HIV This Week

Bwambale FM, Ssali SN, Byaruhanga S, Kalyango JN, Karamagi CA. Voluntary HIV counselling and testing among men in rural western Uganda: Implications for HIV prevention. BMC Public Health. 2008 Jul 30;8:263.

Voluntary HIV counselling and testing (VCT) is one of the key strategies in the prevention and control of HIV in Uganda. However, the utilization of VCT services particularly among men is low in Kasese district. Bwambale et al conducted a study to determine the prevalence and factors associated with VCT use among men in Bukonzo West health sub-district, Kasese district. A population-based cross-sectional study employing both quantitative and qualitative techniques of data collection was conducted between January and April 2005. Using cluster sampling, 780 men aged 18 years and above, residing in Bukonzo West health sub-district, were sampled from 38 randomly selected clusters. Data was collected on VCT use and independent variables. Focus group discussions (4) and key informant interviews (10) were also conducted. Binary logistic regression was performed to determine the predictors of VCT use among men. Overall VCT use among men was 23.3% (95% CI 17.2-29.4). Forty six percent (95% CI 40.8-51.2) had pre-test counselling and 25.9% (95%CI 19.9-31.9) had HIV testing. Of those who tested, 96% returned for post-test counselling and received HIV results. VCT use was higher among men aged 35 years and below (OR = 2.69, 95%CI 1.77-4.07), non-subsistence farmers (OR = 2.37, 95%CI 2.37), in couple testing (OR = 2.37, 95%CI 1.02-8.83) and among men with intention to disclose HIV test results to sexual partners (OR = 1.64, 95%CI 1.04-2.60). The major barriers to VCT use among men were poor utilization of VCT services due to poor access, stigma and confidentiality of services. VCT use among men in Bukonzo West, Kasese district was low. In order to increase VCT use among men, the VCT programme needs to address HIV stigma and improve access and confidentiality of VCT services. Among the more promising interventions are the use of routine counselling and testing for HIV of patients seeking health care in health units, home based VCT programmes, and mainstreaming of HIV counselling and testing services in community development programmes.

Editors’ note: Kasese District in western Uganda had an HIV prevalence of 13.3% in 2005 at the time of this study and yet only 23.3% of the 780 men in this representative study population had ever had an HIV test and learned their results. Over half (61.8%) of the men believed that a couple could not have discordant HIV results. A combination of provider-initiated testing and counselling in health services, home-based offers of testing, and integration of testing services into community development programmes could remove many of the barriers to HIV testing raised by the participants of this study.

Sebert Kuhlmann AK, Kraft JM, Galavotti C, Creek TL, Mooki M, Ntumy R. Radio role models for the prevention of mother-to-child transmission of HIV and HIV testing among pregnant women in Botswana. Health Promot Int. 2008 Apr 11 [Epub ahead of print]

Although Botswana supports a program for the prevention of mother-to-child-transmission of HIV (PMTCT), many women initially did not take advantage of the program. Using data from a 2003 survey of 504 pregnant and post-partum women, Sebert Kuhlmann and his colleagues assessed associations between exposure to a long-running radio serial drama that encourages use of the PMTCT program and HIV testing during pregnancy. Controlling for demographic, pregnancy and other variables, women who spontaneously named a PMTCT character in the serial drama as their favourite character were nearly twice as likely to test for HIV during pregnancy as those who did not. Additionally, multiparity, knowing a pregnant woman taking AZT, having a partner who tested, higher education and PMTCT knowledge were associated with HIV testing during pregnancy. Identification with characters in the radio serial drama is associated with testing during pregnancy. Coupled with other supporting elements, serial dramas could contribute to HIV prevention, treatment and care initiatives.

Editors’ note: This programme went further than public service announcements and counselling sessions to raise awareness of PMTCT services. It used two fundamental principles: modelling (showing people how to change) and reinforcement (supporting their efforts to change and to maintain healthy behaviours). The radio drama was the modelling component and may have helped some women to see HIV testing in pregnancy as a good choice supported by social norms. It is interesting to speculate whether this programme paved the way for broad acceptance of the introduction of a routine offer of antenatal testing in 2004.

Wringe A, Isingo R, Urassa M, Maiseli G, Manyalla R, Changalucha J, Mngara J, Kalluvya S, Zaba B. Uptake of HIV voluntary counselling and testing services in rural Tanzania: implications for effective HIV prevention and equitable access to treatment. Trop Med Int Health. 2008;13(3):319-27.

