Voluntary counseling, testing, and referral for HIV: new technologies, research findings create dynamic opportunities

Challenges in initiating antiretroviral therapy for all HIV-infected people regardless of CD4 cell count

Introduction

Recently published large randomized controlled trials, START, TEMPRANO and HPTN 052 show the clinical benefit of early initiation of antiretroviral treatment (ART) in HIV-infected persons and in reducing HIV transmission. The trials influenced the World Health Organization (WHO) decision to issue updated recommendations to prescribe ART to all individuals living with HIV, irrespective of age and CD4 cell count.

Discussion

It is clear that the new 2015 WHO recommendations if followed, will change the face of the HIV epidemic and probably curb its burden over time. Implementation however, requires that health systems, especially those in low and middle-income settings, be ready to face this challenge on a large scale. HIV prevention and treatment are easy in theory yet hard in practice. The new WHO guidelines for initiation of ART regardless of CD4 cell count will lead to upfront increases in the costs of healthcare delivery as the goal is to treat all those now newly eligible for ART. Around 22 million people living with HIV qualify and will therefore require ART. Related challenges immediately follow: firstly, that everyone must be tested for HIV; secondly, that anyone who has had an HIV test should know their result and understand its significance; and, thirdly, that every person identified as HIV-positive should receive and remain on ART. The emergence of HIV drug resistant strains when treatment is started at higher CD4 cell count thresholds is a further concern as persons on HIV treatment for longer periods of time are at increased risk of intermittent medication adherence.

Conclusions

The new WHO recommendations for ART are welcome, but lacking as they fail to consider meaningful solutions to the challenges inherent to implementation. They fail to incorporate actual strategies on how to disseminate and adopt these far-reaching guidelines, especially in sub-Saharan Africa, an area with weak healthcare infrastructures. Well-designed, high-quality research is needed to assess the feasibility, safety, acceptability, impact, and cost of innovations such as the universal voluntary testing and immediate treatment approaches, and broad consultation must address community, human rights, ethical, and political concerns.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0179-9) contains supplementary material, which is available to authorized users.

Introducing rapid oral-fluid HIV testing among high risk populations in Shandong, China: feasibility and challenges

BACKGROUND

This study was conducted to ascertain the feasibility of using rapid oral fluid testing as an alternative HIV testing method in China.

METHOD

This is a mixed-method study among men who have sex with men (MSM), female sex workers (FSW) and VCT clients, conducted in 4 cities in Shandong Province. A pre-tested questionnaire was administered to 1137 participants through face-to-face interview to assess demographic characteristics, HIV testing histories and willingness to accept rapid oral fluid testing. VCT clients were provided with the saliva test kits for a screening test and errors in operation were recorded. Testing results were compared between oral and blood testing. Short feedback questionnaire was administered to 200 FSW who had undergone oral testing.

RESULTS

The rate of willingness to take oral-fluid HIV testing among MSM, FSW and VCT clients was 72.8%, 72.1% and 67.4% respectively. Common errors recorded during test kit operation by the 229 VCT clients included: unpreparedness, wrong swab sampling, wrong dilution, wrong testing and inability to read test results. Advantages of oral testing listed by participants included: less intrusive, painlessness, easy self- testing and privacy. Disadvantages included perceived unreliable results (55.5%) and not nationally recognised (9%). Comparison of saliva and the blood testing results recorded a consistency rate of 0.970 (χ2 = 153.348, P < 0.001), implying an excellent consistency.

CONCLUSION

Introduction of oral rapid fluid testing as an alternative HIV testing method in China is highly feasible but with some challenges including low recognition and operation errors.

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

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

HIV testing and care systems focused on sexually transmitted HIV in China

BACKGROUND

Over three-quarters of new HIV infections in China during 2009 were estimated to be from sexual transmission. Over half of those living with HIV do not know their serostatus and identifying and treating individuals with sexually transmitted HIV infection has been challenging.

