negative and invalid respectively. There were no significant demographic predictors for false negative self-testing or wrongly interpreting positive or invalid sample results as negative. Eighty-seven percent would purchase the kit over-the-counter; 89% preferred to take HIV tests in private. 72.5% and 74.9% felt the need for pre- and post-test counseling respectively. Only 28% would pay at least USD15 for the test.

CONCLUSIONS/SIGNIFICANCE

Self-testing was associated with high specificity, and a small but significant number of false negatives. Incorrectly identifying model results as invalid was a major reason for incorrect result interpretation. Survey responses were supportive of making self-testing available.

Voluntary counseling and testing (VCT) for changing HIV-related risk behavior in developing countries

BACKGROUND

Voluntary counseling and testing (VCT) continues to play a critical role in HIV prevention, care and treatment. In recent years, different modalities of VCT have been implemented, including clinic-, mobile- and home-based testing and counseling. This review assesses the effects of all VCT types on HIV-related risk behaviors in low- and middle-income countries.

OBJECTIVES

The primary objective of this review is to systematically review the literature examining the efficacy of VCT in changing HIV-related risk behaviors in developing countries across various populations.

SEARCH METHODS

Five electronic databases - PubMed, Excerpta Medica Database (EMBASE), PsycINFO, Sociological Abstracts, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) - were searched using predetermined key words and phrases. Hand-searching was conducted in four key journals including AIDS, AIDS and Behavior, AIDS Education and Prevention, and AIDS Care; the tables of contents of these four journals during the included time period were individually screened for relevant articles. The reference lists of all articles included in the review were screened to identify any additional studies; this process was iterated until no additional articles were found.

SELECTION CRITERIA

To be included in the review, eligible studies had to meet the following inclusion criteria: 1) Take place in a low- or middle-income country as defined by the World Bank, 2) Published in a peer-reviewed journal between January 1, 1990 and July 6, 2010, 3) Involve client-initiated VCT, including pre-test counseling, HIV-testing, and post-test counseling, and 4) Use a pre/post or multi-arm design that compares individuals before and after receiving VCT or individuals who received VCT to those who did not, and 5) Report results pertaining to behavioral, psychological, biological, or social HIV-related outcomes.

DATA COLLECTION AND ANALYSIS

All citations were initially screened and all relevant citations were independently screened by two reviewers to assess eligibility. For all included studies data were extracted by two team members working independently using a standardized form.  Differences were resolved through consensus or discussion with the study coordinator when necessary. Study rigor was assessed using an eight point quality score and through the Cochrane Collaboration's Risk of Bias Assessment Tool. Outcomes comparable across studies, including condom use and number of sex partners, were meta-analyzed using random effects models. With respect to both meta-analyses, data were included from multi-arm studies and from pre/post studies if adequate data were provided. Other outcomes, including HIV-incidence, STI incidence/prevalence, and positive and negative life events were synthesized qualitatively. For meta-analysis, all outcomes were converted to the standard metric of the odds ratio. If an outcome could not be converted to an odds ratio, the study was excluded from analysis.

MAIN RESULTS

 An initial search yielded 2808 citations. After excluding studies failing to meet the inclusion criteria, 19 were deemed eligible for inclusion. Of these studies, two presented duplicate data and were removed. The remaining 17 studies were included in the qualitative synthesis and 8 studies were meta-analyzed.  Twelve studies offered  clinic-based VCT, 3 were employment-based, 1 involved mobile VCT, and 1 provided home-based VCT.  In meta-analysis, the odds of reporting increased number of sexual partners were reduced when comparing participants who received VCT to those who did not, unadjusted random effects pooled OR= 0.69 (95% CI: 0.53-0.90, p=0.007). When stratified by serostatus, these results only remained significant for those who tested HIV-positive. There was an insignificant increase in the odds of condom use/protected sex among participants who received VCT compared to those who did not, unadjusted random effects pooled OR=1.39 (95% CI: 0.97-1.99, p=0.076). When stratified by HIV status, this effect became significant among HIV-positive participants, random effects pooled OR= 3.24 (95% CI: 2.29-4.58, p<0.001).

AUTHORS' CONCLUSIONS

These findings add to growing evidence that VCT can change HIV-related sexual risk behaviors thereby reducing HIV-related risk, and confirming its importance as an HIV prevention strategy. To maximize the effectiveness of VCT, more studies should be conducted to understand which modalities and counseling strategies produce significant reductions in risky behaviors and lead to the greatest uptake of VCT.

Patient and provider acceptance of oral HIV screening in a dental school setting

In 2006, the Centers for Disease Control and Prevention (CDC) recommended routine HIV screening in health care settings regardless of the patient's level of risk. This pilot study was developed in response to the suggestion by some health care professionals that dental settings would be appropriate for expansion of HIV testing. This project consisted of two parts: oral fluid HIV testing of patients in the clinic of a dental school and a survey of the clinical dental faculty members' attitudes about acceptability of routine HIV testing in the dental clinic. When patients' agreement to participate in oral fluid HIV testing was examined, 8.2 percent of the patients contacted by the clinic administration staff completed testing. When approached by a faculty member or student during the dental visit admission and tested during the dental visit, however, 88.2 percent completed testing. Of the faculty members who took the survey, 27.4 percent were neutral, 26.4 percent were somewhat in agreement, and 32.1 percent were willing to incorporate HIV testing into routine dental care. In this pilot study, HIV testing of dental patients was most successful when a dental care provider approached patients about testing. If consent was given, the testing was performed during the visit. For the faculty members, the major barrier to testing was a lack of protocol familiarity.

