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.

Structuration Theory: A Conceptual Framework for HIV/AIDS Stigma

The continuing paucity of effective interventions to reduce HIV/AIDS stigma is troubling, given that stigma has long been recognized as a significant barrier to HIV prevention, treatment, care, and support. Ineffectual HIV/AIDS stigma-reduction interventions are the product of inadequate conceptual frameworks and methodological tools. And while there is a paucity of effective interventions to reduce stigma, there is no shortage of conceptual frameworks intending to offer a comprehensive understanding of stigma, ranging from sociocognitive models at the individual level to structural models at the macrolevel. Observations highlighting inadequacies in the individualistic and structural models are offered, followed by the theory of structuration as a possible complementary conceptual base for designing HIV/AIDS stigma-reduction interventions.

The relative persuasiveness of gain-framed versus loss-Framed HIV testing message: evidence from a field experiment in northwest Ethiopia

This study assessed the relative advantages of gain- versus loss-framed messages for promoting HIV testing among a sample of urban and rural residents in northwest Ethiopia. The authors randomly assigned 394 participants to read gain-framed (n = 196) or loss-framed (n = 198) HIV testing message prepared in a form of brochure. Experience with HIV testing, concern about and information needs on HIV/AIDS, and urbanity versus rurality significantly moderated the effects of framing on intention to test for HIV. A gain-frame advantage was found among urbanites, participants with high experience with HIV testing, and those with high concern about and information needs on HIV/AIDS, suggesting a more likely construal of HIV testing as a prevention behavior among these individuals. In contrast, a loss-frame advantage was found among ruralites and participants with low concern about and information needs on HIV/AIDS, suggesting a more likely construal of HIV testing as a detection behavior among such individuals. Moreover, gain- and loss-framing led to similar outcomes among individuals with low levels of experience with HIV testing, with a slight advantage for the loss-framed message. All of the framing effects obtained were of small to medium size.

Structuration Theory: A Conceptual Framework for HIV/AIDS Stigma

The continuing paucity of effective interventions to reduce HIV/AIDS stigma is troubling, given that stigma has long been recognized as a significant barrier to HIV prevention, treatment, care, and support. Ineffectual HIV/AIDS stigma-reduction interventions are the product of inadequate conceptual frameworks and methodological tools. And while there is a paucity of effective interventions to reduce stigma, there is no shortage of conceptual frameworks intending to offer a comprehensive understanding of stigma, ranging from sociocognitive models at the individual level to structural models at the macrolevel. Observations highlighting inadequacies in the individualistic and structural models are offered, followed by the theory of structuration as a possible complementary conceptual base for designing HIV/AIDS stigma-reduction interventions.

Pilot of non-invasive (oral fluid) testing for HIV within a community setting

BACKGROUND

The present study sought to determine the level of undiagnosed HIV infection within a community setting of men who have sex with men (MSM) and identify any associated sexual risk behaviours.

METHODS

A total of 427 MSM were recruited in sex-on-premises venues (SOPV) and gay bars within the inner city of Brisbane. An additional 37 MSM were recruited in a smaller, regional centre (Toowoomba). Oral fluid testing for HIV antibodies was undertaken using the Orasure collection system and assay. Each participant was invited to complete a brief behaviour questionnaire and submit an oral fluid specimen. Confirmed serology results were linked to reported sexual behaviours, testing patterns and HIV status.

RESULTS

Of the 464 men surveyed, 33 identified as HIV-positive, and all of these were reactive by the Orasure assay. A further eight people who identified as negative or unknown serostatus, had confirmed Orasure reactive results, resulting in 1.9% of the 'non-HIV positive' MSM sample unaware of their positive HIV status. Therefore, 19.5% of the total confirmed HIV-positive individuals were not aware of their true serostatus.

CONCLUSIONS

A significant minority of HIV-positive MSM are currently unaware of their positive serostatus. However, an analysis of their risk behaviour does not seem to indicate any significant difference to those who are HIV-negative. Interestingly, 86% of those who were unaware they were HIV-positive identified that they had been tested in the previous 6 months and all of them claimed to have been tested in the previous 2 years.

WITHDRAWN: 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.

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.

Pilot of non-invasive (oral fluid) testing for HIV within a clinical setting

BACKGROUND

The objectives of the present study were: to determine the sensitivity and specificity of oral fluid testing compared with the performance of standard blood-based HIV enzyme immunoassay; to assess the feasibility of oral fluid specimen collection from clients for the purposes of HIV testing within a clinical setting; and to assess the clinical and laboratory impact regarding staffing, material resources, expertise and funding of oral fluid testing.

