Incorporating rapid HIV testing into partner counseling and referral services

Integrating HIV Cluster Analysis in Everyday Public Health Practice: Lessons Learned From a Public Health--Academic Partnership

BACKGROUND

The use of molecular HIV cluster analysis to supplement public health contact tracing has shown promise in addressing HIV outbreaks. However, the potential of HIV cluster analysis as an adjunct to daily, person-by-person HIV prevention efforts remains unknown. We documented lessons learned within a unique public health-academic partnership while guiding workaday HIV prevention efforts with near-real-time molecular cluster analysis.

SETTING

A public health-academic partnership in the State of Rhode Island, the United States.

METHODS

We recorded perceptions of our team of academicians and public health practitioners that were encountered in an 18-month study evaluating the integration of molecular cluster analysis with HIV contact tracing for public health benefit. The focus was on monthly conferences where molecular clustering of each new statewide diagnosis was discussed to facilitate targeted interventions and on attempted reinterviews of all newly HIV-diagnosed persons statewide whose HIV sequences clustered to increase partner naming.

RESULTS

Three main themes emerged: First, multidisciplinary conferences are substantially beneficial for gleaning actionable inferences from integrating molecular cluster analysis and public health data. Second, universal reinterviews were perceived to potentially have negative consequences but may be selectively beneficial. Third, the translation of cluster analysis into public health action is hampered by jurisdictional surveillance boundaries and within-jurisdictional data silos, across which data sharing is problematic.

CONCLUSIONS

Insights from a statewide public health-academic partnership support integration of molecular HIV cluster analyses with public health efforts, which can guide public health activities to prevent transmission while identifying substantial barriers to integration, informing continued research.

HIV Testing Strategies for Health Departments to End the Epidemic in the U.S

An important goal of the Ending the HIV Epidemic in the U.S. initiative is the timely diagnosis of all people with HIV as early as possible after infection. To end the HIV epidemic, health departments were encouraged to propose new and innovative HIV testing strategies and improve the reach of existing programs. These activities were divided into 3 core strategies: expansion of routine screening in healthcare settings, locally tailored HIV testing initiatives in nonhealthcare settings, and specific efforts to increase the frequency of testing for individuals with increased potential for acquiring HIV. Because HIV testing is such a crucial part of the core activities of the Centers for Disease Control and Prevention's HIV prevention programs, there are many examples of evidence-based programs and best practices for HIV testing in both clinical and nonclinical settings. This article reviews the evidence base for these strategies and some of the activities proposed under the Diagnose pillar to achieve the goal of diagnosing all HIV infections as early as possible. All other Ending the HIV Epidemic in the U.S. activities start with an awareness of HIV status, which is actually the indicator for which most health departments are closest to the proposed targets. There are both proven and emerging approaches to increasing HIV screening and increasing the frequency of HIV screening available. The Ending the HIV Epidemic in the U.S. initiative provides the motivation, the resources, and a coordinated plan to bring them to scale.

Connecting the dots: network data and models in HIV epidemiology

Effective HIV prevention requires knowledge of the structure and dynamics of the social networks across which infections are transmitted. These networks most commonly comprise chains of sexual relationships, but in some populations, sharing of contaminated needles is also an important, or even the main mechanism that connects people in the network. Whereas network data have long been collected during survey interviews, new data sources have become increasingly common in recent years, because of advances in molecular biology and the use of partner notification services in HIV prevention and treatment programmes. We review current and emerging methods for collecting HIV-related network data, as well as modelling frameworks commonly used to infer network parameters and map potential HIV transmission pathways within the network. We discuss the relative strengths and weaknesses of existing methods and models, and we propose a research agenda for advancing network analysis in HIV epidemiology. We make the case for a combination approach that integrates multiple data sources into a coherent statistical framework.

The prevalence and correlates of receiving confirmatory HIV test results among newly diagnosed HIV-positive individuals at a community-based testing center

This study examined the prevalence and correlates of completing the HIV testing process-specifically receiving a confirmatory HIV test and returning for the results-in a sample of newly diagnosed HIV-positive individuals at an HIV testing center in New York City. Of the 213 individuals who received a reactive rapid HIV test result, 82% received a confirmatory HIV test. Of the 236 individuals who received a positive result on a rapid or traditional HIV test that was validated by a positive confirmatory HIV test, 65% returned for the confirmatory test results. Multivariate analyses revealed that being a non-U.S. citizen, homeless/living in transitional housing, being uninsured, and testing off-site were significantly associated with completing the HIV testing process. The findings indicate the need to explore strategies that address obstacles to receiving confirmatory HIV testing and returning for the results, in addition to the feasibility of a rapid confirmatory HIV test.

Comparison of methods for estimating the cost of human immunodeficiency virus-testing interventions

CONTEXT

The Centers for Disease Control and Prevention (CDC), Division of HIV/AIDS Prevention, spends approximately 50% of its $325 million annual human immunodeficiency virus (HIV) prevention funds for HIV-testing services. An accurate estimate of the costs of HIV testing in various settings is essential for efficient allocation of HIV prevention resources.

OBJECTIVES

To assess the costs of HIV-testing interventions using different costing methods.

DESIGN, SETTINGS, AND PARTICIPANTS

We used the microcosting-direct measurement method to assess the costs of HIV-testing interventions in nonclinical settings, and we compared these results with those from 3 other costing methods: microcosting-staff allocation, where the labor cost was derived from the proportion of each staff person's time allocated to HIV testing interventions; gross costing, where the New York State Medicaid payment for HIV testing was used to estimate program costs, and program budget, where the program cost was assumed to be the total funding provided by Centers for Disease Control and Prevention.