Rates and predictors of consistent condom-use by people living with HIV/AIDS on antiretroviral treatment in Uganda

Antiretroviral treatment (ART) has been recognized as one of the methods for reducing the risk of HIV transmission, and access to this is being rapidly expanded. However, in a generalized HIV epidemic, ART could increase unprotected sex by people living with HIV/AIDS (PHAs). This paper assessed the rates and predictors of consistent condom-use by sexually-active PHAs after initiating ART. The study used cross-sectional data on sexual behaviour of 269 sexually-active ART-experienced individuals (95 males and 174 females) aged 18 years and above. The results revealed that 65% (70% of men and 61% of women) used condom consistently after initiating ART. Consistent use of condom was more likely if PHAs had secondary- or tertiary-level education and had more than one sex partner in the 12 months preceding the study. However, PHAs were less likely to have used condom consistently if they worked in the informal and formal sectors, belonged to the medium- and high-income groups, and were married. PHAs, who were on ART for less than 1 year and 1-2 year(s), had a good self-perception of health, had a sexual partner who was HIV-negative or a partner with unknown HIV status, and desired to bear children, were also less likely to have used condom consistently. The paper concluded that, although the majority of PHAs consistently used condom, there was potential for unprotected sex by PHAs on ART.

Social and individual risk determinants of HIV testing practices among noninjection drug users at high risk for HIV/AIDS

HIV testing services and research among drug users has largely focused on injection drug users (IDUs); yet noninjection drug users (NIDUs) are also at increased risk for HIV due to high-risk sexual behaviors and overlapping networks with IDUs. This study examined drug use, sexual risk, and social network characteristics associated with recent HIV testing (testing within past year) among NIDUs. Interviewer-administered questionnaires were conducted among 418 NIDUs and log-binomial regression models were used to identify correlates of recent HIV testing. Prevalence ratios (PR) with 95% confidence intervals (CI) were reported. Nearly 97% of NIDUs reported having ever been tested for HIV and most participants (85.7%) indicated testing for HIV within the past year. Factors independently associated with recent HIV testing were higher educational attainment (PR: 1.86; 95% CI: 1.03, 3.34) and networks to discuss health and medical services (PR: 1.84; 95% CI: 1.06, 1.20). A prior positive sexually transmitted infection was associated with decreased likelihood of recent HIV test (PR: 0.43; 95% CI 0.25, 0.74). Identifying specific social network characteristics may be effective in facilitating HIV testing and prevention strategies targeting NIDUs.

Factors that affect HIV testing and counseling services among heterosexuals in Canada and the United Kingdom: an integrated review

OBJECTIVE

To examine factors that affect the utilization of HIV testing and counseling (HTC) services among heterosexual populations in Canada and the U.K.

METHODS

We conducted an integrated review of published and unpublished literature (1996-September 2010) using Scopus, OVID-EMBASE, CSA illumina, CINHAL, PROQuest, Web of Science, and Google.

RESULTS

Twenty-seven studies met the inclusion criteria. We identified and categorized the key factors into three broad categories depending on their source. Personal-related factors included socio-demographic characteristics, risk perception, illness, HIV-related stigma, level of HIV and testing knowledge, and culture. Provider-related factors included provider-recommended HIV testing, provision of culturally and linguistically appropriate services, and doctor-patient relationship. System-related factors included integrating HIV testing with other health care services, anonymity of testing services, suitability of testing venues, technical aspects of HIV testing, and funding for immigrant health services.

CONCLUSION

The findings from our review indicate that HTC behaviors of heterosexuals in the Canada and the U.K. are likely influenced by several unchangeable (socio-demographic characteristics) and amenable factors. There is need to step-up research to confirm whether these associations are causal using stronger research designs. PRACTICAL IMPLICATION: We have made several recommendations that could be used to improve existing services in Canada.

A randomized controlled trial to evaluate the relative efficacy of enhanced versus standard voluntary counseling and testing on promoting condom use among men who have sex with men in China

The randomized controlled trial investigated the relative efficacy of an enhanced (EVCT) versus standard (SVCT) voluntary counseling and testing in reducing unprotected anal intercourse (UAI) among men who have sex with men (MSM) in China. 295 participants who recruited by respondent driven sampling methods were randomly allocated to the two arms. In addition to the SVCT, the EVCT group watched a theory-based video narrated by a HIV positive MSM, received enhanced counseling and a reminder gift. As compared to the SVCT group, the EVCT group reported lower prevalence of UAI with any male sex partners (48.4% versus 66.7%, RR = 0.7, ARR = -18.3%, p = 0.010) and with regular male sex partners (52.2% versus 68.9%, RR = 0.8, ARR = -16.7%, p = 0.043) at Month 6, whilst baseline between-group differences were statistically non-significant. Between-group differences in HIV/syphilis incidence were statistically non-significant. Translational research should be conducted to integrate non-intensive enhancements such as the EVCT into regular testing services.

HIV testing in non-traditional settings--the HINTS study: a multi-centre observational study of feasibility and acceptability

BACKGROUND

UK guidelines recommend routine HIV testing in healthcare settings if the local diagnosed HIV prevalence >2/1000 persons. This prospective study assessed the feasibility and acceptability, to patients and staff, of routinely offering HIV tests in four settings: Emergency Department, Acute Care Unit, Dermatology Outpatients and Primary Care. Modelling suggested the estimated prevalence of undiagnosed HIV infection in attendees would exceed 1/1000 persons. The prevalence identified prospectively was not a primary outcome.

METHODS

Permanent staff completed questionnaires assessing attitudes towards routine HIV testing in their workplace before testing began. Subsequently, over a three-month period, patients aged 16-65 were offered an HIV test by study staff. Demographics, uptake, results, and departmental activity were collected. Subsets of patients completed questionnaires. Analyses were conducted to identify factors associated with test uptake.

FINDINGS

Questionnaires were received from 144 staff. 96% supported the expansion of HIV testing, but only 54% stated that they would feel comfortable delivering testing themselves, with 72% identifying a need for training. Of 6194 patients offered a test, 4105 (66·8%) accepted (61·8-75·4% across sites). Eight individuals were diagnosed with HIV (0-10/1000 across sites) and all transferred to care. Younger people, and males, were more likely to accept an HIV test. No significant associations were found between uptake and ethnicity, or clinical site. Questionnaires were returned from 1003 patients. The offer of an HIV test was acceptable to 92%. Of respondents, individuals who had never tested for HIV before were more likely to accept a test, but no association was found between test uptake and sexual orientation.