METHODS

A parallel comparative trial of oral fluid and blood testing was conducted among a group of HIV positive clients and a group of unknown HIV serostatus clients where each client was offered both tests. An ambulatory HIV clinic recruited 175 known HIV positive clients and 179 persons were recruited through an inner city sexual health clinic while attending for routine sexual health checks. Client responses to oral fluid collection were assessed. The sensitivity and specificity of oral fluid testing were calculated.

RESULTS

Of the 176 confirmed HIV reactive blood test results, the OraSure (OraSure Technologies, Beaverton, OR, USA) assay failed to detect only one of these, demonstrating a sensitivity of 99.4%. Of the 178 blood specimens that were tested as non-reactive by the AxSYM (Abbott Laboratories, Abbott Park, IL, USA) Combo system, OraSure recorded four of the corresponding oral fluid specimens as reactive (assumed to be false-positive), giving a specificity of 97.6%. Although evaluation of patients undergoing the test showed a large proportion (88.6%) preferred the OraSure test to conventional blood testing, a large minority of these (22.6%) made such a preference conditional on the OraSure test being as reliable as current blood testing.

CONCLUSIONS

This limited clinic based trial of oral fluid testing for HIV antibodies among an outpatient population has demonstrated the potential of oral fluid as a specimen for HIV testing. However, the lower performance of the test compared with current serum-based tests may limit the usefulness of OraSure to epidemiological studies or as an alternative screening tool in outreach settings among higher risk populations.

Knowledge and attitude toward HIV voluntary counseling and testing services among pregnant women attending an antenatal clinic in Sudan

Human immunodeficiency virus (HIV) infection and the development of the acquired immunodeficiency syndrome (AIDS) are increasing at an alarming rate especially in the sub-Saharan region. Pregnant women susceptible to HIV and its transmission to the fetus provide a unique opportunity for implementing preventive strategy against HIV infection of newborn babies. During the period of August-December 2005 a cross-sectional study was conducted at the Fath-Elrahman Elbashir antenatal clinic, Khartoum Teaching Hospital, to investigate pregnant women's basic knowledge and attitude toward HIV and mother to child transmission as well as voluntary counseling and testing. Pre-tested structured questionnaires were given to antenatal attendants by professional counselors. Their basic socio-demographic and obstetric characteristics were obtained. Respondents' knowledge about HIV and mother to child transmission were tested. In addition, their willingness toward HIV testing was also reported. Out of the 1,005 women investigated, 79% had basic knowledge about HIV. Those who were resident in Khartoum and whose age was > or =26.1 years and their education level was secondary and above were found to be more knowledgeable about HIV. More than half of respondents were aware of mother to child transmission. Older (> or =26.1 years), educated, and working mothers were found to be more knowledgeable about mother to child transmission. Willingness to undergo the test was demonstrated in 72.8% of respondents. However, only 30.3% had the test done. Older women, primigravidae, and Muslims have higher acceptance of voluntary counseling and testing. There is a need to extend the voluntary counseling and testing program in all antenatal clinics. In addition, there is a need to increase the level of education and raise health awareness about HIV and mother to child transmission.

Bathhouse-Based Voluntary Counseling and Testing Is Feasible and Shows Preliminary Evidence of Effectiveness

The goal of this study was to provide evidence for the feasibility and effectiveness of conducting voluntary counseling and testing (VCT) for HIV in a bathhouse setting. Four hundred ninety-two men participated in bathhouse-based VCT offered at a single venue over a 13-month period. A convenience sample of 133 of these testers was assessed at 2 points: immediately before and 3 months after testing. Thirty-eight percent of men in the sample reported unprotected anal intercourse (UAI) with 1 of their 2 most recent partners in the 3 months before testing, and 48% of those men had not otherwise been tested for HIV in the previous 12 months. Results showed that in the months after VCT, men were less likely to engage in UAI, decreased their frequency of engaging in sex while drunk or high, and were more likely to communicate about HIV with their sexual partners. Bathhouse-based VCT seems to be a feasible approach for reaching significant numbers of men at risk for HIV and shows preliminary evidence of effectiveness in changing some specific HIV-related risk and precautionary behaviors.

