Eliminating access to anonymous HIV antibody testing in North Carolina: effects on HIV testing and partner notification

Individual and jurisdictional factors associated with voluntary HIV testing in Canada: Results of a national survey, 2011

OBJECTIVE

HIV testing remains a central strategy for HIV prevention for its ability to link those who test positive to treatment and support. In Canada, national guidelines have recently changed as part of standard primary care to recommend voluntary HIV testing for those aged 16-64 years. Using results from a nationally representative survey, we examined individual and jurisdictional factors associated with voluntary testing.

METHODS

A total of 2,139 participants were sampled using a regionally stratified, two-stage recruitment process. English or French interviews (by phone or online) were conducted during May 2011. Voluntary testing was defined as testing at least once for reasons other than blood donation, insurance purposes, immigration screening or research participation. Weighted logistic regression analysis (including socio-demographic, sexual activity, HIV/AIDS knowledge and jurisdictional factors of HIV prevalence and anonymous testing availability) were conducted for the overall sample, and stratified by sex.

RESULTS

Twenty-nine percent (29%) of survey participants reported at least one lifetime voluntary HIV test. For the full-sample model, the following were associated with increased odds of testing: age <60 years, female sex, sexual minority status, perceived HIV knowledge, casual sex partner in previous year, and living in a higher-prevalence jurisdiction. For men, the strongest factor related to testing was sexual minority status (OR = 5.15, p < 0.001); for women, it was having a casual sex partner in the previous year (OR = 2.57, p = 0.001). For both men and women, residing in a jurisdiction with lower HIV prevalence decreased odds of testing.

DISCUSSION

Sex differences should be considered when designing interventions to increase testing uptake. Jurisdictional factors, including HIV prevalence and testing modality, should be investigated further.

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.

Decisional balance, perceived risk and HIV testing practices

Improving our understanding of how individuals decide to take an HIV test is essential for designing effective programs to increase testing. This paper assesses the relationship of decisional balance and perceived risk to HIV testing history in a cross-sectional community sample of 1523 HIV-negative men and women at risk due to drug use or sexual behavior. We developed scales to measure perceived advantages (pros) and perceived disadvantages (cons) of taking an HIV test and assessed their content using factor analysis. Perceived risk was highly related to the pros and cons scales. Multivariate analyses revealed that the pros scale had positive associations with having ever tested and the number of tests taken, while the cons scale had negative associations with these testing measures. Perceived risk was not related to testing practices. These results suggest that interventions to increase HIV testing need to address anticipated positive and negative outcomes of getting tested.

Case-Finding Effectiveness of Partner Notification and Cluster Investigation for Sexually Transmitted Diseases/HIV

OBJECTIVE

To assess the case-finding effectiveness of partner notification(PN) and cluster investigation for sexually transmitted disease (STD)/human immunodeficiency virus (HIV).

STUDY

Literature review and quantitative summary.

RESULTS

Since 1975, the median case-finding yield for syphilis, gonorrhea, and chlamydia PN reported in the literature is about 1 new case found for every 4 or 5 cases interviewed. The yield from HIV PN is approximately half as large, although there is substantial variability in yield across reports for each disease. Published reports underline the central role provider referral plays in effective PN and case-finding. Successful PN is more likely with index cases who are of majority ethnicity and detected through screening or spontaneous presentation for care with symptoms and with partners with whom index cases have had sexual contact that is recent, frequent, and of long duration. The case-finding yield for HIV PN also is much higher when cases are diagnosed through confidential, rather than anonymous, testing. Cluster investigation and related strategies tend to have lower case-finding yields than PN but can play a very useful case-finding role, especially in settings with high disease incidence.

CONCLUSIONS

STD/HIV PN and cluster investigation can contribute meaningfully to case finding. More research is needed to strengthen the empiric foundation of PN and related strategies, including the impact they have on disease transmission.

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.