OBJECTIVE

This global assessment explores Chinese systems for detecting and treating those with HIV infection with a particular focus on groups at increased risk of sexually transmitted HIV.

METHODS

Published literature, grey sources and non-governmental reports were reviewed to describe HIV testing and care systems in China.

RESULTS

HIV testing and care in China involve several parallel health systems and have been largely successful in reaching large numbers of vulnerable individuals. Provider-initiated testing and counselling has been more effective than voluntary counselling and testing programmes for expanding HIV testing efforts in China. Individuals with sexually transmitted HIV infection are underrepresented in the antiretroviral care system compared with other high-risk groups.

CONCLUSIONS

Comprehensive HIV testing and care bring together a number of Chinese health systems, but there are still gaps and challenges. Research and programmes focused on HIV testing and care for those with increased sexual risk are needed.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Opt-out testing for stigmatized diseases: a social psychological approach to understanding the potential effect of recommendations for routine HIV testing

OBJECTIVE

Little research has studied experimentally whether an opt-out policy will increase testing rates or whether this strategy is especially effective in the case of stigmatized diseases such as HIV.

DESIGN AND MAIN OUTCOME MEASURES

In Study 1, a 2 x 2 factorial design asked participants to make moral judgments about a person's decision to test for stigmatized diseases under an opt-in versus an opt-out policy. In Study 2, a 2 x 2 factorial design measuring testing rates explored whether opt-out methods reduce stigma and increase testing for stigmatized diseases.

RESULTS

Study 1 results suggest that getting tested draws suspicion regarding moral conduct in an opt-in system, whereas not getting tested draws suspicion in an opt-out system. Study 2 results suggest that an opt-out policy may increase testing rates for stigmatized diseases and lessen the effects of stigma in people's reluctance to test.

DISCUSSION

A social psychological approach to health services can be used to show how testing policies can influence both the stigmatization associated with testing and participation rates. An understanding of how testing policies may affect patient decision making and behavior is imperative for creating effective testing policies.

Using motivational interviewing in HIV field outreach with young African American men who have sex with men: a randomized clinical trial

OBJECTIVES

We sought to determine whether field outreach with motivational interviewing, as compared with traditional field outreach, leads to increases in HIV counseling and testing and rates of return for test results among young African American men who have sex with men (MSM).

METHODS

In a randomized, 2-group, repeated-measures design, 96 young African American MSM completed a motivational interviewing-based field outreach session and 92 young African American MSM completed a traditional field outreach session. The percentages of participants agreeing to traditional HIV counseling and testing (an oral swab of the cheek) and returning for test results were the primary outcome measures.

RESULTS

More of the participants in the motivational interviewing condition than the control condition received HIV counseling and testing (49% versus 20%; chi(2)(1) = 17.94; P = .000) and returned for test results (98% versus 72%; chi(2)(1) = 10.22; P = .001).

CONCLUSIONS

The addition of motivational interviewing to field outreach is effective in encouraging high-risk young African American MSM to learn their HIV status. Also, peer outreach workers can be effectively trained to reduce health disparities by providing evidence-based brief counseling approaches targeting high-risk minority populations.

The potential role of biomarkers in HIV preventive vaccine trials

BACKGROUND

Successful conduct of HIV vaccine efficacy trials entails identification and enrollment of at-risk populations, assessment of appropriate end points as measures of vaccine efficacy for prevention of HIV acquisition, and amelioration of disease course among infected vaccinees, as well as identification of potential confounders or effect modifiers. Although not invariably useful and bringing their own cost in terms of measurement and validation, a variety of biomarkers may aid at each stage of trial conduct.

METHODS

A review of selected articles, chosen based on quality, relevance of the biomarker to HIV vaccine trials, and availability of the publication, was conducted. The authors also drew experience from current trials and other planned or ongoing trials.

