Return rates and partner notification in HIV-positive men seeking anonymous versus confidential antibody testing

The effect of name-based reporting and partner notification on HIV testing in New York State

OBJECTIVES

We examined the effect of New York's HIV Reporting and Partner Notification law on HIV testing levels and on the HIV testing decisions of high-risk individuals.

METHODS

In-person interviews were administered to 761 high-risk individuals to assess their knowledge, attitudes, and behaviors regarding HIV testing and reporting. Trends in HIV testing were also assessed in publicly funded HIV counseling and testing programs, Medicaid, and New York's Maternal Pediatric Newborn Prevention and Care Program.

RESULTS

High-risk individuals had limited awareness of the reporting and notification law, and few cited concern about named reporting as a reason for avoiding or delaying HIV testing. HIV testing levels, posttest counseling rates, and anonymous-to-confidential conversion rates among those who tested HIV positive were not affected by the law. Medicaid-related HIV testing rates also remained stable. HIV testing during pregnancy continued to trend upward following implementation of the law. Findings held true within demographic and risk-related subgroups.

CONCLUSIONS

HIV reporting has permitted improved monitoring of New York's HIV/AIDS epidemic. This benefit has not been offset by decreases in HIV testing behavior, including willingness to test among those at high risk of acquiring HIV.

The effectiveness of HIV partner counseling and referral services in increasing identification of HIV-positive individuals a systematic review

Partner counseling and referral services (PCRS) are part of the spectrum of care for HIV-positive people and their sexual or needle-sharing partners. Referral includes notifying partners of exposure, after which they are (ideally) tested and receive prevention or risk reduction counseling or enter into care (if they test positive). Using The Guide to Community Preventive Services's methods for systematic reviews, the effectiveness of PCRS was evaluated, including partner notification, in identifying a population at high risk of HIV infection and in increasing testing in those populations. In this review, PCRS efforts using provider referral were found to be effective in reaching a population with a high prevalence of HIV. Nine studies qualified for the review. In these studies, a range of one to eight partners was identified per index case (a person newly diagnosed with HIV who has partners who should be notified); a mean of 67% of identified partners were found and notified of their potential exposure to HIV, and a mean of 63% of those notified were tested (previously known "positives" were not tested). Of those tested, a mean of 20% were HIV positive. Therefore, even given that not all partners could be found and notified and that some who could be found did not accept testing, 1% to 8% of people named as potentially exposed and not previously known to be HIV positive were identified as HIV positive through partner notification (although these people were not necessarily infected by the index case). Evidence was insufficient to determine whether PCRS, including partner notification, was also effective in changing behavior or reducing transmission because available studies did not generally report on these outcomes. Little empirical evidence was available to assess potential harm of the interventions, but current studies have not shown substantial harms. Based on Community Guide rules of evidence, sufficient evidence shows that PCRS with partner notification by a public health professional ("provider referral") effectively increases identification of a high-prevalence target population for HIV testing.

Failure to return for HIV test results: a pilot study of three community testing sites

BACKGROUND

Individuals at elevated risk of contracting HIV frequently fail to return for their test result. Because rapid HIV antibody testing is still not widely implemented, failure to return for test results under conditions of standard testing remains a problem.

METHODS

Direct field observation and semistructured interviews with clients (N = 16) and test counselors (N = 16) of 3 community HIV testing sites were conducted.

RESULTS

Clients faced 5 barriers to receiving their result: (1) fear, (2) busyness, (3) apathy,(4) inebriation at the time of testing, and (5) testing "on a whim." Motivators that encouraged clients to receive their results were (1) positive counselor/client interactions, (2) client-friendly policies regarding picking up the test result, (3) clients' psychological "need to know," (4) incentives for picking up the result, and (5) established protocols for contacting clients who fail to return.

CONCLUSION

Findings highlight the need for interventions to improve the return rate for HIV results.

Anonymous versus confidential HIV testing: client and provider decision making under uncertainty

Six intensive observational studies of HIV testing sites were undertaken in order to improve understanding of confidential and anonymous testing. Three sites offered only confidential testing (a large health maintenance organization's Urgent Care clinic, the same organization's HIV clinic, and a private medical practitioner's office), one offered only anonymous testing (a free clinic), and two offered a choice of confidential or anonymous testing (a thrift shop alternate testing site and a mobile testing unit). Multiple data collection strategies were used including direct field observation, semistructured interviews with clients and providers, and document and policy analysis. Using an organizational/interactional uncertainty framework, this study found that the choice between anonymous and confidential testing is a central aspect of the HIV testing process, that some clients are unclear about the differences between anonymous and confidential testing, that alternate testing sites' providers play a significant role in encouraging confidential rather than anonymous testing in order to further their organization's resource needs and public health goals, and that testing counselors' may consider that some clients prefer anonymous testing because of fear of stigma, discrimination, or loss of privacy.