Wringe and colleagues aimed to describe the associations between socio-demographic, behavioural and clinical characteristics and the use of HIV voluntary counselling and testing (VCT) services among residents in a rural ward in Tanzania. Eight thousand nine hundred and seventy participants from a community-based cohort were interviewed, provided blood for research HIV testing, and were offered VCT. Univariate and multivariate logistic regression was used to identify socio-demographic, clinical, and behavioural factors associated with VCT use. Although 31% (1246/3980) of men and 24% (1195/4990) of women expressed an interest in the service, only 12% of men and 7% of women subsequently completed VCT. Socio-demographic factors, such as marital status, area of residence, religion and ethnicity influenced VCT completion among males and females in different ways, while self-perceived risk of HIV, prior knowledge of VCT, and sex with a high-risk partner emerged as important predictors of VCT completion among both sexes. Among males only, those infected with HIV for 5 years or less tended to self-select for VCT compared to HIV-negatives (adjusted odds ratio = 1.43; 95% CI: 0.99-2.14). This contributed to a higher proportion of HIV-positive males knowing their status compared to HIV-positive females.  In this setting, a disproportionate number of HIV-positive women are failing to learn their status, which has implications for equitable access to onward referral for care and treatment services. Evidence that some high-risk behaviours may prompt VCT use is encouraging, although further interventions are required to improve knowledge about HIV risk and the benefits of VCT. Targeted interventions are also needed to promote VCT uptake among married women and rural residents.

Editors´note: Both the proportion of people interested in learning their HIV serostatus and the proportion of people who actually got tested are very low for a country with a sizeable HIV epidemic. It is likely that fear of stigma and discrimination had remained an important barrier to HIV testing during this study, since the Tanzanian government had already announced on radio and in newspapers that it intended to start providing free antiretroviral treatment though major hospitals.

Pai NP, Barick R, Tulsky JP, Shivkumar PV, Cohan D, Kalantri S, Pai M, Klein MB, Chhabra S. Impact of round-the-clock, rapid oral fluid HIV testing of women in labor in rural India. PLoS Med. 2008;5(5):e92.

Testing pregnant women for HIV at the time of labour and delivery is the last opportunity for prevention of mother-to-child HIV transmission measures, particularly in settings where women do not receive adequate antenatal care. However, HIV testing and counselling of pregnant women in labour is a challenge, especially in resource-constrained settings. In India, many rural women present for delivery without any prior antenatal care. Those who do get antenatal care are not always tested for HIV, because of deficiencies in the provision of HIV testing and counselling services. In this context, we investigated the impact of introducing round-the-clock, rapid, point-of-care HIV testing and counselling in a busy labour ward at a tertiary care hospital in rural India. After they provided written informed consent, women admitted to the labour ward of a rural teaching hospital in India were offered two rapid tests on oral fluid and finger-stick specimens (OraQuick Rapid HIV-1/HIV-2 tests, OraSure Technologies). Simultaneously, venous blood was drawn for conventional HIV ELISA testing. Western blot tests were performed for confirmatory testing if women were positive by both rapid tests and dual ELISA, or where test results were discordant. Round-the-clock (24 h, 7 d/wk) abbreviated prepartum and extended postpartum counselling sessions were offered as part of the testing strategy. HIV-positive women were administered prevention of mother-to-child HIV transmission interventions. Of 1,252 eligible women (age range 18 y to 38 y) approached for consent over a 9 month period in 2006, 1,222 (98%) accepted HIV testing in the labour ward. Of these, 1,003 (82%) women presented with either no reports or incomplete reports of prior HIV testing results at the time of admission to the labour ward. Of 1,222 women, 15 were diagnosed as HIV-positive (on the basis of two rapid tests, dual ELISA and Western blot), yielding a seroprevalence of 1.23% (95% confidence interval [CI] 0.61%-1.8%). Of the 15 HIV test-positive women, four (27%) had presented with reported HIV status, and 11 (73%) new cases of HIV infection were detected due to rapid testing in the labour room. Thus, 11 HIV-positive women received prevention of mother-to-child transmission interventions on account of round-the-clock rapid HIV testing and counselling in the labour room. While both OraQuick tests (oral and finger-stick) were 100% specific, one false-negative result was documented (with both oral fluid and finger-stick specimens). Of the 15 HIV-infected women who delivered, 13 infants were HIV seronegative at birth and at 1 and 4 mo after delivery; two HIV-positive infants died within a month of delivery. In a busy rural labour ward setting in India, Pai and colleagues demonstrated that it is feasible to introduce a program of round-the-clock rapid HIV testing, including prepartum and extended postpartum counselling sessions. Their data suggest that the availability of round-the-clock rapid HIV testing resulted in successful documentation of HIV serostatus in a large proportion (82%) of rural women who were unaware of their HIV status when admitted to the labour room. In addition, 11 (73%) of a total of 15 HIV-positive women received prevention of mother-to-child transmission interventions because of round-the-clock rapid testing in the labour ward. These findings are relevant for prevention of mother-to-child transmission programs in developing countries.

Editors´note: Despite the fact that labour is not an ideal time to make a decision about learning one’s serostatus, offering HIV testing during labour is the last chance for women who have had no antenatal care or were not given the opportunity to be tested during pregnancy. Acceptance was high in this study, with HIV prevalence of 1.23% mirroring the 1% anticipated in recent antenatal sentinel surveillance. Studies of cost-effectiveness may be needed to convince policy makers in some resource-constrained settings that this “catch up” approach for women of unknown HIV status has merit.

