A serostatus-based approach to HIV/AIDS prevention and care in Africa

Spatial pattern and associated factors of HIV testing and counselling among youths (15-24 years) in Ethiopia

BACKGROUND

HIV testing and counseling (HTC) services are key for HIV prevention, treatment, care, and support. Although the prevalence of HIV infection is high among adolescents and young adults, evidence suggests the utilization of HTC service among youth is very low in Ethiopia. Identifying factors and the geographic variation of HTC uptake is important to prioritize and design targeted prevention programs to increase its utilization and reduce HIV infection in hot spot areas.

METHODS

Data from the 2016 Ethiopian Demographic and Health Survey were used to analyze 10,781 youth aged 15-24 years. The spatial analysis was performed in ArcGIS 10.1. The Bernoulli model was used by applying Kulldorff methods using the SaTScan software to analyze the purely spatial clusters of HTC uptake. A multilevel logistic regression analysis was used to identify the associated individual and community-level factors of HTC uptake and estimate between community variance. All models were fitted in Stata version 14.0 and finally, the adjusted odds ratio (AOR) with a corresponding 95% confidence interval (CI) were reported.

RESULTS

In this study, the spatial patterns of HTC uptake were found to be non-random (Global Moran's I = 0.074, p value< 0.001). Forty-seven primary clusters were identified that were located in the entire Somali region with a relative likelihood of 1.50 and the Log-Likelihood Ratio of 135.57. Youth who were ever married (AOR = 4.65; 95% CI; 4.05, 5.34), those attended higher education (AOR = 3.97; 95% CI; 3.10,5.08), those from richest household (AOR = 1.86; 95% CI; 1.44, 2.39), aged 20-24 years (AOR = 2.25; 95% CI; 2.02,2.51), having compressive HIV related knowledge (AOR = 2.05; 95% CI; 1.75,2.41), and exposed to media (AOR = 1.38; 95% CI; 1.22,1.57) were positive association with HTC uptake. However, being male (AOR = 0.81; 95% CI; 0.73,0.91) and having high HIV related stigma (AOR = 0.53; 95% CI; 0.42,0.67) were negatively associated with HTC uptake. At the community-level, youth from communities with a high percentage of educated (AOR = 1.45; 95% CI; 1.17,1.80) were more likely to utilize HTC compared with those from communities with low percentages of educated.

CONCLUSION

The current study indicated differences in HTC uptake in the country. Both individual and community-level factors affected HTC uptake in Ethiopia. Multifaceted intervention approaches that consider individual and community factors are required to improve HTC uptake.

[Characteristics of people who voluntarily repeat the HIV test, 2012-2015]

OBJECTIVE

To compare the characteristics of people with risky sexual behavior who participated in campaigns directed to take the first HIV test and voluntarily returned to retake the test afterwards.

MATERIALS AND METHODS

In Cali Colombia, between 2012 and 2015, 82 people over the age of 18 participated voluntarily in this campaign. A structured questionnaire was applied to assess sociodemographic characteristics, knowledge and behaviors related to HIV. Descriptive and comparative analyses of related samples were performed.

RESULTS

The average age of the participants was 26.9±8.6 years. 100% were homosexual men, mostly with low educational attainment and income. Nearly half of the sample reported risky use of alcohol and psychoactive substances. Most of them had little knowledge about HIV transmission and a low rate of condom use with a stable partner. The comparison between the moment when the first HIV test was taken and the repetition did not show significant changes regarding knowledge and behaviors, only a lower report of substance use (p=0.0209) and an increase in the practice of tattoos/piercings (p=0.0455). The reactive result of the second test was 4.9% (95%CI: 0.1%-9.6%).

CONCLUSION

The results suggest that the voluntary return to retake the HIV test in this group of people who share risk practices for HIV infection does not show changes in knowledge or behavior.

HIV prevention among youth: A randomized controlled trial of voluntary counseling and testing for HIV and male condom distribution in rural Kenya

OBJECTIVE

Voluntary Counseling and Testing for HIV (VCT) and increasing access to male condoms are common strategies to respond to the HIV/AIDS pandemic. Using biological and behavioral outcomes, we compared programs to increase access to VCT, male condoms or both among youth in Western Kenya with the standard available HIV prevention services within this setting.

DESIGN

A four arm, unblinded randomized controlled trial.

METHODS

The sample includes 10,245 youth aged 17 to 24 randomly assigned to receive community-based VCT, 150 male condoms, both VCT and condoms, or neither program. All had access to standard HIV services available within their communities. Surveys and blood samples for HSV-2 testing were collected at baseline (2009-2010) and at follow up (2011-2013). VCT was offered to all participants at follow up. HSV-2 prevalence, the primary outcome, was assessed using weighted logistic regressions in an intention-to-treat analysis.

RESULTS

For the 7,565 respondents surveyed at follow up, (effective tracking rate = 91%), the weighted HSV-2 prevalence was similar across groups (control group = 10.8%, condoms only group = 9.1%, VCT only group = 10.2%, VCT and condoms group = 11.5%). None of the interventions significantly reduced HSV-2 prevalence; the adjusted odds ratios were 0.87 (95% CI: 0.61-1.25) for condoms only, 0.94 (95% CI: 0.64-1.38) for VCT only, and 1.12 (95% CI: 0.79-1.58) for both interventions. The VCT intervention significantly increased HIV testing (adj OR: 3.54, 95% CI: 2.32-5.41 for VCT only, and adj OR: 5.52, 95% CI: 3.90-7.81 for condoms and VCT group). There were no statistically significant effects on risk of HIV, or on other behavioral or knowledge outcomes including self-reported pregnancy rates.

CONCLUSION

This study suggests that systematic community-based VCT campaigns (in addition to VCT availability at local health clinics) and condom distribution are unlikely on their own to significantly reduce the prevalence of HSV-2 among youth.

The Differential Effects of an Opt-Out HIV Testing Policy for Pregnant Women in Ethiopia When Accounting for Stigma: Secondary Analysis of DHS Data

Individual factors associated with HIV testing have been studied across multiple populations; however, testing is not just an individual-level phenomenon. This secondary analysis of 2005 and 2011 Ethiopia Demographic and Health Survey data was conducted to determine the extent to which the 2007 institution of an opt-out policy of HIV testing during antenatal care increased testing among women, and whether effects differed by women's stigmatizing beliefs about HIV. A logit model with interaction between pre-/post-policy year and policy exposure (birth in the past year) was used to estimate the increased probability of past-year testing, which may be attributable to the policy. Results suggested the policy contributed to a nine-point increase in the probability of testing (95% CI 0.06-0.13, p < 0.0001). A three-way interaction was used to compare the effects of exposure to the policy among women holding higher and lower HIV stigmatizing beliefs. The increase in the probability of past-year testing was 16 percentage points greater among women with lower stigmatizing beliefs (95% CI 0.06-0.27, p = 0.002). Women with higher stigmatizing beliefs were less likely to report attending antenatal care (ANC), testing at their last ANC visit, or being offered a test at their last ANC visit. We encourage researchers and practitioners to explore interventions that operate at multiple levels of socio-ecological spheres of influence, addressing both stigma and structural barriers to testing, in order to achieve the greatest results in preventing HIV.