CONCLUSIONS

HIV testing in these settings is acceptable, and operationally feasible. The strategy successfully identified, and transferred to care, HIV-positive individuals. However, if HIV testing is to be included as a routine part of patients' care, additional staff training and infrastructural resources will be required.

Allocating HIV prevention funds in the United States: recommendations from an optimization model

The Centers for Disease Control and Prevention (CDC) had an annual budget of approximately $327 million to fund health departments and community-based organizations for core HIV testing and prevention programs domestically between 2001 and 2006. Annual HIV incidence has been relatively stable since the year 2000 [1] and was estimated at 48,600 cases in 2006 and 48,100 in 2009 [2]. Using estimates on HIV incidence, prevalence, prevention program costs and benefits, and current spending, we created an HIV resource allocation model that can generate a mathematically optimal allocation of the Division of HIV/AIDS Prevention’s extramural budget for HIV testing, and counseling and education programs. The model’s data inputs and methods were reviewed by subject matter experts internal and external to the CDC via an extensive validation process. The model projects the HIV epidemic for the United States under different allocation strategies under a fixed budget. Our objective is to support national HIV prevention planning efforts and inform the decision-making process for HIV resource allocation. Model results can be summarized into three main recommendations. First, more funds should be allocated to testing and these should further target men who have sex with men and injecting drug users. Second, counseling and education interventions ought to provide a greater focus on HIV positive persons who are aware of their status. And lastly, interventions should target those at high risk for transmitting or acquiring HIV, rather than lower-risk members of the general population. The main conclusions of the HIV resource allocation model have played a role in the introduction of new programs and provide valuable guidance to target resources and improve the impact of HIV prevention efforts in the United States.

HIV-Related knowledge, attitudes, and practice among educated young adults in Botswana

Students at the University of Botswana, an at-risk group, have previously been shown to have high levels of risky sexual behavior despite widespread knowledge that these behaviors might lead to HIV-1 infection. As there have recently been considerable efforts focused on HIV-1 prevention in Botswana through nationwide media education campaigns and the opening of voluntary counselling and testing centers, re-evaluation of HIV-related knowledge, attitudes, and practices among students is needed. A cross-sectional survey was administered to 393 students chosen via a random cluster method. Respondents were 50% junior and 50% senior students with 42% males. Half (52%) were "single", 44% were "in a relationship", and 4% were "married". The mean percentage of knowledge questions answered correctly was 96%. 98% agreed that all sexually active adults should know their status and that condom use is important, but only 56% believed getting tested was common and 66% believed that it was common for students to always use a condom. As with the previous survey, we again found that students had excellent knowledge yet perceived use of testing services and condoms remain lower than might be predicted based on knowledge scores.

Early identification of HIV: empirical support for jail-based screening

BACKGROUND

Although routine HIV testing is recommended for jails, little empirical data exist describing newly diagnosed individuals in this setting.

METHODS

Client-level data (CLD) are available on a subset of individuals served in EnhanceLink, for the nine of the 10 sites who enrolled newly diagnosed persons in the client level evaluation. In addition to information about time of diagnosis, we analyzed data on initial CD4 count, use of antiretroviral therapy (ART), and linkage to care post discharge. Baseline data from newly diagnosed persons were compared to data from persons whose diagnoses predated jail admission.

RESULTS

CLD were available for 58 newly diagnosed and 708 previously diagnosed individuals enrolled between 9/08 and 3/11. Those newly diagnosed had a significantly younger median age (34 years) when compared to those previously diagnosed (41 years). In the 30 days prior to incarceration, 11% of those newly diagnosed reported injection drug use and 29% reported unprotected anal intercourse. Median CD4 count at diagnosis was 432 cells/mL (range: 22-1,453 cells/mL). A minority (21%, N = 12) of new diagnoses started antiretroviral treatment (ART) before release; 74% have evidence of linkage to community services.

CONCLUSION

Preliminary results from a cross-sectional analysis of this cohort suggest testing in jails finds individuals early on in disease progression. Most HIV(+) detainees did not start ART in jail; therefore screening may not increase pharmacy costs for jails. Detainees newly diagnosed with HIV in jails can be effectively linked to community resources. Jail-based HIV testing should be a cornerstone of "test and treat" strategies.

The contribution of maternal HIV seroconversion during late pregnancy and breastfeeding to mother-to-child transmission of HIV

BACKGROUND

The prevention of mother-to-child transmission (PMTCT) of HIV has been focused mainly on women who are HIV positive at their first antenatal visit, but there is uncertainty regarding the contribution to overall transmission from mothers who seroconvert after their first antenatal visit and before weaning.

METHOD

A mathematical model was developed to simulate changes in mother-to-child transmission of HIV over time, in South Africa. The model allows for changes in infant feeding practices as infants age, temporal changes in the provision of antiretroviral prophylaxis and counseling on infant feeding, as well as temporal changes in maternal HIV prevalence and incidence.

RESULTS

The proportion of mother-to-child transmission (MTCT) from mothers who seroconverted after their first antenatal visit was 26% [95% confidence interval (CI): 22% to 30%] in 2008, or 15,000 of 57,000 infections. It is estimated that by 2014, total MTCT will reduce to 39,000 per annum, and transmission from mothers seroconverting after their first antenatal visit will reduce to 13,000 per annum, accounting for 34% (95% CI: 29% to 39%) of MTCT. If maternal HIV incidence during late pregnancy and breastfeeding were reduced by 50% after 2010, and HIV screening were repeated in late pregnancy and at 6-week immunization visits after 2010, the average annual number of MTCT cases over the 2010-2015 period would reduce by 28% (95% CI: 25% to 31%), from 39,000 to 28,000 per annum.

CONCLUSION

Maternal seroconversion during late pregnancy and breastfeeding contributes significantly to the pediatric HIV burden and needs greater attention in the planning of prevention of MTCT programs.