Zhang Q, Wang L, Jiang Y, Fang L, Pan P, Gong S, Yao J, Tang YW, Vermund SH, Jia Y. Early infant HIV-1 diagnosis suitable for resource-limited settings with multiple circulating subtypes: Nested, 3-monoplex DNA PCR on dried blood spots. J Clin Microbiol. 2007; 46(2):721-6.

Early infant diagnosis of HIV-1 infection is complicated by the persistence of maternal antibodies and by diverse HIV-1 subtypes. Zhang and colleagues developed a nested, 3-monoplex HIV-1 DNA polymerase chain reaction (N3M-PCR) assay to detect diverse HIV-1 subtypes in infants born to infected mothers. They optimized the test for use with dried blood spot samples for ease of storage and transport from rural China to central laboratories. Six pairs of primers were designed targeting env, gag, and pol genomes run in three reactions with an analytical sensitivity of 10 copies DNA per reaction to cover nine HIV-1 subtypes A, B, C, D, F, G, CRF01_AE, CRF08_BC, and CRF07_BC. Assay performance was evaluated on 347 dried blood spot specimens from 151 exposed infants in four diverse provinces of China with multiple circulating subtypes. Results were compared with HIV antibody enzyme immunoassay and Western blot confirmation in the infants at >/=18 months of age, or convincing clinical and epidemiologic data for deceased infants. Sensitivity of the N3M-PCR assay was 30.0% (3/10) for infants at 48 hours after birth, 91.7% (11/12) at 1-2 months, and 93.7% (15/16) at 3-6 months of age. Specificity was 100% (94/94) at all three time points. The polymerase chain reaction reproducibility in the three DNA regions was 100% for samples at 48 hours after birth, 96.7% at 1-2 months, and 100% at 3-6 months of age. The HIV-1 DNA N3M-PCR assay on dried blood spots offers a simple and affordable approach for early infant HIV-1 diagnosis in regions with diverse HIV-1 circulating subtypes.

Editors’ note: The numbers of samples tested in this study in China are small but the results are very encouraging. This polymerase chain reaction (PCR) test is detecting the virus, not antibody, and its performance is judged against the presence of antibodies after 18 months of age. Test sensitivity is good by one month when the test is missing up to 10% of infected infants and test specificity is excellent (no false positive results) from 48 hours of life on. Dried blood spots (DBS) require minimal storage facilities because they are stable at room temperature for prolonged periods and can be safely and easily shipped for centralised testing with economies of scale. As for the DBS-ELISA of Patton et al (below), further testing of the DBS-PCR for infant diagnosis is now needed on a larger scale.

The diagnostic accuracy of the modified p24 Ag assay on paediatric dried blood spots was evaluated. Samples analyzed within 6 weeks of collection yielded no false positive results (specificity 100%) and few false negative results (sensitivity 96.5%-98.3%). Laboratory services with limited resources should assess this option for routine infant diagnosis.

Editors’ note: In this South African study, dried blood spot specimens from 147 six-week old babies born to HIV-seropositive mothers and 99 children known to be infected (median age 20 months) were tested with good sensitivity and excellent specificity. Dried blood spots were obtained from capillary blood obtained by heel stick. The test was an ultra sensitive 24 antigen ELISA and specimens were collected on two types of filter paper. Storage with a desiccant conserved test sensitivity. As with the DBS-PCR of Zhang et al (above), testing should proceed in other settings with larger numbers to validate these findings.

Chomba E, Allen S, Kanweka W, Tichacek A, Cox G, Shutes E, Zulu I, Kancheya N, Sinkala M, Stephenson R, Haworth A. Evolution of Couples’ Voluntary Counseling and Testing for HIV in Lusaka, Zambia. J Acquir Immune Defic Syndr 2008; 47(1):108-15.

Chomba and colleagues describe promotional strategies for couples’ voluntary HIV counselling and testing and demographic risk factors for couples in Lusaka, Zambia, where an estimated two thirds of new infections occur in cohabiting couples. Couples’ voluntary HIV counselling and testing attendance as a function of promotional strategies is described over a 6-year period. Cross-sectional analyses of risk factors associated with HIV in men, women, and couples are presented. Community workers recruited from couples seeking voluntary HIV counselling and testing promoted testing in their communities. Attendance dropped when community worker outreach ended, despite continued mass media advertisements. In Lusaka, 51% of 8500 cohabiting couples who sought HIV testing were concordant negative for HIV and 26% concordant positive; 23% of couples were serodiscordant (that is, had 1 HIV-positive partner/1 HIV-negative partner), with 11% HIV-positive man/HIV-negative woman and 12% HIV-negative man/HIV-positive woman. HIV infection was associated with men’s age 30 to 39, women’s age 25 to 34, duration of union <3 years, and number of children <2. Even among couples with only 1-2 or no risk factors, HIV prevalence was 45% and 29%, respectively. Many married African adult couples do not have high-risk profiles, nor do they realize that one of the partners may have HIV. Active and sustained promotion is needed to encourage all couples to be jointly tested and counselled.