Factors associated with changes in uptake of HIV testing among young women (aged 15-24) in Tanzania from 2003 to 2012

Background

This study explored the factors associated with changes in HIV testing uptake among young women in Tanzania, based on an analysis of data from the 2003–2004 Tanzania HIV/AIDS Indicator Survey, and the 2007–2008 and 2011–2012 Tanzania HIV/AIDS and Malaria Indicator Surveys.

Methods

The study population consisted of young women aged 15–24 years at the time of the survey. Multivariate decomposition analysis was used to assess factors associated with changes in HIV testing uptake between the 2003–2004 and 2007–2008 surveys, and between the 2007–2008 and 2011–2012 surveys.

Results

HIV testing uptake among the study population was 7 % in 2003–2004, 31 % in 2007–2008 and 40 % in 2011–2012. The time period of the survey had a substantial effect on the uptake of HIV testing independent of other covariates. The characteristics that were significantly associated with a higher chance of HIV testing uptake across the surveys were age (20–24), education level (primary and secondary), ever being married, having at least one lifetime sexual partner, having a sexually transmitted infection or associated symptoms, and receiving antenatal care.

Conclusions

Changes in the study participants’ characteristics in the 2003–2004 survey compared with the 2007–2008 survey were associated with a decrease in HIV testing uptake. Comparing the 2007–2008 survey with the 2011–2012 survey shows that the changes in the participants’ characteristics contributed to 22 % of the changes in HIV testing uptake, while 78 % of the changes were attributed to coefficients.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0180-3) contains supplementary material, which is available to authorized users.

Strategies for delivery of HIV test results in population-based HIV seroprevalence surveys: a review of the evidence

OBJECTIVES

Many population-based demographic surveys assess local and national HIV prevalence in developing countries through home-based HIV testing and counselling (HBHTC), but results are rarely returned to participants. This review gathered evidence on the feasibility and best practices of providing HIV test results during such surveys by reviewing population-based surveys that provided test results.

STUDY DESIGN

Literature review.

METHODS

This review was conducted as part of a broader literature review related to HBHTC. We present results from population-based HIV seroprevalence surveys conducted between January 1984 and June 2013.

RESULTS

We identified eighteen population-based surveys describing uptake of results when testing or results were offered in the home, four of which compare home uptake to facility-based testing. All were from Sub-Saharan Africa. More people tested and received results in HBHTC compared to facility-based testing. Uptake of test results (72%) and the percentage of the population tested (59%) was highest when testing and the provision of results were provided in the home compared to the provision of results elsewhere (41% uptake; 37% population coverage), as well as mobile/facility-based testing and the provision of results (15% uptake; 13% population coverage). Providing results the same day as testing in HBHTC produces higher uptake (97% uptake; 74% population coverage) than delayed results.

CONCLUSIONS

Inclusion of home testing and provision of HIV results to participants in national population-based surveys in Sub-Saharan Africa is possible and should be prioritized. The timing and location of testing and the provision of results during HBHTC as part of population-based surveys affects uptake of testing and population coverage.

A New Approach to Health Services and Pharmacy in Cuba

In December 17, 2014, U.S. President Barack Obama surprised the world by announcing his intention to enter into negotiations aimed at reestablishing diplomatic relations with Cuba. Since then, expectations and interest regarding the health system of that country have increased. This report focuses on the Cuban health and pharmacy systems from a practical and educational standpoint. Pharmaceutical services, strengths, opportunities, and challenges are described. Cuba's new trends toward patient-centered care are analyzed to provide insights for developing pharmaceutical care practice and implementing policies suitable for practice in all health care settings.

Ethical issues surrounding the provider initiated opt--Out prenatal HIV screening practice in Sub-Saharan Africa: a literature review

Background

Prevention of mother to child transmission of HIV remains a key public health priority in most developing countries. The provider Initiated Opt – Out Prenatal HIV Screening Approach, recommended by the World Health Organization (WHO) lately has been adopted and translated into policy in most Sub – Saharan African countries. To better ascertain the ethical reasons for or against the use of this approach, we carried out a literature review of the ethics literature.

Methods

Papers published in English and French Languages between 1990 and 2015 from the following data bases were searched: Pubmed, Cochrane literature, Embase, Cinhal, Web of Science and Google Scholar. After screening from 302 identified relevant articles, 21 articles were retained for the critical review.

Discussion

Most authors considered this approach ethically justifiable due to its potential benefits to the mother, foetus and society (Beneficence). The breaching of respect for autonomy was considered acceptable on the grounds of libertarian paternalism. Most authors considered the Opt - Out approach to be less stigmatizing than the Opt - In. The main arguments against the Opt - Out approach were: non respect of patient autonomy, informed consent becoming a meaningless concept and the HIV test becoming compulsory, risk of losing trust in health care providers, neglect of social and psychological implications of doing an HIV test, risk of aggravation of stigma if all tested patients are not properly cared for and neglect of sociocultural peculiarities.

Conclusions

The Opt – Out approach could be counterproductive in case gender sensitive issues within the various sociocultural representations are neglected, and actions to offer holistic care to all women who shall potentially test positive for HIV were not effectively ascertained. The Provider Initiated Opt – Out Prenatal HIV Screening option remains ethically acceptable, but deserves caution, active monitoring and evaluation within the translation of this approach into to practice.

A Cost-Effectiveness Analysis of a Home-Based HIV Counselling and Testing Intervention versus the Standard (Facility Based) HIV Testing Strategy in Rural South Africa

INTRODUCTION

There is growing evidence concerning the acceptability and feasibility of home-based HIV testing. However, less is known about the cost-effectiveness of the approach yet it is a critical component to guide decisions about scaling up access to HIV testing. This study examined the cost-effectiveness of a home-based HIV testing intervention in rural South Africa.

METHODS

Two alternatives: clinic and home-based HIV counselling and testing were compared. Costs were analysed from a provider's perspective for the period of January to December 2010. The outcome, HIV counselling and testing (HCT) uptake was obtained from the Good Start home-based HIV counselling and testing (HBHCT) cluster randomised control trial undertaken in KwaZulu-Natal province. Cost-effectiveness was estimated for a target population of 22,099 versus 23,864 people for intervention and control communities respectively. Average costs were calculated as the cost per client tested, while cost-effectiveness was calculated as the cost per additional client tested through HBHCT.

RESULTS

Based on effectiveness of 37% in the intervention (HBHCT) arm compared to 16% in control arm, home based testing costs US$29 compared to US$38 per person for clinic HCT. The incremental cost effectiveness per client tested using HBHCT was $19.

CONCLUSIONS

HBHCT was less costly and more effective. Home-based HCT could present a cost-effective alternative for rural 'hard to reach' populations depending on affordability by the health system, and should be considered as part of community outreach programs.

Advice dilemmas: Managing advice against the competing public health and counselling imperatives that shape VCT in South Africa

The public health and counselling imperatives that shape VCT create advice dilemmas for counsellors. Public health proponents view the dispensing of advice as important, whilst most contemporary counselling dictates that advice should not be given under any circumstances. Using a qualitative, discursive approach transcripts of twenty-seven videotaped simulated VCT sessions in South Africa were analysed with a view to understanding how counsellors implemented advice in their daily practice and the discursive strategies they used to do so. The results show that counsellors generally struggled to adhere to the dictates of both public health and counselling. In managing their advice-dilemmas, counsellors either tagged an open-ended question to the end of a directive advice statement, or told clients what to do but softened these with client-centred skills. As a dual-identified encounter, the role of advice in VCT needs to be clarified. Key to resolving this issue is an acknowledgement that, whether as counsellor or health adviser, persuasion and influence are central features of the VCT interaction. Clear practice guidelines and tools are required to assist counsellors to distinguish between advice, suggestion or mere confirmation of an intended client action, and the circumstances under which these would be recommended or not.