HIV/AIDS-related stigmatizing and discriminatory attitudes and recent HIV testing among men who have sex with men in Beijing

This study assessed the correlates of recent HIV testing and HIV/AIDS-related stigmatizing and discriminatory attitudes among men who have sex with men (MSM) in Beijing, China. A cross-sectional study probed demographics, sexual and drug use behaviors, HIV testing, and prevention services. Of 500 participants, 39.3% recently received a test for HIV. Recent testing was independently associated with expressing lower levels of HIV/AIDS-related stigmatizing and discriminatory attitudes, more male sex partners, no female sexual partners and knowing HIV status of their last male partner. Expressing lower levels of HIV/AIDS-related stigmatizing and discriminatory attitudes was independently associated with recent testing, younger age, and knowing HIV status of their last male partner. This study revealed that HIV/AIDS-related stigmatizing and discriminatory attitudes were common and inversely associated with recent HIV testing. Low levels of testing highlighted the urgent needs to reduce HIV/AIDS-related stigma and discrimination and expand HIV testing among MSM in Beijing.

HIV diagnosis and sexual risk behavior intentions among couple VCT clients in Ethiopia

This research examines whether members of HIV affected couples are more likely to change their abstinence and condom intentions than members of HIV- couples during couple voluntary counseling and testing (VCT). A total of 1260 couple VCT clients in Ethiopia were asked about their sexual risk behavior intentions for the next two months after pre-test and post-test counseling. Multinomial logistic regression was used to determine whether the couple's HIV status was associated with changed intentions to abstain or use condoms between pre-test and post-test. Individuals belonging to male HIV+ serodiscordant couples (aRRR = 7.98, p < 0.001), female HIV+ serodiscordant couples (aRRR = 5.85, p < 0.001), and HIV+ concordant couples (aRRR = 3.12, p = 0.05) were more likely to have increased their intentions to abstain or use condoms in the next two months than individuals in HIV- concordant relationships. The couple's HIV status was not associated with decreased intentions to abstain or use condoms in the next two months. Counseling for all HIV affected couples should include practical information on obtaining and using condoms. This includes HIV affected couples who intend to abstain from sex, whether for a short or long period of time, so that they are prepared to have protected sex if their intentions change.

Changes in HIV risk behavior and seroincidence among clients presenting for repeat HIV counseling and testing in Moshi, Tanzania

While HIV counseling and testing (HCT) has been considered an HIV preventive measure in Africa, data are limited describing behavior changes following HCT. This study evaluated behavior changes and estimated HIV seroincidence rate among returning HCT clients. Repeat and one-time testing clients receiving HCT services in Moshi, Tanzania were identified. Information about sociodemographic characteristics, HIV-related behaviors and testing reasons were collected, along with HIV serostatus. Six thousand seven hundred and twenty-seven clients presented at least once for HCT; 1235 (18.4%) were HIV seropositive, median age was 29.7 years and 3712 (55.3%) were women. 1382 repeat and 4272 one-time testers were identified. Repeat testers were more likely to be male, older, married, or widowed, and testing because of unfaithful partner or new sexual partner. One-time testers were more likely to be students and testing due to illness. At second test, repeat testers were more likely to report that partners had received HIV testing, not have concurrent partners, not suspect partners have HIV, and have partners who did not have other partners. Clients who intended to change behaviors after the first test were more likely to report having changed behaviors by remaining abstinent (OR 2.58; p<0.0001) or using condoms (OR 2.00; p=0.006) at the second test. HIV seroincidence rate was 1.49 cases/100 person-years (PY). Clients presenting for repeat HCT reported some reduction of risky behavior and improved knowledge of sexual practices and HIV serostatus of their partners. Promoting behavior change through HCT should continue to be a focus of HIV prevention efforts in sub-Saharan Africa.

Disparities in access to HIV prevention among men of Mexican descent living in the Midwestern United States

Men of Mexican descent (MMD) in the U.S. are disproportionately affected by HIV. Understanding MMD's access to HIV prevention is necessary to reduce their transmission rates. We explored disparities in access to HIV prevention among MMD of different assimilation status, healthcare access, and sexual risk behavior. 322 Midwestern MMD completed a survey assessing their access to passive interventions (e.g., lectures), interactive interventions (e.g., counseling), HIV testing, media information, and information from the Internet. 64% MMD had received passive interventions, 36% interactive interventions, 42% HIV testing, 41% information from media, and 12% from the Internet. MMD who were less assimilated to the U.S., had lower healthcare access, and were at risk for HIV, were less likely to have accessed prevention interventions but more likely to have received media information. Access to HIV prevention among Midwestern MMD is tied to their assimilation and healthcare access. Findings have implications for developing strategies of intervention delivery.

Rapid HIV testing in dental practices

Despite increasing discussion about the dental care setting as a logical, potentially fruitful venue for rapid HIV testing, dentists' willingness to take on this task is unclear. Semistructured interviews with 40 private practice dentists revealed their principal concerns regarding offering patients HIV testing were false results, offending patients, viewing HIV testing as outside the scope of licensure, anticipating low patient acceptance of HIV testing in a dental setting, expecting inadequate reimbursement, and potential negative impact on the practice. Dentists were typically not concerned about transmission risks, staff opposition to testing, or making referrals for follow-up after a positive result. A larger cultural change may be required to engage dentists more actively in primary prevention and population-based HIV screening.

Using social networks to reach Black MSM for HIV testing and linkage to care

Black men who have sex with men (MSM) are disproportionately affected by HIV infection. Black MSM in San Francisco may have higher rates of unrecognized HIV infections. Increased HIV testing among Black MSM may reduce the numbers of unrecognized infections, inform more men of their status and thus reduce the potential for ongoing transmissions. Social network HIV testing programs have focused on asking HIV-positive and/or high-risk negative men to recruit their social or sexual contacts. We used a network approach to deliver HIV testing to Black MSM in San Francisco and collected risk assessment data. Participants were asked to recruit any of their social contacts who were also Black MSM. Recruitment by risk level and HIV status was heterogeneous. HIV infection among this population is associated with older age, having a high school education or higher and currently being homeless. Fully 23% of HIV positive Black MSM are unaware of their infection. Only a third of unrecognized infections were recruited by a known HIV-positive participant. Linkage to care was a challenge and underscores the need for comprehensive systems and support to link Black MSM to care and treatment.