Editors’ note: This study highlights the importance of knowing your epidemic and tailoring effective responses to it. In mature HIV epidemics such as this one, as much as two-thirds of all HIV transmission is occurring within cohabiting couples. Serodiscordant couples have an HIV prevalence of 50% in their marital bed of which they may be unaware. Community mobilisation to create new social norms around knowledge of serostatus and the advantages of joint testing can provide couples with the opportunity to learn how they can prevent HIV from entering, or being transmitted within, their couple, while linking those already infected to treatment and support services. This study focused on couples seeking testing but home-based testing outreach in the community can achieve very high uptake with few negative social consequences if communities are engaged in the design, conduct, and evaluation of such programmes.

Prost and colleagues explore the feasibility and acceptability of translating a successful voluntary counselling and testing service model from Kenya to African communities in London. The authors conducted a qualitative study with focus group discussions and a structured workshop with key informants. Five focus group discussions were conducted in London with 42 participants from 14 African countries between August 2006 and January 2007. A workshop was held with 28 key informants. Transcripts from the group discussions and workshop were analysed for recurrent themes. Participants indicated that a community-based HIV voluntary counselling and testing service would be acceptable to African communities in London, but also identified barriers to uptake: HIV-related stigma, concerns about confidentiality, and doubts about the ability of community-based services to maintain professional standards of care. Workshop participants highlighted three key requirements to ensure feasibility: (a) efficient referrals to sexual health services for the newly diagnosed; (b) a locally appropriate testing algorithm and quality assurance scheme; (c) a training programme for voluntary counselling and testing counsellors. In conclusion, offering a community-based voluntary counselling and testing with rapid HIV tests appears feasible within a UK context and acceptable to African communities in London, provided that clients’ confidentiality is ensured and appropriate support is given to the newly diagnosed. However, the persistence of concerns related to HIV-related stigma among African communities suggests that routine opt-out testing in healthcare settings may also constitute an effective approach to reducing the proportion of late diagnoses in this group. HIV service models and programmes from Africa constitute a valuable knowledge base for innovative interventions in other settings, including developed countries.

Editors’ note: Provider-initiated testing and counselling can reduce the proportion of late diagnoses among African communities in cities such as London but it does not address the issue of HIV-related stigma. Research such as this, working with communities to identify barriers and facilitators of feasibility and acceptance, is key to ensuring that community-based testing increases knowledge of serostatus in a supportive environment.

Chersich MF, Luchters SM, Othigo MJ, Yard E, Mandaliya K, Temmerman M. HIV testing and counselling for women attending child health clinics: an opportunity for entry to prevent mother-to-child transmission and HIV treatment. Int J STD AIDS. 2008 Jan;19(1):42-6.

This study assessed the potential for HIV testing at child health clinics to increase knowledge of HIV status, and entry to infant feeding counselling and HIV treatment. At a provincial hospital in Mombasa, Kenya, HIV testing and counselling were offered to women bringing their child for immunization or acute care services. Most women said HIV testing should be offered in these clinics (472/493, 95.7%), with many citing the benefits of regular testing and entry to prevent mother-to-child transmission. Of 500 women, 416 (83.4%) received test results, 97.6% on the same day. After 50 participants, point-of-care testing replaced laboratory-based rapid testing. Uptake increased 2.6 times with point-of-care testing (95% confidence interval = 1.4-5.1; P = 0.003). Of 124 women who had not accessed HIV testing during pregnancy, 98 tested in the study (79.0%). Measured by uptake and attitudes, HIV testing in child health clinics is acceptable. This could optimize entry into HIV treatment, infant feeding counselling and family planning services.

Editors’ note: One in four women in this study had not accessed HIV testing during pregnancy, limiting their access to antenatal, perinatal, and post-partum HIV prevention services. Offering HIV testing for mother and father at well-baby clinics and paediatric acute care services can identify babies that have been exposed to HIV infection for cotrimoxazole prophylaxis and assist parents with unmet needs for family planning, an important component (prong 2) of prevention of mother-to-child transmission programmes. If current trials of antiretroviral prophylaxis during breastfeeding prove it is effective, there will be yet another benefit of post-partum HIV testing and counselling.

Ersoy N, Akpinar A. Attitudes about prenatal HIV testing in Turkey. Nurs Ethics. 2008 Mar;15(2):222-33.

The aim of this study was to assess the attitudes of Turkish pregnant women and antenatal health care providers towards prenatal HIV testing. A self-administered questionnaire was used. The relationships between the different groups’ knowledge and attitudes were analysed by using the chi-squared statistic. A total of 494 pregnant women and 181 care providers participated. Forty-four per cent of the pregnant women thought that prenatal HIV testing should be mandatory, and 84% of the health care providers thought it should be performed routinely or be mandatory. The majority of the pregnant women (74%) and half of the care providers agreed that the test results should be disclosed first to the pregnant woman. The study results also revealed that most of the prenatal care providers would not protect pregnant women’s autonomy and privacy, contrary to the pregnant women’s own preferences. It is essential to establish national prenatal HIV testing policies in order to prevent unethical practices and ensure satisfaction for pregnant women and health care providers.