Poor-quality health services and lack of programme support leads to low uptake of HIV testing in rural Mozambique

Mozambique has one of the world's highest burdens of HIV infection. Despite the increase in HIV-testing services throughout the country, the uptake has been low. To identify barriers to HIV testing we conducted a study in six rural districts in Zambézia Province. We recruited a total of 124 men and women from the community through purposeful sampling to participate in gender-specific focus group discussions about barriers to HIV testing. The participants noted three main barriers to HIV testing: 1) poor conduct by clinicians, including intentional disclosure of patients' HIV status to other community members; 2) unintentional disclosure of patients' HIV status through clinical practices; and, 3) a widespread fatalistic belief that HIV infection will result in death, particularly given poor access to adequate food. Improving quality and confidentiality within clinical service delivery, coupled with the introduction of food-supplement programmes should increase people's willingness to test and remain in care for HIV disease.

Tuberculosis and HIV at the national level in Kenya: results from the Second Kenya AIDS Indicator Survey

BACKGROUND

Co-morbidity with tuberculosis and HIV is a common cause of mortality in sub-Saharan Africa. In the second Kenya AIDS Indicator Survey, we collected data on knowledge and experience of HIV and tuberculosis, as well as on access to and coverage of relevant treatment services and antiretroviral therapy (ART) in Kenya.

METHODS

A national, population-based household survey was conducted from October 2012 to February 2013. Information was collected through household questionnaires, and blood samples were taken for HIV, CD4 cell counts, and HIV viral load testing at a central laboratory.

RESULTS

Overall, 13,720 persons aged 15-64 years participated; 96.7% [95% confidence interval (CI): 96.3 to 97.1] had heard of tuberculosis, of whom 2.0% (95% CI: 1.7 to 2.2) reported having prior tuberculosis. Among those with laboratory-confirmed HIV infection, 11.6% (95% CI: 8.9 to 14.3) reported prior tuberculosis. The prevalence of laboratory-confirmed HIV infection in persons reporting prior tuberculosis was 33.2% (95% CI: 26.2 to 40.2) compared to 5.1% (95% CI: 4.5 to 5.8) in persons without prior tuberculosis. Among those in care, coverage of ART for treatment-eligible persons was 100% for those with prior tuberculosis and 88.6% (95% CI: 81.6 to 95.7) for those without. Among all HIV-infected persons, ART coverage among treatment-eligible persons was 86.9% (95% CI: 74.2 to 99.5) for persons with prior tuberculosis and 58.3% (95% CI: 47.6 to 69.0) for those without.

CONCLUSIONS

Morbidity from tuberculosis and HIV remain major health challenges in Kenya. Tuberculosis is an important entry point for HIV diagnosis and treatment. Lack of knowledge of HIV serostatus is an obstacle to access to HIV services and timely ART for prevention of HIV transmission and HIV-associated disease, including tuberculosis.

The impact of voluntary counselling and testing services on sexual behaviour change and HIV incidence: observations from a cohort study in rural Tanzania

Background

It is widely assumed that voluntary counselling and testing (VCT) services contribute to HIV prevention by motivating clients to reduce sexual risk-taking. However, findings from sub-Saharan Africa have been mixed, particularly among HIV-negative persons. We explored associations between VCT use and changes in sexual risk behaviours and HIV incidence using data from a community HIV cohort study in northwest Tanzania.

Methods

Data on VCT use, sexual behaviour and HIV status were available from three HIV serological surveillance rounds undertaken in 2003–4 (Sero4), 2006–7 (Sero5) and 2010 (Sero6). We used multinomial logistic regression to assess changes in sexual risk behaviours between rounds, and Poisson regression to estimate HIV incidence.

Results

The analyses included 3,613 participants attending Sero4 and Sero5 (3,474 HIV-negative and 139 HIV-positive at earlier round) and 2,998 attending Sero5 and Sero6 (2,858 HIV-negative and 140 HIV-positive at earlier round). Among HIV-negative individuals VCT use was associated with reductions in the number of sexual partners in the last year (aRR Seros 4–5: 1.42, 95% CI 1.07-1.88; aRR Seros 5–6: 1.68, 95% CI 1.25-2.26) and in the likelihood of having a non-cohabiting partner in the last year (aRR Seros 4–5: 1.57, 95% CI 1.10-2.25; aRR Seros 5–6: 1.48, 95% CI 1.07-2.04) or a high-risk partner in the last year (aRR Seros 5–6 1.57, 95% CI 1.06-2.31). However, VCT was also associated with stopping using condoms with non-cohabiting partners between Seros 4–5 (aRR 4.88, 95% CI 1.39-17.16). There were no statistically significant associations between VCT use and changes in HIV incidence, nor changes in sexual behaviour among HIV-positive individuals, possibly due to small sample sizes.

Conclusions

We found moderate associations between VCT use and reductions in some sexual risk behaviours among HIV-negative participants, but no impacts among HIV-positive individuals in the context of low overall VCT uptake. Furthermore, there were no significant changes in HIV incidence associated with VCT use, although declining background incidence and small sample sizes may have prevented us from detecting this. The impact of VCT services will ultimately depend upon rates of uptake, with further research required to better understand processes of behaviour change following VCT use.

Quality of home-based rapid HIV testing by community lay counsellors in a rural district of South Africa

Introduction

Lack of universal, annual testing for human immunodeficiency virus (HIV) in health facilities suggests that expansion of HIV testing and counselling (HTC) to non-clinical settings is critical to the achievement of national goals for prevention, care and treatment. Consideration should be given to the ability of lay counsellors to perform home-based HTC in community settings.

Methods

We implemented a community cluster randomized controlled trial of home-based HTC in Sisonke District, South Africa. Trained lay counsellors conducted door-to-door HIV testing using the same rapid tests used by the local health department at the time of the study (SD Bioline and Sensa). To monitor testing quality and counsellor skill, additional dry blood spots were taken and sent for laboratory-based enzyme-linked immunosorbent assay (ELISA) testing. Sensitivity and specificity were calculated using the laboratory result as the gold standard.

Results and discussion

From 3986 samples, the counsellor and laboratory results matched in all but 23 cases. In 18 cases, the counsellor judged the result as indeterminate, whereas the laboratory judged 10 positive, eight negative and three indeterminate, indicating that the counsellor may have erred on the side of caution. Sensitivity was 98.0% (95% CI: 96.3–98.9%), and specificity 99.6% (95% CI: 99.4–99.7%), for the lay counsellor field-based rapid tests. Both measures are high, and the lower confidence bound for specificity meets the international standard for assessing HIV rapid tests.

Conclusions

These findings indicate that adequately trained lay counsellors are capable of safely conducting high-quality rapid HIV tests and interpreting the results as per the kit guidelines. These findings are important given the likely expansion of community and home-based testing models and the shortage of clinically trained professional staff.