Essentiality of HIV testing and education for effective HIV control in the national pilot harm reduction program: the Taiwan experience

In 2005, a national pilot harm reduction program (PHRP), which mainly included a methadone maintenance treatment program (MMTP) and a needle/syringe exchange program (NSP), was implemented in Taiwan. We conducted this study to evaluate the effectiveness of harm reduction measures on HIV control among injecting drug users (IDUs) between PHRP and nonPHRP. The data on HIV, collected from incumbent Taiwanese authorities, were analyzed for their associations, risk and protective factors with PHRP measures. While the monthly HIV incidences did not show significant differences before and after PHRP in the four areas with PHRP (Taipei City, Taipei County, Taoyuan County and Tainan County), a significant increase in the HIV incidence was found in the 21 areas without PHRP. Hence, the implementation of the PHRP did result in a significant difference in the monthly HIV incidence between areas with and without the PHRP. Mandatory HIV testing was significantly associated with the HIV incidence according to the generalized estimation equations (GEE) model. With adjustments of time period and area with PHRP, and urban area, protective factors associated with HIV incidence were: educational materials, condoms, dilution water, and alcohol sponges/swabs. MMTP contributed to a higher HIV incidence, probably due to the concurrent HIV testing upon admission. Since HIV testing was not required in the NSP, the HIV testing-dependent MMTP may explain the association of the PHRP intervention and an increased HIV incidence. In summary, HIV testing and education were essential for effective HIV control upon implementing the PHRP.

Preferences for rapid point-of-care HIV testing in primary care

Although the identification of individuals infected with HIV is an important element of treatment and prevention programs, many people living with HIV are unaware of their status. Thus, individuals are unable to benefit from treatment, and preventable HIV transmission continues to occur. Rapid point-of-care testing for HIV has been found to be preferred by patients in some contexts. However, few studies have examined preferences in primary care populations. This study investigates HIV testing preferences within an urban primary care clinic. Employing a cross-sectional design, data were collected on demographic characteristics, HIV risk factors, and testing history and preferences of participants. A total of 81% of participants stated that they would prefer rapid testing to standard testing, a finding that is consistent across demographic variables and risk factors examined. Increased availability of this modality may decrease barriers to HIV testing, with positive implications both for clinical management of HIV infection and prevention of HIV transmission.

Determinants of condom uptake among HIV voluntary counselling and testing clients: experiences from a hospital-based study in south India

Background

HIV voluntary counselling and testing was a key HIV prevention strategy brought to scale by India's National AIDS Control Organization. Condom uptake is an essential metric of intervention impact given the expansion of the epidemic into an increasingly diverse population. With only 20% of first-time counselling and testing clients at the largest HIV treatment hospital in south India reporting previous condom use, the question of intervention impact on condom use deserves investigation. In this study, we track intervention impact across various demographic groups and identify the added value of more thorough counselling.

Methods

Data were collected from 8,865 individuals who attended counselling multiple times at the Tamil Nadu Government Hospital of Thoracic Medicine over the years 2004-2009. Counsellors recorded client demographic characteristics, HIV risk behaviours reported, and counselling services provided after each counselling session. Matching and regression methods were used to determine the probability of condom uptake by serostatus, gender, and receipt of personalized risk reduction counselling while controlling for other characteristics.

Results

HIV counselling and testing was associated with condom uptake among 29.2% of HIV positive women (CI 24.5-34.4%), 31.7% of HIV positive men (CI 27.8-35.4%), 15.5% of HIV negative women (CI 11.2-20.8%), and only 3.6% of HIV negative men (CI 1.9-5.9%) who had previously never used condoms. Personalized risk reduction counselling increased impact in some groups; for example an additional 18% of HIV negative women (CI 11.3-24.4%) and 17% of HIV positive men (CI 10.9-23.4%) started using condoms. The number of sexual partners was not associated with the impact of counselling completeness.

Conclusions

Because the components of testing and counselling impact the condom use habits of men and women differently, understanding the dynamics of condom use negotiation between partners is essential to optimizing impact on Indian couples. Clients' predicted condom uptake ranged between 4% and 47% depending on factors like gender, serostatus, and services provided. Personalized risk reduction counselling is associated with increased chance of condom use, with larger gains in HIV negative women and HIV positive men. HIV negative men are least likely to start using condoms and least impacted by additional counselling.

Paying for prevention: challenges to health insurance coverage for biomedical HIV prevention in the United States

Reducing the incidence of HIV infection continues to be a crucial public health priority in the United States, especially among populations at elevated risk such as men who have sex with men, transgender women, people who inject drugs, and racial and ethnic minority communities. Although most HIV prevention efforts to date have focused on changing risky behaviors, the past decade yielded efficacious new biomedical technologies designed to prevent infection, such as the prophylactic use of antiretroviral drugs and the first indications of an efficacious vaccine. Access to prevention technologies will be a significant part of the next decade's response to HIV and advocates are mobilizing to achieve more widespread use of these interventions. These breakthroughs, however, arrive at a time of escalating healthcare costs; health insurance coverage therefore raises pressing new questions about priority-setting and the allocation of responsibility for public health. The goals of this Article are to identify legal challenges and potential solutions for expanding access to biomedical HIV prevention through health insurance coverage. This Article discusses the public policy implications of HIVprevention coverage decisions, assesses possible legal grounds on which insurers may initially deny coverage for these technologies, and evaluates the extent to which these denials may survive external and judicial review. Because several of these legal grounds may be persuasive, particularly denials on the basis of medical necessity, this Article also explores alternative strategies for financing biomedical HIV prevention efforts.

HIV testing behaviors among female sex workers in Southwest China

Despite the recognized importance of HIV testing in prevention, care and treatment, HIV testing remains low in China. Millions of female sex workers (FSW) play a critical role in China's escalating HIV epidemic. Limited data are available regarding HIV testing behavior among this at-risk population. This study, based on a cross-sectional survey of 1,022 FSW recruited from communities in Southwest China, attempted to address the literature gap. Our data revealed that 48% of FSW ever took HIV testing; older age, less education, working in higher-income commercial sex venues and better HIV knowledge were associated with HIV testing. Those who never took HIV testing were more likely to engage in high-risk behaviors including inconsistent condom use with clients and stable partners. A number of psychological and structural barriers to testing were also reported. We call for culturally appropriate interventions to reduce HIV risks and promote HIV testing for vulnerable FSW in China.