Editors’ note: These discrepancies in the attitudes of prenatal care providers and pregnant women are striking and underscore the importance of Turkey moving now to establish a national policy and programming framework for client-initiated and provider-initiated HIV testing. Protecting the autonomy and privacy of pregnant women, preventing discrimination and stigmatisation of those found to be HIV-positive, providing treatment and care, and agreeing on choices for serostatus disclosure are among the key elements of such a framework.

Ncama BP. Acceptance and disclosure of HIV status through an integrated community/home-based care program in South Africa. Int Nurs Rev 2007;54(4):391-7.

This was a comparative study of acceptance and disclosure of the HIV status among people living with HIV (PLHIV) served by an integrated community/home-based care programme and those who are not in any home-based care programme. One of the major challenges in HIV care in developing countries is acceptance and disclosure of a positive HIV status by PLHIV. Denial and non-disclosure of HIV status hinders prevention efforts as well as access to treatment, care and support for these people. Quantitative data were collected in 2004 from a group of PLHIV served by the integrated community/home-based care programme and a group that was not receiving any community/home-based care. Data were compared between the two groups in terms of acceptance and disclosure of HIV status. The integrated community/home-based care programme was effective in improving acceptance and disclosure of the HIV-positive status by PLHIV. People living with HIV in the integrated community/home-based care programme did not find disclosure of their status difficult, and had disclosed their positive HIV status to more people than those who were not in any programme. PLHIV in the integrated community/home-based care programme not only disclosed their positive HIV status within their family network and households, but also disclosed to the community in general, sports group, religious groups and other social networks. Ncama and colleagues conclude that community/home-based care programmes can serve as catalysts for acceptance and disclosure of a positive HIV status by people living with HIV.

Editors’ note: Home-based care services such as this one can foster an individual’s acceptance of his/her HIV status. Disclosure of one’s HIV status, which is linked to acceptance of an HIV-positive diagnosis, is the first step in accessing family and community support. The more that people can come to terms with and disclose their HIV status, the more likely it is that their community’s awareness, openness, and understanding about HIV will increase, particularly in the context of access to care and treatment for those in need.

De Baets AJ, Sifovo S, Parsons R, Pazvakavambwa IE. HIV disclosure and discussions about grief with Shona children: A comparison between health care workers and community members in Eastern Zimbabwe. Soc Sci Med 2008; 66: 479-491.

Research in HIV-related counselling for African children has concentrated on urban tertiary hospitals, but most children have their first health care encounter at a rural primary health care centre. This study investigated perceptions about the acceptability of disclosing the parents’ or child’s HIV status to a child and talking about grief with children, as well as the preferred time, type, and setting for HIV disclosure. An anonymous survey was taken from 64 primary health care workers and 131 community members from rural Eastern Zimbabwe. The results expressed a high need and desire for such communications and should be interpreted against a background of high perceived confidence to talk about grief with adults and a high degree of familiarity with child bereavement and foster care. The participants preferred that partial disclosure occurs from the age of 10.8 (+/-4.2) years and full disclosure from the age of 14.4 (+/-4.5) years.  Compared to community members, health care workers were significantly more open to full disclosure and disclosure at a younger age but were slightly less open to discussing grief. The different preferred combinations of persons to initiate such communications included a health care worker in up to 56% of the responses and a family member in up to 52%. The most commonly preferred family members were father’s sister (up to 37%) and grandmother (up to 40%) rather than the partner (up to 15%). Southern African family dynamics may hinder a mother initiating HIV disclosure and discussions about grief, even though she is traditionally present during HIV diagnosis, counselling, and health education. A more culturally adapted approach than the standard Western ‘couple approach’ may thus be required.  Consequently, counselling training models may need to be adapted. Further research into empowering mothers to involve significant members from the extended family may be highly beneficial.

Editors’ note: The high acceptability of disclosure to children of their own and/or their parents’ serostatus and the perceived need for open communication about grief seen in this study contrasts with assumptions that there is great stigma in rural communities. Accommodating cultural sensitivities means that health care workers should ask the parents to bring the most appropriate family member to attend the child’s counselling sessions, unless parents prefer to initiate HIV disclosure and discussions about grief with their own children without any assistance – one third preferred this option in this study.

Holtgrave DR. Costs and consequences of the US Centers for Disease Control and Prevention’s recommendations for opt-out HIV testing. PLoS Med 2007 4:e194.