The elimination of anonymous HIV testing: a case study in North Carolina

In May 1997, anonymous human immunodeficiency virus testing in publicly funded clinics was eliminated throughout North Carolina. There were concerns that this decision would disenfranchise testers with certain behavioral profiles. North Carolina's counseling and testing system was used to evaluate the effect of this policy change. A 10.3 percent decline in overall testing and a 21.7 percent decline among men who had sex with other men were identified in the year following the policy change. However, between 13 and 24 months after the policy change, the number of tests administered returned to near pre-policy levels. Understanding North Carolina's experience can assist others considering similar policy changes.

The transformation of partner notification

Since 1996, several traditional epidemiological studies of program efficacy have done little to alter the fixed opinions of promoters or detractors of partner notification. Modeling studies have appeared that confirm the value of the contact-tracing approach in locating and treating persons who may be important in transmission. These provide a theoretical base for a number of empirical studies that have applied social network methods to classical partner-notification approaches, which have demonstrated the dense networks and geographic clustering of persons involved in sexually transmitted disease transmission and have provided justification for focusing efforts on small groups that may be critical to epidemicity or its maintenance. These initial studies would appear to warrant a broad-based inclusion of network concepts into programmatic activities, with careful monitoring and analysis of the impact they have on both the traditional indices of partner notification as well as the larger effect on disease transmission.

Factors affecting the delivery of HIV/AIDS prevention programs by community-based organizations

Community based organizations (CBOs) play a frontline role in HIV/AIDS prevention activities. CBOs face formidable challenges to effective delivery of HIV prevention services including client characteristics such as homelessness and CBO characteristics such as limited resources and staff turnover. Despite these obstacles, CBOs are generally well positioned to deliver services to specific high-risk populations because they understand their local communities and are connected to the groups they serve. [C1]This qualitative study illustrates that structural, sociocultural, organizational, and individual client factors both facilitate and act as barriers to delivery of HIV prevention services. These challenges and successes help identify critical technical assistance needs.

A street intercept survey to assess HIV-testing attitudes and behaviors

Nationally, it has been estimated that 44% of adults in the United States have been tested for HIV, with substantial individual and community-level variations in HIV-testing attitudes and behaviors. HIV-testing behaviors and intentions and attitudes toward HIV testing, particularly toward home tests, were assessed among 385 adults recruited in a street intercept survey from a gay-identified agency, a substance-abuse treatment program, and inner-city community venues (a shopping mall and community center). Across these Los Angeles sites, the proportion of persons reported being tested for HIV in their lifetime (77%) was higher than the national estimate. Gay-identified agency (88%) and substance-abuse treatment program participants (99%) were more likely to have been tested than were the community participants (67%). Participants from a gay-identified agency were more likely to have had an anonymous test (51%) than were those from a substance-abuse treatment program (25%) or community sites (24%). Attitudes toward HIV testing, including mail-in home-test kits and instant home tests, were very positive. Most participants were willing to pay about $20 for a home-test kit. Participants from the community sites (82%) and the substance-abuse treatment program participants (87%) endorsed notification of HIV status to health departments and sexual partners more than did participants from the gay identified agency (48%). The street intercept survey appears to be a quick and feasible method to assess HIV testing in urban areas.

Surveillance, social risk, and symbolism: framing the analysis for research and policy

Name-based surveillance for HIV, considered alone, is a useful public health measure; its benefits outweigh its direct costs. There is little evidence that name-based surveillance directly deters individuals at risk of HIV from being tested, or exposes them to significant social risks. Yet such surveillance is chronically controversial. Understood in a broader context of the social risks and symbolic politics of HIV, as subjectively experienced by people at risk, this opposition is both rational and instructive. Although often discussed, the social risks of HIV infection are poorly understood. To the extent these risks have been addressed by privacy and antidiscrimination laws, the solution has been less complete than many public health professionals appear to believe: developments in law and policy, including the increasing prevalence of criminal HIV transmission laws and proposed changes in HIV testing and counseling standards, are contextual factors that help explain the opposition to name-based surveillance. Rather than focusing piecemeal on specific "barriers" to testing and care, an appreciation of the surveillance debate in context suggests a positive undertaking in public health policy to provide the conditions of opportunity, information, motivation and confidence that people with HIV need to accept an effective program of early intervention.