Client satisfaction with rapid HIV testing: comparison between an urban sexually transmitted disease clinic and a community-based testing center

Rapid HIV testing allows same-day results, increasing the number of persons who learn their HIV status. Understanding how clients in different settings perceive rapid testing may increase acceptance of this technology. From June 1999 to August 2001 we interviewed 256 clients at a publicly funded urban sexually transmitted disease (STD) clinic and 1201 clients at a community- based HIV counseling, testing, and referral center (Los Angeles Gay and Lesbian Center; LAGLC) about their posttest satisfaction with rapid HIV testing. HIV prevalence was 3.9% at the STD clinic and 5.3% at the LAGLC. In multivariate analysis, adjusting for age, sexual orientation, race/ethnicity, history of STDs, self-perceived HIV risk, prior HIV test and HIV testing results, clients at the STD clinics (versus LAGLC) were more likely to find testing stressful (adjusted odds ratio [AOR]: 1.75, 95% confidence limits [CL]: 1.27, 2.42) and feel that they received their results too quickly (AOR: 2.05, 95% CL: 1.39, 3.03). Latinos (versus whites) were more likely to report that they received their results too quickly (AOR: 4.99, 95% CL: 3.48, 7.14) and that it would be better to wait a week for HIV test results (AOR: 2.48, 95% CL: 1.51, 4.09). Further research may elucidate the reasons why some groups prefer to wait for results, and enable policymakers to better design strategies to reach high-risk groups with rapid HIV testing.

Magnitude and determinants of first-time and repeat testing among individuals with newly diagnosed HIV infection between 2000 and 2001 in Alberta, Canada: results from population-based laboratory surveillance

The purpose of the study was to determine the magnitude and predictors of first-time and repeat testing for HIV infection among newly diagnosed cases in Alberta, Canada, and to determine the extent of co-infection with hepatitis C (HCV) and hepatitis B (HBV). Using the Provincial Laboratory for Public Health (PLPH) database, all newly diagnosed HIV cases in Alberta between 2000 and 2001 were identified and the testing history for HIV, HCV, and HBV among these cases since 1992 was reviewed. Significant differences in the characteristics of first-time and repeat testers were identified using the chi test, and where appropriate, the Fisher exact test. The independent variables examined included age, gender, risk factors, area and population of residence, testing agency, and co-infection with HCV and HBV. Logistical regression analyses were conducted to further explore independent factors associated with first-time vs. repeat testing for HIV infection. Of the 398 cases, 278 (69.8%) were newly diagnosed at their first test for HIV infection, 73.1% during 2000 and 67.3% during 2001 (P = 0.81). Among repeat testers, the mean number of previous negative tests was 3.4 (range = 2-11 tests). The median interval between the last negative and first positive test was 648 days (range = 53-2678 days). Repeat testers were 1.9 times more likely to be injecting drug users and 1.8 times more likely to reside in Northern Alberta. Among those with a laboratory test result in the PLPH database, 53.7% were positive for HCV, 47.7 and 64.5% of first-time and repeat testers, respectively; and 19.1% were positive for HBV, 22 and 13.6% of first-time and repeat testers, respectively. A high proportion of HIV cases newly diagnosed between 2000 and 2001 in Alberta had no previous testing history for HIV infection. Even among repeat testers, HIV testing was sought infrequently. There are significant regional differences within Alberta in the characteristics of the HIV epidemic and associated test-seeking behaviors. These data reinforce the need to make the most of each test-seeking event with proper counseling and other relevant support services. Given the high prevalence of co-infection with HCV, these results clearly support the need for testing and counseling strategies to take into account additional risks associated with HCV infections.

Willingness to use instant home HIV tests: data from the California Behavioral Risk Factor Surveillance Survey

OBJECTIVE

Although home collection HIV tests are available in the United States, home HIV tests providing instant results are not available. The objective of this study was to examine willingness to use instant home HIV tests and what test characteristics are most important to individuals.

METHODS

Six questions were added to the 1999 California Behavioral Risk Factor Surveillance Survey (BRFSS) (n =2964). This state-representative survey is part of the ongoing, 50-state BRFSS sponsored by the Centers for Disease Control and Prevention. Chi-square tests and logistic regression were used to examine willingness to use instant home HIV tests and preferences for HIV test characteristics.

RESULTS

Over one third (37%) of respondents would consider using an instant home HIV test. Respondents willing to use instant home tests were more likely to be Hispanic (odds ratio [OR]=1.55; confidence interval [CI]=1.03-2.34); to have not previously been tested for HIV (OR=1.72; CI=1.20-2.45); to be more likely to plan to be tested in the next 12 months (OR=1.17; CI=1.00-1.37); and to prefer urine sample collection (OR=1.56; CI=1.03-2.37).

CONCLUSION

Over one third of respondents in a large, state-representative sample would consider using an instant home HIV test. Hispanics, individuals who planned to be tested in the next 12 months, and individuals who had never been tested were more willing to use instant home tests.