Correlates of HIV testing uptake among kothi-identified men who have sex with men in public sex environments in Chennai, India

Kothi-identified men who have sex with men in India are highly marginalized and are at high-risk for HIV. This study examines HIV testing among 132 self-reported HIV-negative and unknown serostatus kothis recruited from public sex environments in Chennai, India. Using logistic regression we identified variables associated with HIV testing uptake (i.e., being tested and knowing the result). Sixty-one percent reported HIV testing uptake. At the bivariate level, married men, those with low HIV transmission knowledge, those who engaged in unprotected anal sex and unprotected receptive anal sex were at lower odds of reporting testing uptake. In multivariate analysis, married men and those with low levels of HIV transmission knowledge were at decreased odds of being tested, as were kothis who experienced forced sex. Culturally competent programs engaging married kothis are needed. Interventions to facilitate HIV prevention education and systemic interventions to combat sexual violence may facilitate HIV testing uptake among kothis.

Efficacy of behavioral interventions to increase condom use and reduce sexually transmitted infections: a meta-analysis, 1991 to 2010

OBJECTIVE

In the absence of an effective HIV vaccine, safer sexual practices are necessary to avert new infections. Therefore, we examined the efficacy of behavioral interventions to increase condom use and reduce sexually transmitted infections (STIs), including HIV.

DESIGN

Studies that examined a behavioral intervention focusing on reducing sexual risk, used a randomized controlled trial or a quasi-experimental design with a comparison condition, and provided needed information to calculate effect sizes for condom use and any type of STI, including HIV.

METHODS

Studies were retrieved from electronic databases (eg, PubMed, PsycINFO) and reference sections of relevant papers. Forty-two studies with 67 separate interventions (N = 40,665; M age = 26 years; 68% women; 59% Black) were included. Independent raters coded participant characteristics, design and methodological features, and intervention content. Weighted mean effect sizes, using both fixed-effects and random-effects models, were calculated. Potential moderators of intervention efficacy were assessed.

RESULTS

Compared with controls, intervention participants increased their condom use [d+ = 0.17, 95% confidence interval (CI) = 0.04, 0.29; k = 67], had fewer incident STIs (d+ = 0.16, 95% CI = 0.04, 0.29; k = 62), including HIV (d+ = 0.46, 95% CI = 0.13, 0.79; k = 13). Sample (eg, ethnicity) and intervention features (eg, skills training) moderated the efficacy of the intervention.

CONCLUSIONS

Behavioral interventions reduce sexual risk behavior and avert STIs and HIV. Translation and widespread dissemination of effective behavioral interventions are needed.

Facilitating access to sexual health services for men who have sex with men and male-to-female transgender persons in Guatemala City

The purpose of this study was to identify barriers to accessing sexual health services among gay, bisexual and heterosexual-identifying men who have sex with men and male-to-female transgender persons in Guatemala City, to inform the development of high quality and population-friendly services. In-depth, semi-structured interviews were conducted with 29 purposively sampled individuals, including 8 transgender, 16 gay/bisexual and 5 heterosexual-identifying participants. Topical codes were applied to the data using software Atlas.ti™ to compare data between sub-groups. Analysis revealed that public clinics were most commonly used due to their lower cost and greater accessibility, but many participants experienced discrimination, violation of confidentiality and distrust of these services. Transgender and gay/bisexual-identifying participants preferred clinics where they felt a sense of belonging, while heterosexual-identifying participants preferred clinics unassociated with the men who have sex with men community. The most prominent barriers to sexual health services included fear of discrimination, fear of having HIV, cost and lack of social support. Findings highlight the need to strengthen existing public sexually transmitted infection clinics so that they address the multiple layers of stigma and discrimination that men who have sex with men and transgender persons experience.

Developing and piloting an expert system for better routine voluntary HIV counseling and testing in China: preliminary results and lessons

This study aims at developing and testing a pragmatic expert system for HIV voluntary counseling (VCT-ES) that leverages best practices. The VCT-ES was developed via evolutionary prototyping and piloted in 10 voluntary HIV counseling and testing (VCT) clinics from Anhui and Beijing representative of prefecture and county level VCT clinics in China. All counselors with the clinics and the clients to the clinics within selected two weeks at baseline and the end of study were invited to participate. Assessment measures included essential counseling procedures (ECPs); clients' satisfaction, knowledge, and behavior efficacy. VCT-ES was developed which tries to model and facilitate standard VCT operation procedures and best practices. One hundred and eighty-two (96 at baseline vs. 86 after intervention) cases recordings, 172 (96 vs. 76) client questionnaires, 10 counselor, and 2 expert rating instruments were collected; and 17 clients and 8 counselors participated in qualitative interviews. VCT-ES increased delivery of ECPs from 18.94% to 66.39% on average; increased clients' knowledge from 40.51% to 86.34% and self-efficacy by 22.42%. The VCT-ES applications listed were rated 9.1 on average (maximum = 10). The VCT-ES could be an easy and effective solution to better routine VCT and merits further research.

"The anticipation alone could kill you": past and potential clients' perspectives on HIV testing in non-health care settings

HIV testing in non-health care settings is an effective strategy for increasing the proportion of persons aware of their infection. We conducted 21 focus groups with 186 past and potential clients in five U.S. cities to explore attitudes and experiences related to HIV counseling and testing in non-health care settings. Qualitative analysis yielded several key themes. HIV-related stigma and fear emerged as a main theme throughout the discussions. Knowing one's HIV status quickly and accurately was of primary importance; HIV prevention counseling was secondary. Participants prioritized a supportive, nonjudgmental environment with adequate privacy and confidentiality. Provision of immediate emotional support, medical information, and linkage services to HIV-infected clients were considered essential. Staff with HIV-specific skills to address clients' emotional and informational needs was considered a strength of non-health care testing programs. Frequently, however, participants compared non-health care settings unfavorably to health care settings regarding privacy, competency, confidentiality, and test accuracy. Recommendations for enhancing counseling and testing services in non-health care settings are discussed.