Abbreviated HIV counselling and testing and enhanced referral to care in Uganda: a factorial randomised controlled trial

Background

HIV counselling and testing and linkage to care are crucial for successful HIV prevention and treatment. Abbreviated counselling could save time; however, its effect on HIV risk is uncertain and methods to improve linkage to care have not been studied.

Methods

We did this factorial randomised controlled study at Mulago Hospital, Uganda. Participants were randomly assigned to abbreviated or traditional HIV counselling and testing; HIV-infected patients were randomly assigned to enhanced linkage to care or standard linkage to care. All study personnel except counsellors and the data officer were masked to study group assignment. Participants had structured interviews, given once every 3 months. We compared sexual risk behaviour by counselling strategy with a 6·5% non-inferiority margin. We used Cox proportional hazards analyses to compare HIV outcomes by linkage to care over 1 year and tested for interaction by sex. This trial is registered with ClinicalTrials.gov (NCT00648232).

Findings

We enrolled 3415 participants; 1707 assigned to abbreviated counselling versus 1708 assigned to traditional. Unprotected sex with an HIV discordant or status unknown partner was similar in each group (232/823 [27·9%] vs 251/890 [28·2%], difference −0·3%, one-sided 95% CI 3·2). Loss to follow-up was lower for traditional counselling than for abbreviated counselling (adjusted hazard ratio [HR] 0·61, 95% CI 0·44–0·83). 1003 HIV-positive participants were assigned to enhanced linkage (n=504) or standard linkage to care (n=499). Linkage to care did not have a significant effect on mortality or receipt of co-trimoxazole. Time to treatment in men with CD4 cell counts of 250 cells per μL or fewer was lower for enhanced linkage versus standard linkage (adjusted HR 0·60, 95% CI 0·41–0·87) and time to HIV care was decreased among women (0·80, 0·66–0·96).

Interpretation

Abbreviated HIV counselling and testing did not adversely affect risk behaviour. Linkage to care interventions might decrease time to enrolment in HIV care and antiretroviral treatment and thus might affect secondary HIV transmission and improve treatment outcomes.

Funding

US National Institute of Mental Health.

Low rates of repeat HIV testing despite increased availability of antiretroviral therapy in rural Tanzania: findings from 2003-2010

Background

HIV counselling and testing (HCT) services can play an important role in HIV prevention by encouraging safe sexual behaviours and linking HIV-infected clients to antiretroviral therapy (ART). However, regular repeat testing by high-risk HIV-negative individuals is important for timely initiation of ART as part of the ‘treatment as prevention’ approach.

Aim

To investigate HCT use during a round of HIV serological surveillance in northwest Tanzania in 2010, and to explore rates of repeat testing between 2003 and 2010.

Methods

HCT services were provided during the fourth, fifth and sixth rounds of serological surveillance in 2003–2004 (Sero-4), 2006–2007 (Sero-5) and 2010 (Sero-6). HCT services have also been available at a government-run health centre and at other clinics in the study area since 2005. Questionnaires administered during sero-surveys collected information on socio-demographic characteristics, sexual behaviour and reported previous use of HCT services.

Results

The proportion of participants using HCT increased from 9.4% at Sero-4 to 16.6% at Sero-5 and 25.5% at Sero-6. Among participants attending all three sero-survey rounds (n = 2,010), the proportions using HCT twice or more were low, with 11.1% using the HCT service offered at sero-surveys twice or more, and 25.3% having tested twice or more if reported use of HCT outside of sero-surveys was taken into account. In multivariable analyses, individuals testing HIV-positive were less likely to repeat test than individuals testing HIV-negative (aOR 0.17, 95% CI 0.006–0.52).

Discussion/Conclusions

Although HCT service use increased over time, it was disappointing that the proportions ever testing and ever repeat-testing were not even larger, considering the increasing availability of HCT and ART in the study area. There was some evidence that HIV-negative people with higher risk sexual behaviours were most likely to repeat test, which was encouraging in terms of the potential to pick-up those at greatest risk of HIV-infection.

Patterns of uptake of HIV testing in sub-Saharan Africa in the pre-treatment era

Objectives

To compare nationally representative trends in self-reported uptake of HIV testing and receipt of results in selected countries prior to treatment scale-up.

Methods

Demographic and Health Survey (DHS) data from 13 countries in sub-Saharan Africa were used to describe the pattern of uptake of testing for HIV among sexually active participants. Univariate and multivariate logistic regression were used to analyse the associations between socio-demographic and behavioural characteristics and the uptake of testing.

Results

Knowledge of serostatus ranged from 2.2% among women in Guinea (2005) to 27.4% among women in Rwanda (2005). Despite varied levels of testing, univariate analysis showed the profile of testers to be remarkably similar across countries, with respect to socio-demographic characteristics such as area of residence and socio-economic status. HIV-positive participants were more likely to have tested and received their results than HIV-negative participants, with the exception of women in Senegal and men in Guinea. Adjusted analyses indicate that a secondary or higher level of education was a key determinant of testing, and awareness that treatment exists was independently positively associated with testing, once other characteristics were taken into account.

Conclusion

This work provides a baseline for monitoring trends in testing and exploring changes in the profile of those who get tested after the introduction and scale-up of treatment.

Trends in the uptake of voluntary counselling and testing for HIV in rural Tanzania in the context of the scale up of antiretroviral therapy

OBJECTIVES

To describe trends in voluntary counselling and testing (VCT) use and to assess whether high-risk and infected individuals are receiving counselling and learning their HIV status in rural Tanzania.

METHODS

During two rounds of linked serological surveys (2003-2004 and 2006-2007) with anonymous HIV testing among adults, VCT was offered to all participants. The crude and adjusted odds ratios for completing VCT in each survey were calculated to compare uptake by demographic, behavioural and clinical characteristics, stratified by sex. Repeat testing patterns were also investigated.

RESULTS

The proportion of participants completing VCT increased from 10% in 2003-2004 to 17% in 2006-2007, and among HIV-infected persons from 14% to 25%. A higher proportion of men than women completed VCT in both rounds, but the difference declined over time. Socio-demographic and behavioural factors associated with VCT completion were similar across rounds, including higher adjusted odds of VCT with increasing numbers of sexual partners in the past 12 months. The proportion having ever-completed VCT reached 26% among 2006-2007 attendees, with repeat testing rates highest among those aged 35-44 years. Among 3923 participants attending both rounds, VCT completion in 2006-2007 was 17% among 3702 who were HIV negative in both rounds, 19% among 124 who were HIV infected in both rounds and 22% among 96 who seroconverted between rounds.

CONCLUSION

VCT services are attracting HIV-infected and high-risk individuals. However, 2 years after the introduction of antiretroviral therapy, the overall uptake remains low. Intensive mobilisation efforts are needed to achieve regular and universal VCT use.

Home-based HIV counseling and testing: client experiences and perceptions in Eastern Uganda

BACKGROUND

Though prevention and treatment depend on individuals knowing their HIV status, the uptake of testing remains low in Sub-Saharan Africa. One initiative to encourage HIV testing involves delivering services at home. However, doubts have been cast about the ability of Home-Based HIV Counseling and Testing (HBHCT) to adhere to ethical practices including consent, confidentiality, and access to HIV care post-test. This study explored client experiences in relation these ethical issues.

METHODS

We conducted 395 individual interviews in Kumi district, Uganda, where teams providing HBHCT had visited 6-12 months prior to the interviews. Semi-structured questionnaires elicited information on clients' experiences, from initial community mobilization up to receipt of results and access to HIV services post-test.