CONCLUSIONS

Biomarkers are available to assess HIV incidence in potential study populations, but care is needed in interpreting results of these assays. During trial conduct, sexually transmitted infections such as herpes simplex virus type 2 may act as effect modifiers on primary and secondary end points, including HIV incidence and set point viral load. The utility of sexually transmitted infection biomarkers will likely depend heavily on local epidemiology at clinical trial sites. Analyses from recent large HIV vaccine efficacy trials point to the complexities in interpreting trial results and underscore the potential utility of biomarkers in evaluating confounding and effect modification.

Availability of supplies and motivations for accessing voluntary HIV counseling and testing services in Blantyre, Malawi

BACKGROUND

HIV counseling and testing is an important intervention in the prevention, control and management of the human immunodeficiency virus (HIV). Counseling and testing can be an entry point for prevention, care and support. Knowledge of the quality of services and motivations for testing by individuals is important for effective understanding of the testing environment.

METHODS

A cross sectional explorative study of clients accessing HIV voluntary counseling and testing (VCT) and counselors was conducted in 6 government health centers in Blantyre City, Malawi. We aimed to assess the availability of critical clinic supplies and identify the motivations of clients seeking counseling and testing services. We also aimed to identify the health professional cadres that were providing VCT in Blantyre city.

RESULTS

102 VCT clients and 26 VCT counselors were interviewed. Among the VCT clients, 74% were < or =29 years, 58.8% were females and only 7% reported no formal education. 42.2% were single, 45.1% married, 8.8% widowed and 3.9% divorced or separated. The primary reasons for seeking HIV counseling and testing were: recent knowledge about HIV (31.4%), current illness (22.5%), self-assessment of own behavior as risky (15.5%), suspecting sexual partner's infidelity (13.7%) and seeking HIV confirmatory test (9.8%) and other reasons (6.9%). Of the 26 VCT counselors, 14 were lay volunteers, 7 health surveillance assistants and 5 nurses. All except one had been trained specifically for HIV counseling and testing. All 6 facilities were conducting rapid HIV testing with same day test results provided to clients. Most of the supplies were considered adequate for testing.

CONCLUSION

HIV counseling and testing facilities were available in Blantyre city in all the six public health facilities assessed. The majority of counseling and testing clients were motivated by perceptions of being at risk of HIV infection. In a country with 12% of individuals 15 to 49 years infected, there is need to encourage testing among population groups that may not perceive themselves to be at risk of infection.

Community-based rapid HIV testing in homeless and marginally housed adults in San Francisco

BACKGROUND

Standard two-step HIV testing is limited by poor return-for-results rates and misses high-risk individuals who do not access conventional testing facilities.

METHODS

We describe a community-based rapid HIV testing programme in which homeless and marginally housed adults recruited from shelters, free meal programmes and single room occupancy hotels in San Francisco received OraQuick Rapid HIV-1 Antibody testing (OraSure Technologies, Bethlehem, PA, USA).

RESULTS

Over 8 months, 1614 adults were invited to participate and 1213 (75.2%) underwent testing. HIV seroprevalence was 15.4% (187 of 1213 individuals) overall and 3.5% (37 of 1063) amongst high-risk individuals reporting no previous testing, a prior negative test, or previous testing without result disclosure. All 1213 participants received their results. Of 30 newly diagnosed persons who received confirmatory results, 26 (86.7%) reported at least one contact with a primary healthcare provider in the 6 months following diagnosis.

CONCLUSIONS

We conclude that community-based rapid testing is feasible, acceptable and effective based on the numbers of high-risk persons tested over a short period, the participation rate, the prevalence of new infection, the rate of result disclosure, and the proportion linked to care.

Home-based HIV voluntary counseling and testing in developing countries

BACKGROUND

The low uptake of HIV voluntary counseling and testing (VCT), an effective HIV prevention intervention, has hindered global attempts to prevent new HIV infections, as well as limiting the scale-up of HIV care and treatment for the estimated 38 million infected persons. According to UNAIDS, only 10% of HIV-infected individuals worldwide are aware of their HIV status. At this point in the HIV epidemic, a renewed focus has shifted to prevention, and with it, a focus on methods to increase the uptake of HIV VCT. This review discusses home-based HIV VCT delivery models, which, given the low uptake of facility-based testing models, may be an effective avenue to get more patients on treatment and prevent new infections.