The United States Centers for Disease Control and Prevention (CDC) recently recommended opt-out HIV testing (testing without the need for risk assessment and counselling) in all health care encounters in the United States (US) for persons 13-64 years old. However, the overall costs and consequences of these recommendations have not been estimated before. In this paper, Holtgrave estimates the costs and public health impact of opt-out HIV testing relative to testing accompanied by client-centred counselling, and relative to a more targeted counselling and testing strategy. Basic methods of scenario and cost-effectiveness analysis were used, from a payer’s perspective over a one-year time horizon. The author found that for the same programmatic cost of US$864,207,288, targeted counselling and testing services (at a 1% HIV seropositivity rate) would be preferred to opt-out testing: targeted services would newly diagnose more HIV infections (188,170 versus 56,940), prevent more HIV infections (14,553 versus 3,644), and do so at a lower gross cost per infection averted (US$59,383 versus US$237,149). While the study is limited by uncertainty in some input parameter values, the findings were robust across a variety of assumptions about these parameter values (including the estimated HIV seropositivity rate in the targeted counselling and testing scenario). While opt-out testing may be able to newly diagnose over 56,000 persons living with HIV in one year, abandoning client-centred counselling has real public health consequences in terms of HIV infections that could have been averted. Further, Holtgrave’s analyses indicate that even when HIV seropositivity rates are as low as 0.3%, targeted counselling and testing performs better than opt-out testing on several key outcome variables. These analytic findings should be kept in mind as HIV counselling and testing policies are debated in the US.

Editors’ note: This is the kind of analysis that should have underpinned the policy decision by CDC to change its recommendations on HIV testing. It underscores not only that opt-out testing without counselling misses an important opportunity for opening a dialogue about HIV prevention, but that it is more costly and has less public health impact than targeted client-centred counselling and testing in concentrated epidemics. A different conclusion would likely be reached if the cost-effectiveness analysis focused on non-targeted offering of HIV testing and counselling to all patients in resource-limited settings experiencing substantially higher HIV prevalence.

Cockcroft A, Andersson N, Milne D, Mokoena T, Masisi M. Community views about routine HIV testing and antiretroviral treatment in Botswana: signs of progress from a cross sectional study. BMC Int Health Hum Rights 2007;87:5.

The Botswana government began providing free antiretroviral therapy (ART) in 2002 and in 2004 introduced routine HIV testing (RHT) in government health facilities, aiming to increase HIV testing and uptake of ART. There have been concerns that the RHT programme might be coercive, lead to increased partner violence, and drive people away from government health services. Cockcroft and colleagues conducted a household survey of 1536 people in a stratified random sample of communities across Botswana, asking about use and experience of government health services, views about routine HIV testing, views about ART, and testing for HIV in the last 12 months. Focus groups further discussed issues about ART. Some 81% of respondents had visited a government clinic within the last 24 months. Of these 92% were satisfied with the service, 96% felt they were treated with respect and 90% were comfortable about confidentiality. Almost all respondents said they would choose a government clinic for treatment of AIDS. Nearly one half (47%) thought they were at risk of HIV. Those who had experienced partner violence within the last 12 months were more likely to think themselves at risk. One half of those who had visited a government facility in the last 24 months were offered HIV tests, and nearly half were tested. A few (8%) of those who were not asked thought they were tested. Most people (79%) had heard of routine HIV testing and 94% were in favour of it. Over one half (55%) of the entire sample had been tested for HIV within the last 12 months, one half of these through RHT. Women were more likely to have been tested. Nearly everyone (94%) had heard of ART and thought it could help AIDS. Focus groups identified problems of access to ART due to distance from treatment centres and long queues in the centres. Public awareness and approval of RHT was very high. The high rate of RHT has contributed to the overall high rate of HIV testing. The government’s programme to increase HIV testing and uptake of ART is apparently working well. However, turning the tide of the epidemic will also require further concerted efforts to reduce the rate of new HIV infections.

Editors’ note: It is important to clarify what is meant by the term ‘routine HIV testing’. In the Botswana context, it is clearly intended as a routine offer not a routine test since half of those offered the test decided not to take it up at the time it was offered. Botswana’s approach of offering testing in government health facilities has high community acceptance and has helped normalise knowledge of serostatus – an important step in reducing stigma and increasing the effectiveness of prevention for both those found positive and those found negative. It facilitates timely initiation of prophylaxis and treatment for opportunistic infections for people with HIV infection and antiretroviral treatment for those who need it if it can be made widely and conveniently available.

Mfinanga GS, Mutayoba B, Mbogo G, Kahwa A, Kimaro G, Mhame PP, Mwangi C, Malecela MN, Kitua AY. Quality of HIV laboratory testing in Tanzania: a situation analysis. Tanzan Health Res Bull. 2007 Jan;9(1):44-7.