RESULTS

We found that 95% of our respondents had ever tested (average for Uganda was 38%). Among those who were approached by HBHCT providers, 98% were informed of their right to decline HIV testing. Most respondents were counseled individually, but 69% of the married/cohabiting were counseled as couples. The majority of respondents (94%) were satisfied with the information given to them and the interaction with the HBHCT providers. Most respondents considered their own homes as more private than health facilities. Twelve respondents reported that they tested positive, 11 were referred for follow-up care, seven actually went for care, and only 5 knew their CD4 counts. All HIV infected individuals who were married or cohabiting had disclosed their status to their partners.

CONCLUSION

These findings show a very high uptake of HIV testing and satisfaction with HBHCT, a large proportion of married respondents tested as couples, and high disclosure rates. HBHCT can play a major role in expanding access to testing and overcoming disclosure challenges. However, access to HIV services post-test may require attention.

Barriers to HIV testing in Côte d'Ivoire: the role of individual characteristics and testing modalities

Background

Expanding HIV testing requires a better understanding of barriers to its uptake. We investigated barriers to HIV testing in Côte d'Ivoire, taking into account test circumstances (client vs. provider-initiated).

Methods

We used data from the 2005 nationally representative Demographic and Health Survey conducted in Côte d'Ivoire. Socio-demographic characteristics, sexual behaviour and knowledge and attitudes toward HIV/AIDS associated with recent (<2 years) HIV testing were identified using gender-specific univariate and multivariate logistic regressions. Among women, differential effects of barriers to testing according to test circumstance (whether they have been offered for a prenatal test or not) were assessed through interaction tests.

Results

Recent HIV testing was reported by 6.1% of men and 9.5% of women (including 4.6% as part of antenatal care). Among men, having a low socioeconomic status, having a low HIV-related knowledge level and being employed [compared to those inactive: adjusted Odds Ratio (aOR) 0.46; 95% confidence interval (CI) 0.25–0.87] were associated with lower proportions of recent HIV testing. Among women without a prenatal HIV testing offer, living outside the capital (aOR 0.38; CI 0.19–0.77) and reporting a unique lifetime sexual partner constituted additional barriers to HIV testing. By contrast, among women recently offered to be tested in prenatal care, none of these variables was found to be associated with recent HIV testing.

Conclusions

Various dimensions of individuals' characteristics constituted significant barriers to HIV testing in Côte d'Ivoire in 2005, with gender specificities. Such barriers are substantially reduced when testing was proposed in the framework of antenatal care. This suggests that provider-initiated testing strategies may help overcome individual barriers to HIV testing.

Perception of vulnerability to HIV infection among older people in Nairobi, Kenya: a need for intervention

It is evident that sexual activity tends to decrease with age. Nonetheless, it is still prevalent enough to be considered a risk factor for the spread of HIV among older people. This paper uses quantitative data for 2053 individuals to examine HIV risk perception and correlates of perceived risk among older people aged 50 years and older living in Nairobi slums. It emerged that a majority of older people did not consider themselves at risk of infection. Of those who felt at risk, a greater proportion sensed only a small chance of contracting HIV. Women cited 'no sexual activity' while men mentioned 'having only one and/or a faithful sexual partner' as the primary reasons for perceiving minimal risk of HIV infection. There were no differences by sex in the basis for perceiving moderate-to-great risk of infection. Religion is a key factor in risk perception with Muslims perceiving higher levels of risk and, conversely, devotees irrespective of faith perceiving lower levels of risk. Older people willing to be tested for HIV had a decreased likelihood of perceived risk compared with those unwilling to be tested. This paper recommends evaluation of older people's perception of risk in order to better inform interventions aimed at minimizing their vulnerability to HIV infection.

Knowledge of HIV status prior to a community HIV counseling and testing intervention in a rural district of south Africa: results of a community based survey

BACKGROUND

The low uptake of facility-based HIV counseling and testing (HCT) in South Africa, particularly amongst men and youth has hindered attempts to increase access to effective treatment and prevention strategies. Many barriers to HIV testing have been described including long waiting times, transport to reach facilities, fear of lack of confidentiality and health systems factors such as stock outs of HIV test kits. The aim of this study was to undertake a community survey to determine rates of HCT in a rural area in order to plan a community intervention.

METHODS

A community-based survey was undertaken in 16 communities in Sisonke district, KwaZulu-Natal between September and November 2008. A total of 5821 individuals participated in the survey of which 66% were females. Gender specific mixed effects logistic regression models were used to describe differences in socio-economic characteristics, and their association with HIV testing histories.

RESULTS

Overall 1833 (32%) individuals in this rural area knew their HIV status. Prior testing was higher amongst women (39%) than amongst men (17%). Older men (> 24 years) were more likely to report having tested for HIV previously, with the highest likelihood (adjusted OR = 4.02; 95% CI: 2.71-5.99) among men in age group, 35-49 years. For women, age group 25-34 years had the highest likelihood of having been previously tested (adjusted OR = 1.30; 95% CI: 1.05-1.66). Being currently pregnant (adjusted OR 3.31; 95% CI: 2.29-4.78) or having a child under five (adjusted OR 7.00; 95% CI: 5.84-8.39) were also associated with prior HIV testing amongst women.

CONCLUSIONS

Overall, knowledge of HIV status in this rural sub-district is low. The relatively higher uptake of HIV testing among women is encouraging as it shows that PMTCT services are well functioning. However, these data suggest that there is an urgent need for scaling up HIV testing services in rural communities specifically targeting men and youth.

Provider-initiated HIV testing and counseling: increased uptake in two public community health centers in South Africa and implications for scale-up

Background

International guidance recommends the scale up of routinely recommended, offered, and delivered health care provider-initiated HIV testing and counseling (PITC) to increase the proportion of persons who know their HIV status. We compared HIV test uptake under PITC to provider-referral to voluntary counseling and testing (VCT referral) in two primary health centers in South Africa.

Methods

Prior to introducing PITC, clinical providers were instructed to refer systematically selected study participants to VCT. After PITC and HIV rapid test training, providers were asked to recommend, offer and provide HIV testing to study participants during the clinical consultation. Participants were interviewed before and after their consultation to assess their HIV testing experiences.

Results

HIV test uptake increased under PITC (OR 2.85, 95% CI 1.71, 4.76), and more patients felt providers answered their questions on HIV (104/141 [74%] versus 73/118 [62%] for VCT referral; p 0.04). After three months, only 4/106 (3.8%) HIV-positive patients had registered for onsite HIV treatment. Providers found PITC useful, but tested very few patients (range 0–15).

Conclusion

PITC increased the uptake of HIV testing compared with referral to onsite VCT, and patients reported a positive response to PITC. However, providing universal PITC will require strong leadership to train and motivate providers, and interventions to link HIV-positive persons to HIV treatment centers.