OBJECTIVES

(1) To identify and critically appraise studies addressing the implementation of home-based HIV voluntary counseling and testing in developing countries.(2) To determine whether home-based HIV voluntary counseling and testing (HBVCT) is associated with improvement in HIV testing outcomes compared to facility-based models.

SEARCH STRATEGY

We searched online for published and unpublished studies in MEDLINE (February 2007), EMBASE (February 2007), CENTRAL (February 2007). We also searched databases listing conference proceedings and abstracts; AIDSearch (February 2007), The Cochrane Library (Issue 2, 2007), LILACS, CINAHL and Sociofile. We also contacted authors who have published on the subject of review.

SELECTION CRITERIA

We searched for randomized controlled trials (RCTs) and non-randomized trials (e.g., cohort, pre/post-intervention and other observational studies) comparing home-based HIV VCT against other testing models.

DATA COLLECTION AND ANALYSIS

We independently selected studies, assessed study quality and extracted data. We expressed findings as odds ratios (OR), and relative Risk (RR) together with their 95% confidence intervals (CI).

MAIN RESULTS

We identified one cluster-randomized trial and one pre/post-intervention (cohort) study, which were included in the review. An additional two ongoing RCTs were identified. All identified studies were conducted in developing countries. The two included studies comprised one cluster-randomized trial conducted in an urban area in Lusaka, Zambia and one pre/post-intervention (cohort) study, part of a rural community cohort in Southwestern Uganda. The two studies, while differing in methodology, found very high acceptability and uptake of VCT when testing and or results were offered at home, compared to the standard (facility-based testing and results). In the cluster-randomized trial (n=849), subjects randomized to an optional testing location (including home-based testing) were 4.6 times more likely to accept VCT than those in the facility arm (RR 4.6, 95% CI 3.6-6.2). Similarly, in the pre/post study (n=1868) offering participants the option of home delivery of results increased VCT uptake. In the intervention year (home delivery) participants were 5.23 times more likely to receive their results than during the year when results were available only at the facility. (OR 5.23 95% CI 4.02-6.8).

AUTHORS' CONCLUSIONS

Home-based testing and/or delivery of HIV test results at home, rather than in clinics, appears to lead to higher uptake in testing. However, given the limited extant literature and the limitations in the included existing studies, there is not sufficient evidence to recommend large-scale implementation of the home-based testing model.

Attitudes to HIV and HIV testing in high prevalence areas of China: informing the introduction of voluntary counselling and testing programmes

OBJECTIVES

To assess knowledge and attitudes towards HIV and its testing among pregnant women and health professionals in Yunnan Province, south west China, to inform the introduction of voluntary counselling and testing (VCT) programmes.

METHODS

The study design was a cross sectional survey using self completion questionnaires. It was carried out in 12 hospitals in four high prevalence areas of Yunnan Province. Questionnaires were completed under examination conditions by health professionals, and at the routine antenatal examination by pregnant women.

RESULTS

Completed questionnaires were obtained from 840 pregnant women and 780 health professionals. Knowledge of HIV and its modes of transmission were good in health professionals but patchy in pregnant women. The weakest area in both groups was knowledge of maternal to child transmission. There was strong support for compulsory testing in pregnancy and at the premarital examination. But attitudes towards HIV/AIDS were negative: 23% of health professionals and 45% of pregnant women thought HIV was a disease of "low class and illegal" people, 48% of health professionals and 59% of pregnant women thought that HIV positive individuals should not be allowed to get married, and 30% of the health professionals were not willing to treat an HIV positive individual. Levels of knowledge were higher and attitudes more positive in younger health professionals and better educated pregnant women.