MAIN OUTCOME MEASURES

Total program cost, cost per person tested, and cost per person notified of new HIV diagnosis.

RESULTS

The median costs per person notified of a new HIV diagnosis were $12 475, $15 018, $2697, and $20 144 based on microcosting-direct measurement, microcosting-staff allocation, gross costing, and program budget methods, respectively. Compared with the microcosting-direct measurement method, the cost was 78% lower with gross costing, and 20% and 61% higher using the microcosting-staff allocation and program budget methods, respectively.

CONCLUSIONS

Our analysis showed that HIV-testing program cost estimates vary widely by costing methods. However, the choice of a particular costing method may depend on the research question being addressed. Although program budget and gross-costing methods may be attractive because of their simplicity, only the microcosting-direct measurement method can identify important determinants of the program costs and provide guidance to improve efficiency.

Partner Referral by HIV-Infected Persons to Partner Counseling and Referral Services (PCRS) - Results from a Demonstration Project

Objective:

The objectives of this article are to determine factors associated with refusal and agreement to provide partner information, and evaluate the effectiveness of referral approaches in offering PCRS.

Methods:

Index clients from 5 sites that used 3 different PCRS approaches were interviewed to obtain demographic and risk characteristics and choice of partner referral method for PCRS. Logistic regression was used to assess factors associated with providing partner information.

Results:

The percentage of index clients who refused to provide partner information varied by site (7% to 88%). Controlling for PCRS approach, index clients who were older than 25 years, male, or reported having male-male sex in the past 12 months were more likely (p <0.01) to refuse to provide partner information. Overall, 72% of named partners referred by index clients were located and offered PCRS. The proportion of partners who were located and offered PCRS differed by referral approach used, ranging from 38% using contract referral (index clients agree to notify their partners within a certain timeframe, else a disease intervention specialist or health care provider will notify them) to 98% using dual referral (index clients notify their partners with a disease intervention specialist or provider present).

Conclusion:

Success in obtaining partner information varied by the PCRS approach used and effectiveness in locating and notifying partners varied by the referral approach selected. These results provide valuable insights for enhancing partner services.

The effect of HIV field-based testing on the proportion of notified partners who test for HIV in New York City

HIV partner services can effectively reach populations with high HIV prevalence. However, located and notified sex and needle-sharing partners of persons infected with HIV often fail to test. Field testing may increase the proportion of notified partners who test for HIV. In 2008, New York City's health department incorporated field testing into partner services. After the introduction of field testing, the proportion of notified partners who tested for HIV rose from 52% to 76% (P<.001). HIV prevalence fell slightly among notified partners who accepted testing (12% to 9%, P=.82), but we identified more than double the number of new positives (11 vs 25). All positive and 97% of negative results were received by the person tested.

Increasing public health partner services for human immunodeficiency virus: results of a second national survey

BACKGROUND

Recent US national efforts taken to prevent human immunodeficiency virus (HIV) infection have emphasized HIV case-finding, including partner services (PS).

METHODS

We collected data on HIV PS procedures and outcomes in 2006 from health departments in US metropolitan areas with the highest number of cases of acquired immunodeficiency syndrome, gonorrhea, chlamydial infection, and primary and secondary syphilis, and compared our results with the data collected through a similar study carried out in 2001.

RESULTS

Of the 71 eligible jurisdictions, 51 (72%) participated in this study. In 2006, health departments interviewed 11,270 (43%) of the 26,185 persons with newly reported HIV, which was an increase from the 32% reported in 2001 (P < 0.01). Among 10,498 potentially exposed partners, 2228 (21%) had been previously diagnosed with HIV, 803 (8%) were newly HIV-diagnosed, 3337 (32%) tested HIV-negative, and 4130 (39%) were not successfully notified, were notified but refused HIV testing and denied previous diagnosis, or did not have an outcome recorded. Combining data from all jurisdictions, public health staff needed to interview 13.6 persons with HIV to identify one new case of infection; this number was unchanged from 2001 (13.8; P = 0.75).

CONCLUSION

In the United States, the proportion of persons diagnosed with HIV receiving PS has increased since 2001, whereas HIV case-finding yields have remained stable. Despite this, most people newly diagnosed with HIV still do not receive PS.

Costs and effectiveness of partner counseling and referral services with rapid testing for HIV in Colorado and Louisiana, United States

OBJECTIVE

Health departments offer partner counseling and referral services (PCRS) to HIV-infected index patients and their partners. Point-of-care rapid HIV testing makes it possible for partners of index patients to learn their HIV serostatus in nonclinical settings.

STUDY DESIGN

We assessed costs and effectiveness of PCRS with rapid HIV testing in Colorado and Louisiana (April 2004-January 2006). Colorado provided PCRS to the index patients and partners statewide; Louisiana provided PCRS to those in Baton Rouge and New Orleans. The key effectiveness measures were number of partners tested and number of partners informed of a new HIV diagnosis after rapid testing. We obtained program costs for personnel, travel, utilities, supplies, equipment, and facility space.

RESULTS

Colorado identified a yearly average of 328 index patients and 253 partners and tested 43 partners. Louisiana identified a yearly average of 81 index patients and 138 partners and tested 83 partners. The rates of previously undiagnosed HIV infection among partners tested were 6.6% in Colorado and 9.9% in Louisiana. The average costs per partner tested and per partner informed of a new HIV diagnosis were $1459 and $22,243 in Colorado and $714 and $7231 in Louisiana.

CONCLUSIONS

Program costs varied substantially by location. Our analysis helps program managers and health care providers to understand the resources needed for implementing the PCRS in diverse settings.