HIV/AIDS stigma and refusal of HIV testing among pregnant women in rural Kenya: results from the MAMAS Study

HIV/AIDS stigma is a common thread in the narratives of pregnant women affected by HIV/AIDS globally and may be associated with refusal of HIV testing. We conducted a cross-sectional study of women attending antenatal clinics in Kenya (N = 1525). Women completed an interview with measures of HIV/AIDS stigma and subsequently information on their acceptance of HIV testing was obtained from medical records. Associations of stigma measures with HIV testing refusal were examined using multivariate logistic regression. Rates of anticipated HIV/AIDS stigma were high—32% anticipated break-up of their relationship, and 45% anticipated losing their friends. Women who anticipated male partner stigma were more than twice as likely to refuse HIV testing, after adjusting for other individual-level predictors (OR = 2.10, 95% CI: 1.15–3.85). This study demonstrated quantitatively that anticipations of HIV/AIDS stigma can be barriers to acceptance of HIV testing by pregnant women and highlights the need to develop interventions that address pregnant women’s fears of HIV/AIDS stigma and violence from male partners.

Strategic framework for increasing accessibility and utilization of voluntary counseling and testing services in Uganda

Despite the usefulness of VCT service as an entry point to prevention for the HIV-uninfected people and care, treatment and support for those who test HIV positive, VCT service remains poorly utilized among the fishing communities. The aim of the study was to identify factors influencing VCT service delivery and utilisation among fishing communities in Uganda and consequently, formulated a strategic framework for improving VCT service delivery and utilisation in the fishing communities. The study followed a 3-phased approach, collecting and analyzing quantitative data from Kasenyi fishing community under phase I, collecting and analyzing qualitative data from hospital managers and VCT counselors in phases II and III, respectively. Results indicate that VCT services delivery and utilisation is affected by factors at government (macro) level, the institution (meso) level, and at the individual (micro) level. Based on this, a strategic framework was designed, expected to increase VCT service availability, accessibility, and acceptability if applied. The researcher recommends the use of this useful tool in the design of VCT programs.

A cost-effectiveness analysis of alternative HIV retesting strategies in sub-saharan Africa

BACKGROUND

Guidelines in sub-Saharan Africa on when HIV-seronegative persons should retest range from never to annually for lower-risk populations and from annually to every 3 months for high-risk populations.

METHODS

We designed a mathematical model to compare the cost-effectiveness of alternative HIV retesting frequencies. Cost of HIV counseling and testing, linkage to care, treatment costs, disease progression, and mortality, and HIV transmission are modeled for three hypothetical cohorts with posited annual HIV incidence of 0.8%, 1.3%, and 4.0%, respectively. The model compared costs, quality-adjusted life-years gained, and secondary infections averted from testing intervals ranging from 3 months to 30 years. Input parameters from sub-Saharan Africa were used and explored in sensitivity analyses.

RESULTS

Accounting for secondary infections averted, the most cost-effective testing frequency was every 7.5 years for 0.8% incidence, every 5 years for 1.3% incidence, and every 2 years for 4.0% incidence. Optimal testing strategies and their relative cost-effectiveness were most sensitive to assumptions about HIV counseling and testing and treatment costs, rates of CD4 decline, rates of HIV transmission, and whether tertiary infections averted were taken into account.

CONCLUSIONS

While higher risk populations merit more frequent HIV testing than low risk populations, regular retesting is beneficial even in low-risk populations. Our data demonstrate benefits of tailoring testing intervals to resource constraints and local HIV incidence rates.

Early initiation of antiretroviral therapy and universal HIV testing in sub-Saharan Africa: has WHO offered a milestone for HIV prevention?

The majority of new HIV infections occur in sub-Saharan Africa and other developing countries with scarce financial resources and meagre health system infrastructure. Expansion of Antiretroviral Therapy (ART) may overwhelm health services capacity, result in suboptimal care, and divert attention from crucial preventive measures. A 2009 WHO guideline recommends earlier initiation of ART for adults and adolescents, treatment at CD4 counts of 350 cells/mm³ along with universal testing. For sub-Saharan Africa, WHO previously recommended a threshold of 200 cells/mm³. Despite vast potential benefits of early ART initiation at individual and community levels, it does not necessary follow that clinical experience in industrialised countries can be replicated in resource-limited settings with moderate to high HIV burdens. Adherence to the 2009 WHO guidelines is unlikely to be sustainable without guarantees of adequate national and donor support--something all developing countries need to consider before adoption of the new policy.

Opt-out HIV testing during antenatal care: experiences of pregnant women in rural Uganda

Two years after the introduction of provider-initiated, opt-out HIV counselling and testing during antenatal care (ANC) in Uganda, HIV testing uptake is still low. This study was carried out to explore pregnant women's experiences of, and views on, the policies for opt-out, and couple HIV testing, and to understand how the policy implementation could be improved in order to increase access to prevention of mother-to-child-transmission (PMTCT) services. The study was conducted at three ANC health facilities at different levels of care in rural eastern Uganda. Data were collected through sit-in observations during ANC and 18 semi-structured interviews with pregnant women receiving ANC, and thereafter analysed using latent content analysis. Pregnant women who received ANC from facilities that provided HIV testing on-site perceived HIV testing as compulsory without actually fully realizing the benefits of HIV testing and PMTCT. No referral for HIV testing or information about testing was given at ANC facilities that lacked HIV testing on-site. A major challenge of couple HIV testing was that pregnant women were made responsible for recruiting their spouses for testing, a precarious dilemma for many women who tried to fulfil health workers' requests without having the power to do so. In order to increase uptake of PMTCT services, the pre-test counselling in groups that precedes the provider-initiated HIV testing should be adjusted to inform women about the benefits of PMTCT. Further, if testing is perceived as compulsory it could potentially deter some women from seeking ANC services. In order to increase HIV testing of male partners new strategies are needed, for example peer-sensitization and male clinics. Moreover, to achieve the desired outcomes of the PMTCT programme, monitoring and evaluation should be built into the programme.

Exploring the condom gap: is supply or demand the limiting factor - condom access and use in an urban and a rural setting in Kilifi district, Kenya

OBJECTIVE

to explore the extent of the condom gap, investigating the relative roles of supply-side and demand-side factors in determining condom use.

DESIGN

GPS mapping of condom outlets, and population-based survey.

METHODS

an urban and a rural site were selected within the Epidemiological and Demographic Surveillance Site in Kilifi district, Kenya. Potential condom outlets (n = 281) were mapped and surveyed, and questionnaires on condom access and use (n = 630) were administered to a random sample of men and women aged 15-49. Multivariate logistic regression was performed to assess the relative roles of supply-side and demand-side barriers on condom use.

RESULTS

the median straight-line distance to free condoms was 18-fold higher in the rural versus urban site. Among sexually active respondents, 42% had ever used a condom, and 23% had used a condom over the past 12 months, with lower levels among rural versus urban respondents (P < 0.05). The mean number of condoms used was 2.2/person per year among all sexually active individuals (condom users and nonusers), amounting to 8.2% protected sex acts/person per year. The adjusted odds of condom use (past 12 months) were 8.1 times greater among individuals experiencing no supply-side or demand-side barriers, compared with individuals experiencing both types of barriers. Despite low levels of usage and the presence of supply-side and demand-side barriers, reported unmet need for condoms was low.

CONCLUSIONS

there is an urgent need for renewed condom promotion efforts aimed at building demand, in addition to improving physical access, in resource-limited settings with generalized HIV epidemics in sub-Saharan Africa.