CONCLUSIONS

Community education programmes and intensive training of health workers must precede or accompany VCT programmes. They must particularly address negative attitudes towards people with HIV. Pilot VCT programmes are now under way in two of the areas studied.

Rapid whole-blood finger-stick test for HIV antibody: performance and acceptability among women in northern Thailand

Although use of rapid HIV antibody tests of finger-stick blood specimens could expand voluntary counseling and testing in areas where fear of venipuncture and delays in learning test results are barriers, there is little information on performance and acceptability of these tests in Asia. We used the Hema. Strip HIV-1/2 test (Saliva Diagnostic Systems, Vancouver, WA) in a prospective cohort study of HIV seroincidence among women in northern Thailand from 1998 to 1999. Nurses obtained whole-blood specimens by finger-stick testing and provided test results and counseling at each visit. Acceptability of the rapid test was assessed at the first 6-month follow-up visit. HIV-1 seroprevalence among the 804 women screened at enrollment was 3.1%. Positive rapid test results from 25 women were confirmed by enzyme immunoassay and Western blot analysis using serum obtained by venipuncture. Of the 741 women who returned for follow-up, 56% preferred specimen collection by finger-stick testing to venipuncture, 80% preferred immediate rather than delayed test results, 79% preferred the rapid test method to typical testing methods, and 97% were satisfied with the test method used. Results from this study demonstrate the utility and acceptability of the rapid finger-stick test for HIV antibody among women in northern Thailand.

Screening for HIV infection in high-risk communities by urine antibody testing

OBJECTIVES

To evaluate the effectiveness of urine screening to detect HIV-infected individuals in high-prevalence communities.

METHODS

Urine HIV testing was performed at 16 discrete events and four ongoing testing sites in Baltimore communities with a high incidence of HIV infection. When possible, positive urine test results were confirmed by blood testing. In addition, we attempted to obtain blood samples from subjects who reported a possible exposure to HIV but did not have a positive urine test.

RESULTS

From February 1998 to August 2001, we screened 1718 persons. Overall, 210 persons (12%) were HIV-positive, of whom 169 (80%) had never previously tested positive; 87% of those who tested positive received their results, and most were referred for medical care.

CONCLUSIONS

Urine-based screening for HIV infection in high-prevalence inner city communities can be an effective tool for identifying and treating infected persons who are unaware of their infection.

Are HIV care providers talking with patients about safer sex and disclosure?: A multi-clinic assessment

OBJECTIVES

To examine HIV-positive patients' reports of whether HIV care providers ever talked with them about practicing safer sex and disclosing seropositive status to sex partners.

DESIGN

Cross-sectional survey (1998-1999) of HIV-positive men and women sampled randomly at six public HIV clinics in California.

METHODS

Participants were interviewed and asked whether applicable clinic providers (physician, physician assistant, nurse practitioner, nurse, social worker, health educator, psychologist, psychiatrist) ever talked with them about safer sex or disclosure. Responses were analyzed by clinic site, HIV medical status (viral load), demographic, and behavioral variables (unprotected intercourse, non-disclosure).

RESULTS

The sample (n = 839) included heterosexual men (n = 127), men who have sex with men (MSM; n = 607), and women (n = 105). Thirty-nine percent were white, 36% Hispanic, 17% black, and 8% other/mixed ethnicity. Overall, 71% reported that an applicable provider had talked with them at least once about safer sex (range across clinics, 52-94%); 50% reported discussion of disclosure (range across clinics, 31-78%). Discussion of safer sex was more prevalent with physicians than with other clinic staff. In multivariate analyses, in addition to significant clinic differences, MSM (versus heterosexual men) and whites (versus blacks or Hispanics) were less likely to receive prevention messages on these topics. Patients' behaviors (unsafe sex, non-disclosure) and HIV medical status were not independently associated with provider communication.

CONCLUSIONS

HIV clinics differed substantially in the percentage of patients who reported that they received prevention messages from clinic staff. Care providers should assess and overcome barriers to providing prevention messages to patients.