Qualitative analysis of an educational intervention with HIV-discordant heterosexual Latino couples

OBJECTIVE

This qualitative analysis elucidates the potential elements of the intervention that may be effective in terms of a) increasing knowledge about HIV/ AIDS in the members of this population; b) increasing the use of male condoms and the practice of mutual masturbation; and c) changing opinions toward male condom use and mutual masturbation.

METHODS

Five heterosexual HIV-discordant couples participated in the adapted intervention, which consisted of four three-hour-long sessions. One month after the intervention, we conducted a qualitative semi-structured interview with every participant to evaluate issues related to the process and content of the activities comprising the intervention, the impact of the intervention, logistics, and recruitment and retention as well as to make a more general evaluation. The information was submitted to qualitative content analysis.

RESULTS

After the intervention, participants reported having better attitudes regarding safer sex, particularly in terms of condom use. A reason given by the participants to feel more positive toward condom use and mutual masturbation was that these practices could prevent the infection of the HIV-negative partner.

CONCLUSION

This study provides important evidence of an intervention that promises to be efficacious in preventing some high-risk sexual behaviors among Latino HIV-discordant heterosexual couples. The evidence presented seems to suggest that an intervention that includes basic relevant information about HIV/AIDS, that explains the benefits of condom use and other safer sex options, and that provides effective negotiation and communication strategies could significantly reduce HIV transmission among these couples.

Acceptability and feasibility of rapid HIV testing in an adolescent clinic setting: youth testing attitudes, knowledge, and behaviors

PURPOSE

To assess youths' attitudes, knowledge, and behaviors regarding rapid HIV testing (RHT) and measure acceptability and feasibility of RHT in an adolescent clinic setting.

METHODS

A 2007-2008 project introduced free RHT at an urban, hospital-based adolescent and young adult clinic in Boston, MA. Patients and HIV testing clients were offered either free nonrapid tests or fingerstick RHT. An anonymous questionnaire assessed youths' testing attitudes, knowledge, and behaviors (N = 127). Ordinal logistic regression model was used to determine associations with youth demographic characteristics and testing experience.

RESULTS

Most participants valued rapid results. A minority desired confidentiality from parents and insurance providers. Older youth were more likely to know about testing methods (OR: 1.25; CI: 1.04-1.51) and plan for follow-up (OR: 1.43; CI: 1.14-1.81). Age, gender, and race were unrelated to testing facilitators such as rapidity, confidentiality, and cost, although younger clients were more likely to prefer noninvasive methods. Individuals with previous testing experience were more likely to say that they would contribute to expenses and value rapidity over cost.

CONCLUSION

There was strong support for RHT among youth receiving HIV testing. Offering RHT to youth may facilitate routine testing. Future research should focus on increasing RHT access among diverse populations of youth.

Access to housing subsidies, housing status, drug use and HIV risk among low-income U.S. urban residents

BACKGROUND

Much research has shown an association between homelessness and unstable housing and HIV risk but most has relied on relatively narrow definitions of housing status that preclude a deeper understanding of this relationship. Fewer studies have examined access to housing subsidies and supportive housing programs among low-income populations with different personal characteristics. This paper explores personal characteristics associated with access to housing subsidies and supportive housing, the relationship between personal characteristics and housing status, and the relationship between housing status and sexual risk behaviors among low-income urban residents.

METHODS

Surveys were conducted with 392 low-income residents from Hartford and East Harford, Connecticut through a targeted sampling plan. We measured personal characteristics (income, education, use of crack, heroin, or cocaine in the last 6 months, receipt of welfare benefits, mental illness diagnosis, arrest, criminal conviction, longest prison term served, and self-reported HIV diagnosis); access to housing subsidies or supportive housing programs; current housing status; and sexual risk behaviors. To answer the aims above, we performed univariate analyses using Chi-square or 2-sided ANOVA's. Those with significance levels above (0.10) were included in multivariate analyses. We performed 2 separate multiple regressions to determine the effects of personal characteristics on access to housing subsidies and access to supportive housing respectively. We used multinomial main effects logistic regression to determine the effects of housing status on sexual risk behavior.

RESULTS

Being HIV positive or having a mental illness predicted access to housing subsidies and supportive housing, while having a criminal conviction was not related to access to either housing subsidies or supportive housing. Drug use was associated with poorer housing statuses such as living on the street or in a shelter, or temporarily doubling up with friends, acquaintances or sex partners. Living with friends, acquaintances or sex partners was associated with greater sexual risk than those living on the street or in other stable housing situations.

CONCLUSIONS

Results suggest that providing low-income and supportive housing may be an effective structural HIV prevention intervention, but that the availability and accessibility of these programs must be increased.

Identifying barriers to HIV testing: personal and contextual factors associated with late HIV testing

Late diagnosis of HIV is associated with increased morbidity, mortality, and health care costs. Despite the availability of HIV testing, persons continue to test late in the course of HIV infection. We used the HIV/AIDS case registry of San Francisco Department of Public Health to identify and recruit 41 persons who developed AIDS within 12 months of their HIV diagnosis to participate in a qualitative and quantitative interview regarding late diagnosis of HIV. Thirty-one of the participants were diagnosed with HIV because of symptomatic disease and 50% of the participants were diagnosed with HIV and AIDS concurrently. Half of the subjects had not been tested for HIV prior to diagnosis. Fear was the most frequently cited barrier to testing. Other barriers included being unaware of improved HIV treatment, free/low cost care, and risk for HIV. Recommendations for health care providers to increase early diagnosis of HIV include routine ascertainment of HIV risk behaviors and testing histories, stronger recommendations for patients to be tested, and incorporating testing into routine medical care. Public health messages to increase testing include publicizing that (1) effective, tolerable, and low cost/free care for HIV is readily available, (2) early diagnosis of HIV improves health outcomes, (3) HIV can be transmitted to persons who engage in unprotected oral and insertive anal sex and unprotected receptive anal intercourse without ejaculation and from HIV-infected persons whose infection is well-controlled with antiretroviral therapy, (4) persons who may be infected based upon these behaviors should be tested following exposure, (5) HIV testing information will be kept private, and (6) encouraging friends and family to get HIV tested is beneficial.