Asking God about the date you will die: HIV testing as a zone of uncertainty in rural Malawi

Testing for HIV is becoming more available in Africa. Global advocates of testing see it as key to AIDS prevention. However, testing is not always perceived as a good thing by people at risk. Here, we consider testing from the perspective of people in a high-prevalence community. Using qualitative data from rural Malawi, we show that the decision to test is not as straightforward as suggested in the testing advocacy literature, but is marked by uncertainty and ambivalence. Reluctance to test is connected to the perception that testing inevitably leads to a positive diagnosis, and subsequent deterioration and death. This fear is in turn linked to overestimation of the transmissibility of HIV. We recommend that testing advocates address this concern that being tested means having a death sentence pronounced, and emphasize the benefits of testing for the majority who are HIV-negative, as well as the minority who are HIV-positive.

Antiretroviral therapy for tuberculosis control in nine African countries

HIV has increased the incidence of tuberculosis (TB) by up to sevenfold in African countries, but antiretroviral therapy (ART) reduces the incidence of AIDS-related TB. We use a mathematical model to investigate the short-term and long-term impacts of ART on the incidence of TB, assuming that people are tested for HIV once a year, on average, and start ART at a fixed time after HIV seroconversion or at a fixed CD4(+) cell count. We fit the model to trend data on HIV prevalence and TB incidence in nine countries in sub-Saharan Africa. If HIV-positive people start ART within 5 y of seroconversion, the incidence of AIDS-related TB in 2015 will be reduced by 48% (range: 37-55%). Long-term reductions depend sensitively on the delay to starting ART. If treatment is started 5, 2, or 1 y after HIV seroconversion, or as soon as people test positive, the incidence in 2050 will be reduced by 66% (range: 57-80%), 95% (range: 93-96%), 97.7% (range: 96.9-98.2%) and 98.4% (range: 97.8-98.9%), respectively. In the countries considered here, early ART could avert 0.71 ± 0.36 [95% confidence interval (CI)] million of 3.4 million cases of TB between 2010 and 2015 and 5.8 ± 2.9 (95% CI) million of 15 million cases between 2015 and 2050. As more countries provide ART at higher CD4(+) cell counts, the impact on TB should be investigated to test the predictions of this model.

Integrating HIV screening into routine health care in resource-limited settings

The United Nations is committed to achieving universal access to human immunodeficiency virus (HIV) care, treatment, and prevention. Although the gateway to HIV care and secondary prevention is knowledge of serostatus, use of voluntary counseling and testing in resource-limited settings with the highest burden of HIV infection and AIDS has been limited. On the basis of evidence of increased patient uptake and the opportunity to avoid missed HIV testing opportunities in health care facilities, in 2007, the World Health Organization recommended provider-initiated HIV testing as a standard part of medical care in settings with generalized HIV epidemics. Although provider-initiated testing has shown promise, optimal implementation strategies that ensure broad coverage, while preserving human rights, remain an active area of research. We review the benefits of knowledge of HIV serostatus and evidence from multiple countries surrounding the successes and pitfalls of provider-initiated testing in health care and home-based settings.

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.

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.

Same-visit HIV testing in Trinidad and Tobago

Background

The Ministry of Health (hereafter, Ministry) of Trinidad and Tobago is responsible for delivery of all health services in the country. The Ministry takes responsibility for direct delivery of care in the public sector and has initiated a process whereby those seeking HIV test results could obtain confidential reports during a single-visit to a testing location. The Ministry requested technical assistance with this process from the Caribbean Epidemiology Centre (CAREC). The United States Centers for Disease Control and Prevention (CDC) played an important role in this process through its partnership with CAREC.

Methods

Under the technical guidance of CAREC and CDC, the Ministry organized a technical working group which included representatives from key national HIV program services and technical assistance partners. This working group reviewed internationally-recognized best practices for HIV rapid testing and proposed a program that could be integrated into the national HIV programs of Trinidad and Tobago. The working group wrote a consensus protocol, defined certification criteria, prepared training materials and oversaw implementation of "same-visit" HIV testing at two pilot sites.

Results

A Ministry-of-Health-supported program of "same-visit" HIV testing has been established in Trinidad and Tobago. This program provides confidential testing that is independent of laboratory confirmation. The program allows clients who want to know their HIV status to obtain this information during a single-visit to a testing location. Testers who are certified to provide testing on behalf of the Ministry are also counselors. Non-laboratory personnel have been trained to provide HIV testing in non-laboratory locations. The program includes procedures to assure uniform quality of testing across multiple testing sites. Several procedural and training documents were developed during implementation of this program. This report contains links to those documents.

Conclusions

The Ministry of Health has implemented a program of "same-visit" HIV testing in Trinidad and Tobago. This program provides clients confidential HIV test reports during a single visit to a testing location. The program is staffed by non-laboratory personnel who are trained to provide both testing and counseling in decentralized (non-laboratory) settings. This approach may serve as a model for other small countries.

HIV testing rates and outcomes in a South African community, 2001-2006: implications for expanded screening policies

BACKGROUND

Revised World Health Organization recommendations seek to increase HIV testing. We assessed the need for expanded testing in South Africa by examining current testing and treatment trends among a high prevalence population.

METHODS

We determined the numbers of adults receiving HIV testing and antiretroviral treatment (ART) during 2001-2006 using testing registers linked to patient records from 2 health care facilities believed responsible for virtually all HIV services available to the population. We evaluated annual population testing rates using census population counts; proportions of clients testing seropositive (yield); CD4 counts and World Health Organization stage at diagnosis; and ART initiation rates.

RESULTS

HIV testing rates rose from 4% in 2001 to 20% in 2006 (P < 0.001) and were highest among pregnant females receiving provider-initiated testing. Yield for first-time testers decreased from 47% in 2001 to 28% in 2006; annual incidence of seroconversion among initially HIV-negative retesters was 1.9%. Median CD4 counts and World Health Organization stage distributions for newly diagnosed clients remained stable. HIV-infected clients receiving ART within 6 months of eligibility increased from 0% in 2001 to 68% in 2006 (P < 0.001).

CONCLUSIONS

Population testing and ART initiation rates rose dramatically during 2001-2006. Yet, yield remained high, and HIV-infected persons continued to receive late diagnoses. These findings highlight the continuing need for expanded testing and linkage to care.

Women living with HIV and AIDS: right to prevention, treatment, and health care

Women living with HIV/AIDS not only bear the burden of this pandemic in under-resourced countries, but are faced with the human rights issues concerning the management of their condition, not only for their own health, but also for prevention of mother-to-child transmission of the virus and infertility investigation. This article tackles the issues of reproductive health rights pertaining to prevention of HIV, and rights regarding HIV testing including the ethical dilemmas associated with "opt in," "opt out," and mandatory testing. Accountability, rights to treatment and travel, and employment issues are also discussed.

Routine offering of HIV testing to hospitalized pediatric patients at university teaching hospital, Lusaka, Zambia: acceptability and feasibility

OBJECTIVES

The difficulties diagnosing infants and children with HIV infection have been cited as barriers to increasing the number of children receiving antiretroviral therapy worldwide.

DESIGN

We implemented routine HIV antibody counseling and testing for pediatric patients hospitalized at the University Teaching Hospital, a national reference center, in Lusaka, Zambia. We also introduced HIV DNA polymerase chain reaction (PCR) testing for early infant diagnosis.

METHODS

Caregivers/parents of children admitted to the hospital wards were routinely offered HIV counseling and testing for their children. HIV antibody positive (HIV+) children <18 months of age were tested with PCR for HIV DNA.