UNAIDS/G.Pirozzi

Tanzania is scaling up prevention, treatment, care and support of individuals affected with HIV. There is therefore a need for high quality and reliable HIV infection testing and AIDS staging. The objective of this study was to assess laboratories capacities of services in terms of HIV testing and quality control. A baseline survey was conducted from December 2004 to February 2005 in 12 laboratories which were conveniently selected to represent all the zones of Tanzania. The questionnaires comprised of questions on laboratory particulars, internal and external quality control for HIV testing and quality control of reagents. Source and level of customer satisfaction of HIV test kits supply was established. Of 12 laboratories, nine used rapid tests for screening and two used rapid tests for diagnosis. In the 12 laboratories, four used double ELISA and five used single ELISA and three did not use ELISA. Confirmatory tests observed were Western Blot in three laboratories, DNA PCR in two laboratories, CD4 counting in seven laboratories, and viral load in two laboratories. Although all laboratories conducted quality control (QC) of the HIV kits, only two laboratories had Standard Operating Procedures (SOPs). Internal and external quality control (EQC) was done at varied proportions with the highest frequency of 55.6% (5/9) for internal quality control (IQC) for rapid tests and EQC for ELISA, and the lowest frequency of 14.3% (1/ 7) for IQC for CD4 counting. None of the nine laboratories which conducted QC for reagents used for rapid tests and none of the five which performed IQC and EQC had SOPs. HIV kits were mainly procured by the Medical Store Department and most of laboratories were not satisfied with the delay in procurement procedures. Most of the laboratories used rapid tests only, while some used both rapid tests and ELISA method for HIV testing. In conclusion, the survey revealed inadequacy in Good Laboratory Practice and poor laboratory quality control process for HIV testing reagents, internal and external quality control.

Editors’ note: The case of a man whose marriage plans were annulled as a result of a false positive HIV test result underscores the importance of observing Good Laboratory Practice and instituting quality control procedures. This type of situation analysis needs to be conducted in all countries.

All over the world HIV has been stigmatised, making it difficult for people living with HIV to access testing, treatment, care and counselling or even to act on a diagnosis or get advice and treatment, for fear of being judged. Prejudice in society has also often been reflected and reproduced by health care providers. A human rights approach, which positively incorporates sexual and reproductive rights, rather than a restricted medical view, is therefore essential for the achievement of true partnerships between health care providers and service users. This paper is about the experiences of HIV positive women and men in sexual and reproductive health services and HIV testing. It provides guidance not only on how things could and should be done but also on how they should not be done. It outlines the sexual and reproductive rights positive people consider crucial and gives examples of how these are being violated. It presents perceptions and implications of HIV testing and how health services can support people after a positive diagnosis. It analyses the importance of confidentiality, continuity of care, knowledge and information, and the role of support groups and home-based care. It calls on sexual and reproductive health services to address issues of stigma and discrimination when offering and carrying out HIV testing and counselling, and in providing treatment, care and support.

Editors’ note: This paper highlights perspectives of people living with HIV which can help guide best practices in HIV testing, treatment, care and support. Stigma is a huge barrier to care, treatment, and support worldwide, and addressing this barrier will allow improved access, not merely improved offering or availability, of care, treatment, and support.

Because HIV rapid tests are considered for self-testing, this study aims to determine the user acceptability and feasibility of self-testing. A cross-sectional study was performed on 350 systematically sampled participants across 2 Singapore HIV testing centers using the Abbott Determine HIV 1/2 blood sample rapid test (Abbott Laboratories, Abbott Park, IL). Participants were surveyed on knowledge of and attitudes toward rapid testing. To determine interrater agreement between self-testing and trained personnel testing, participants performed self-testing with visual instructions, followed by trained personnel testing. Ability to identify test outcomes was determined through interpretation of sample test results. Eighty-nine percent of participants preferred testing in private, but most indicated that confidential counselling by trained counsellors was necessary. Almost 90% found the kit easy to use and instructions easy to understand. Nevertheless, 85% failed to perform all steps correctly, especially blood sampling, and 56% had invalid results because of incorrect test performance. Interrater agreement between results from self-testing and trained personnel testing had a kappa value of 0.28. Twelve percent could not correctly determine results using sample tests, including 2% and 7% who read positive and negative samples, respectively, incorrectly. A substantial proportion could not perform self-testing or identify outcomes. Self-testing with the Determine HIV 1/2 kit in Singapore should be deferred.

Editors’ note: Although self-testing with rapid tests has the advantages of convenience and anonymity, high levels of inappropriate usage may cause more harm than good. In this study, most participants wanted the support of a trained counsellor which can reduce misunderstandings and alleviate stress/fear. Self-testing test performance will have to improve dramatically before it can be recommended.

Serodiagnosis of HIV infection in infants born to HIV-infected mothers is problematic due to the prolonged presence of maternal antibodies in infants. Nucleic acid-based amplification assays have been used to overcome this problem. Here a simplified, one-tube, real-time, duplex reverse transcription PCR (RT PCR) assay is shown to detect HIV-1 total nucleic acid (TNA) isolated from dried blood spots. The detection of TNA, as opposed to DNA alone, increases the HIV target molecules and thus makes the assay more robust. This method was used to detect HIV from the DBS collected from HIV-1 exposed infants and young children in Uganda (n=128) and Cameroon (n=315). The gold-standards used were a plasma viral assay in Uganda and Amplicor DNA assay in Cameroon. The concordance of this real-time assay and the gold standards was 99.2% (127/128) and 99.4% (313/315) with the Ugandan and Cameroonian samples, respectively. This simple and cost-effective assay is potentially useful for the diagnosis of paediatric HIV infection and for evaluating programs to reduce mother-to-child transmission of HIV-1.