Adolescents and HIV infection: the pediatrician's role in promoting routine testing

Pediatricians can play a key role in preventing and controlling HIV infection by promoting risk-reduction counseling and offering routine HIV testing to adolescent and young adult patients. Most sexually active youth do not feel that they are at risk of contracting HIV and have never been tested. Obtaining a sexual history and creating an atmosphere that promotes nonjudgmental risk counseling is a key component of the adolescent visit. In light of increasing numbers of people with HIV/AIDS and missed opportunities for HIV testing, the Centers for Disease Control and Prevention recommends universal and routine HIV testing for all patients seen in health care settings who are 13 to 64 years of age. There are advances in diagnostics and treatment that help support this recommendation. This policy statement reviews the epidemiologic data and recommends that routine screening be offered to all adolescents at least once by 16 to 18 years of age in health care settings when the prevalence of HIV in the patient population is more than 0.1%. In areas of lower community HIV prevalence, routine HIV testing is encouraged for all sexually active adolescents and those with other risk factors for HIV. This statement addresses many of the real and perceived barriers that pediatricians face in promoting routine HIV testing for their patients.

Changes in sexual risk behavior before and after HIV seroconversion in Southern African women enrolled in a HIV prevention trial

BACKGROUND

We examine changes in sexual risk behaviors before and after HIV seroconversion in southern African women enrolled in the Methods for Improving Reproductive Health in Africa trial.

METHODS

HIV testing and counseling, and assessment of sexual behaviors by audio computer-assisted self-interviewing were performed approximately every 3 months. We compared the following sexual behaviors: being sexually active, coital frequency, consistent male condom use, use of any female condoms, anal sex, and >1 sex partner, at study visits before and after HIV seroconversion.

RESULTS

During the trial, 327 women seroconverted to HIV, contributing 718 pre-HIV and 1110 post-HIV study visits. Women were significantly more likely to report consistent condom use at visits after HIV seroconversion compared with visits before HIV infection [adjusted odds ratio, (AOR): 1.36 (95% confidence interval (CI): 1.11 to 1.67)] and were less likely to have >1 male sex partner after serconversion [AOR: 0.66 (95% CI: 0.48 to 0.91)]. Women reported less frequently being sexually active [AOR: 0.63 (95% CI: 0.39 to 1.02)], fewer episodes of sex [>4 sex acts over the past week AOR: 0.74 (95% CI: 0.60 to 0.91)], and a reduction in anal sex [AOR: 0.58 (95% CI: 0.36 to 0.95)] at visits after HIV seroconversion. The observed reductions in sexual risk behaviors persisted over time.

CONCLUSIONS

Women significantly decreased their sexual risk behaviors after HIV seroconversion, but these changes were relatively modest, suggesting the need for further secondary prevention. Timely notification of HIV status coupled with prevention messages can contribute to reductions in sexual risk behaviors.

The Global Fund's resource allocation decisions for HIV programmes: addressing those in need

BACKGROUND

Between 2002 and 2010, the Global Fund to Fight AIDS, Tuberculosis and Malaria's investment in HIV increased substantially to reach US$12 billion. We assessed how the Global Fund's investments in HIV programmes were targeted to key populations in relation to disease burden and national income.

METHODS

We conducted an assessment of the funding approved by the Global Fund Board for HIV programmes in Rounds 1-10 (2002-2010) in 145 countries. We used the UNAIDS National AIDS Spending Assessment framework to analyze the Global Fund investments in HIV programmes by HIV spending category and type of epidemic. We examined funding per capita and its likely predictors (HIV adult prevalence, HIV prevalence in most-at-risk populations and gross national income per capita) using stepwise backward regression analysis.

RESULTS

About 52% ($6.1 billion) of the cumulative Global Fund HIV funding was targeted to low- and low-middle-income countries. Around 56% of the total ($6.6 billion) was channelled to countries in sub-Saharan Africa. The majority of funds were for HIV treatment (36%; $4.3 billion) and prevention (29%; $3.5 billion), followed by health systems and community systems strengthening and programme management (22%; $2.6 billion), enabling environment (7%; $0.9 billion) and other activities. The Global Fund investment by country was positively correlated with national adult HIV prevalence. About 10% ($0.4 billion) of the cumulative HIV resources for prevention targeted most-at-risk populations.

CONCLUSIONS

There has been a sustained scale up of the Global Fund's HIV support. Funding has targeted the countries and populations with higher HIV burden and lower income. Prevention in most-at-risk populations is not adequately prioritized in most of the recipient countries. The Global Fund Board has recently modified eligibility and prioritization criteria to better target most-at-risk populations in Round 10 and beyond. More guidance is being provided for Round 11 to strategically focus demand for Global Fund financing in the present resource-constrained environment.

HIV incidence and risk behaviours after voluntary HIV counselling and testing (VCT) among adults aged 19–35 years living in peri-urban communities around Chiang Mai city in northern Thailand, 1999

The Thai government began HIV voluntary counselling and testing (VCT) in all provinces in 1992. We evaluated HIV incidence after participants utilized VCT and its effect on risk behaviours among northern Thai adults aged 19-35 years. A total of 924 men and 1,327 women volunteered to participate in the study. Subjects were counseled, interviewed (socio-demographic, HIV risk behaviour, and HIV testing history), and tested for HIV infection at baseline and at 6 months follow-up. All participants were provided group pre-test counselling; HIV test results were provided in individual confidential post-test counselling. Overall, 329 of 391 men and 621 of 669 women who reported a prior HIV test before participating in our study reported negative results at the previous test. Of these, nine men and 13 women tested positive at baseline, giving incidence rates of 1.04 and 0.69 per 100 person years (PY), respectively. Recent risk behaviour was rare; as a result, the effects of VCT on risk behaviours among the study participants could not be determined. The HIV incidence after VCT among this study population is substantial. Studies to investigate factors associated with HIV incidence among VCT clients could provide insights for more effective HIV prevention.