RESULTS

From January 1, 2006, to June 30, 2007, among 15,670 children with unknown HIV status, 13,239 (84.5%) received counseling and 11,571 (87.4%) of those counseled were tested. Overall, 3373 (29.2%) of those tested were seropositive. Seropositivity was associated with younger age: 69.6% of those testing HIV antibody positive were <18 months of age. The proportion of counseled children who were tested increased each quarter from 76.0% in January to March 2006 to 88.2% in April to June 2007 (P < 0.001). From April 2006 to June 2007, 1276 PCR tests were done; 806 (63.2%) were positive. The rate of PCR positivity increased with age from 22% in children <6 weeks of age to 61% at 3-6 months and to 85% at 12-18 months (P < 0.001).

CONCLUSIONS

Routine counseling and antibody testing of pediatric inpatients can identify large numbers of HIV-seropositive children in high prevalence settings. The high rate of HIV infection in hospitalized infants and young children also underscores the urgent need for early infant diagnostic capacity in high prevalence settings.

Vulnerability of women in southern Africa to infection with HIV: biological determinants and priority health sector interventions

OBJECTIVE

To review biomedical determinants of women's vulnerability to infection with HIV and interventions to counter this, within the southern African context.

RESULTS

Apart from number of exposures, if any, several factors influence the efficiency of HIV transmission during sex. Acute HIV infection, with extraordinarily high semen viral load, in conjunction with concurrent partnerships maximizes this efficiency. Delaying sexual debut and avoiding HIV exposure among biologically and socially vulnerable youth is critical. Reducing unintended pregnancies keeps girls in school and prevents vertical (also possibly horizontal) transmission. Female condoms, especially newer versions, are an under-exploited prevention technology. Control of sexually transmitted infections (STI), which facilitate HIV acquisition and transmission, remains important, especially among the most at-risk populations. Pathogens, such as herpes simplex virus type 2, which contribute most to HIV transmission in southern Africa must be targeted, although the importance of bacterial vaginosis and Trichomonas vaginalis is under-recognized. Also, heavy episodic alcohol use affects sexual decision-making and condom skills. Moreover, prevailing social contexts, partly a consequence of poor leadership, constrain the behavioural 'choices' available for girls and women.

CONCLUSIONS

Priority health sector interventions for preventing HIV are: male and female condom programming; prevention and control of STI; outreach to most vulnerable populations; HIV testing in all patient-provider encounters; male circumcision; and the integration of HIV prevention within sexual and reproductive health services. Future interventions during acute HIV infection and microbicides will reduce women's biological vulnerability. Far-reaching measures, such as sexual equity and alcohol control, create conditions necessary for achieving sustained prevention results. These are, however, contingent on stronger, more informed cultural and political leadership.

Individual, household and community factors associated with HIV test refusal in rural Malawi

OBJECTIVE

To investigate individual, household and community factors associated with HIV test refusal in a counselling and testing programme offered at population level in rural Malawi.

METHODS

HIV counselling and testing was offered to individuals aged 18-59 at their homes. Individual variables were collected by interviews and physical examinations. Household variables were determined as part of a previous census. Multivariate models allowing for household and community clustering were used to assess associations between HIV test refusal and explanatory variables.

RESULTS

Of 2303 eligible adults, 2129 were found and 1443 agreed to HIV testing. Test refusal was less likely by those who were never married [adjusted odds ratio (aOR) 0.50 for men (95% CI 0.32; 0.80) and 0.44 (0.21; 0.91) for women] and by farmers [aOR 0.70 (0.52; 0.96) for men and 0.59 (0.40; 0.87) for women]. A 10% increase in cluster refusal rates increased the odds of refusal by 1.48 (1.32; 1.66) in men and 1.68 (1.32; 2.12) in women. Women counsellors increased the odds of refusal by 1.39 (1.00; 1.92) in men. Predictors of HIV test refusal in women were refusal of the husband as head of household [aOR 15.08 (9.39; 24.21)] and living close to the main road [aOR 6.07 (1.76; 20.98)]. Common reasons for refusal were fear of testing positive, previous HIV test, knowledge of HIV serostatus and the need for more time to think.

CONCLUSION

Successful VCT strategies need to encourage couples counselling and should involve participation of men and communities.

Changes in HIV testing policies and the implications for women

The US Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) together with the Joint United Nations Programme on HIV/AIDS (UNAIDS) recently released new guidelines for HIV testing in health care settings. Both sets of guidelines recommend eliminating individual informed consent in favor of an opt-out approach that requires clients to actively decline the HIV test after a pretest information session. The revised guidelines also recommend reducing the amount of counseling that accompanies the HIV test. Women are more likely than men to be affected by efforts to expand access to HIV testing in health care settings because of women's increased vulnerability to HIV and greater contact with the health care system. Women may also be more susceptible to changes to the consent and counseling process for HIV testing because of their marginalized social status in many settings. More research is needed to document women's experiences with provider-initiated, opt-out HIV testing. Understanding women's experiences will help to formulate feasible and effective strategies to support women and ensure they gain access to HIV treatment services.

Acceptability of routine HIV counselling and testing, and HIV seroprevalence in Ugandan hospitals

OBJECTIVE

Mulago and Mbarara hospitals are large tertiary hospitals in Uganda with a high HIV/AIDS burden. Until recently, HIV testing was available only upon request and payment. From November 2004, routine free HIV testing and counselling has been offered to improve testing coverage and the clinical management of patients. All patients in participating units who had not previously tested HIV-positive were offered HIV testing. Family members of patients seen at the hospitals were also offered testing.

METHODS

Data collected at the 25 participating wards and clinics between 1 November 2004 and 28 February 2006 were analysed to determine the uptake rate of testing and the HIV seroprevalence among patients and their family members.

FINDINGS

Of the 51,642 patients offered HIV testing, 50,649 (98%) accepted. In those who had not previously tested HIV-positive, the overall HIV prevalence was 25%, with 81% being tested for the first time. The highest prevalence was found in medical inpatients (35%) and the lowest, in surgical inpatients (12%). The prevalence of HIV was 28% in the 39,037 patients who had never been tested before and 9% in those who had previously tested negative. Of the 10,439 family members offered testing, 9720 (93%) accepted. The prevalence in family members was 20%. Among 1213 couples tested, 224 (19%) had a discordant HIV status.

CONCLUSION

In two large Ugandan hospitals, routine HIV testing and counselling was highly acceptable and identified many previously undiagnosed HIV infections and HIV-discordant partnerships among patients and their family members.

Ethical and public health considerations in HIV counseling and testing: policy implications

HIV counseling and testing is broadly considered a critical component of HIV transmission-prevention and treatment efforts. Given the severity of the AIDS pandemic in sub-Saharan Africa, the potential societal benefit of testing is invoked to call for its massive expansion and to justify a shift from voluntary to routine testing. Surprisingly little evidence has demonstrated, however, that such a shift will result in the intended benefits to communities, particularly that of reducing the horizontal transmission of HIV. This analysis addresses and critiques the assumptions underlying a serostatus-based approach to behavior change and discusses the ethical consequences of transferring control of the decision to be tested from the individual to the provider. It concludes with a discussion of the implications for HIV counseling and testing policies and proposes alternatives to routine testing that have the potential to be effective while preserving the right to know one's HIV status.