Patient perspectives of medical confidentiality: a review of the literature

OBJECTIVE

To lay the groundwork for a better understanding of patient views on medical confidentiality.

DESIGN

Studies were found by searching medline, bioethicsline, and selected bibliographies. Articles concerning physician perspectives or implications of legal and administrative regulations were excluded. Only peer-reviewed journal articles reporting original research on patients' confidentiality views and conduct were included.

MAIN RESULTS

Many patients are unaware of or misunderstand their legal or ethical right to medical confidentiality protections, which leads them to both over- and underestimate confidentiality protections. The possibility that medical information might be revealed, intentionally or not, to acquaintances in a clinic or other social community troubles patients as much as information release to insurers or employers. A significant minority of patients distrust confidentiality protections, leading some to report that they delay or forgo medical care. If doubtful that confidentiality will be upheld, patients will act independently to protect information.

CONCLUSIONS

Our review found a wider variety of understandings and beliefs about medical confidentiality among patients than are often indicated in the writings of practitioners or legal experts. As medical confidentiality regulations evolve, these differences need to be recognized and accounted for in interactions between practitioners and patients.

Failure to return for HIV posttest counseling in an STD clinic population

This study assessed the extent of and characteristics associated with FTR for HIV posttest counseling in persons undergoing an HIV test during their visit to a sexually transmitted disease (STD) clinic. The study population included all 101 newly diagnosed HIV-infected subjects and 411 matched HIV-uninfected subjects, identified over a 5-year period in a publicly funded STD clinic in the southeastern United States. Overall, 55% of subjects failed to return for their test results. HIV testing history, demographic characteristics, and STD diagnosis were associated with FTR. Of clients testing HIV-positive, 58% failed to return. A median of 12 days was required for disease intervention specialists (DIS) to locate HIV-infected subjects who failed to return. The proportion of persons returning for HIV antibody test results is low among patients tested while seeking STD services. Considerable time and effort is required to find and notify those subjects testing HIV-positive who fail to return. To maximize the potential benefit of counseling and testing, interventions need to be designed to target those at highest risk of not returning.

Comparison of clients of a mobile health van and a traditional STD clinic

The objective of this study was to determine if there were any demographic, behavioral, and clinical differences between clients seen aboard a mobile sexually transmitted disease (STD)/HIV clinic compared with those seen in a traditional municipal STD/HIV health clinic for receipt of STD/HIV services. Clients seen in the two different settings were interviewed about demographic characteristics, reasons for their visit, STD history, their HIV/STD risk factors, and the risk factors of their sex partners. Clients in both settings were also offered testing for syphilis, gonorrhea, chlamydia, and HIV. Results suggested that clients seen at the mobile clinic were older, more likely to be injecting drug users themselves and/or to have sex partners who were, or had engaged in prostitution for money or drugs. Over half (54.4%) of the mobile clinic clients sought testing for HIV, and they were far less likely to be seeking care for symptoms of an STD. In contrast, only 7.1% of municipal clinic clients indicated HIV testing as the reason for their visit, whereas nearly two thirds (64.5%) reported symptoms of disease. Two percent of municipal clinic clients and 5.4% of mobile clinic clients had a positive HIV test ( p<.001), and 17.8% of STD clinic clients and 5.6% of mobile van clients had a positive gonorrhea and/or test ( p<.001). These data suggest that a mobile STD/HIV clinic may be an effective strategy to reach individuals at high risk for HIV who are not being served by traditional municipal STD/HIV health clinics.

Accessing HIV testing and care

With the many recent improvements in the medical management of HIV, the benefits of early detection of the virus have increased. People found to be HIV-positive can be offered immediate referrals for medical care and a comprehensive continuum of services. However, it is estimated that, among the 650,000 to 900,000 seropositive persons in the United States, about one third are unaware of their serostatus. Many of those who are tested for HIV do not return for their results. Among those less likely to return for results are young people and black Americans. Many factors at the individual, system and societal levels negatively impact whether individuals at risk for HIV seek HIV testing in the first place, whether they return for their results, and whether they get appropriate care after they are found to be HIV-positive. Some solutions are offered to improve the identification of new HIV infections. These include social marketing campaigns to encourage individuals to be tested for HIV. Also, more use of the rapid HIV test, which will substantially increase the number of people obtaining their HIV results, is recommended. New computer technologies, such as telemedicine, also have the potential to improve linkages to care for newly diagnosed individuals. In addition, it is essential that HIV care continue to be readily available through the Ryan White Care Act.