Editors’ note: Early diagnosis of paediatric HIV infection permits tailored care with closer monitoring to determine eligibility for antiretroviral treatment, continuation of cotrimoxazole prophylaxis, and nutritional counselling.

Debattista J, Bryson G, Roudenko N, Dwyer J, Kelly M, Hogan P, Patten J. Pilot of non-invasive (oral fluid) testing for HIV within a clinical setting. Sex Health 2007;4:105-9.

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. 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 revealed that, 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. In conclusion, 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.

Editors’ note: Sensitivity (ability of a test to recognise true positives) and specificity (ability of a test to correctly identify true negatives) are important test characteristics. They can be improved by use of a second test based on a slightly different principle. However, it is the positive predictive value that makes all the difference. A positive result on a test with the performance characteristics of the Orasure gingival exudate test will have a high positive predictive value (meaning that if it is positive it has a high likelihood of being a true positive) in a high HIV prevalence population but a low positive predictive value when HIV prevalence in a population is low.

To develop new strategies aimed to reduce the delay in seeking HIV diagnosis, Delpierre and colleagues proposed to identify correlates of late diagnosis of HIV infection in France. Late testing was studied among the 1077 patients diagnosed from 1996 and enrolled in the ANRS-EN12-VESPA, a representative sample of the French HIV-infected population. Patients were defined as ‘late testers’ if they had presented either clinical AIDS events or CD4 cell count <200/mm(3) at diagnosis. In all, 33.1% were classified as late testers, among whom 42.6% had discovered their HIV infection at the time of AIDS events. This proportion increased with age and was higher for heterosexual men and migrants. Among the non-migrants heterosexual population, late diagnosis was more frequent among people in longstanding couples, with children and conversely was less likely among individuals with large number of sexual partners. Being on welfare benefit before diagnosis was associated with a lower risk of late diagnosis. Among migrants, lack of recent steady partnership was associated with an increased risk, as being diagnosed during the first year of stay in France. The authors results showed low risk factors of infection were risk factors of late testing. Public communication should aim at improving the awareness of HIV risk in longstanding couples with stable employment, both among homosexual and heterosexual populations. Among migrants, HIV testing with informed consent short after entry should be improved, especially towards individuals not in couples.

Editors’ note: When HIV infection is not suspected by either the patient or the health care provider, late diagnosis and subsequent poorer prognosis may result. France is a low HIV prevalence country in which provider-initiated testing would normally be focused on patients with signs and symptoms of HIV, including tuberculosis; on patients seeking sexual and reproductive health care (e.g. for pregnancy, contraception, sexually transmitted disease); and on people recently arrived from high HIV prevalence settings (migrants or those who have been sexually active in those settings). This study supports the concept of ‘know your status’ campaigns where people have an opportunity to consider being tested for HIV as part of a general population programme.

Kawichai S, Celentano DD, Chariyalertsak S, Visrutaratna S, Short O, Ruangyuttikarn C, Chariyalertsak C, Genberg B, Beyrer C. Community-based Voluntary Counseling and Testing Services in Rural Communities of Chiang Mai Province, Northern Thailand. AIDS Behav 2007 Sep;11(5):770-7

Between September, 2002 to May, 2003, Kawichai and colleagues implemented community-based HIV Voluntary Counselling and Testing (VCT) services in four rural areas of Chiang Mai Province. The services included providing AIDS education and free mobile VCT using rapid testing with same day results. Overall, 427 villagers came for VCT (testers) and consented to be interviewed. HIV prevalence among testers was 4.9%, range from 1.1 to 8.4% by area. ‘It is free’ and/or ‘convenient’ were the most frequently cited factors that motivated them to get tested (72%) from our mobile VCT. Rural residents came for VCT when logistical barriers were removed.  HIV prevalence among testers in some areas was high. Without extending HIV prevention efforts to population segments with less access to health care, the HIV problem in Thailand may re-emerge. Convenient and low-cost VCT may prove crucial for containing this HIV epidemic.

Editors’ note: Rural community-based HIV testing and counselling services can have good uptake it they are free, confidential and convenient. It is important to collect, analyse and publish data on the comparative costs of mobile testing services, including the home-based testing being carried out in Uganda and Kenya, to have a better idea of their relative merit.

The objectives of this study were to examine the determinants of uptake of voluntary counselling and testing (VCT) services, to assess changes in sexual risk behaviour following VCT, and to compare HIV incidence amongst testers and non-testers. This was a prospective population-based cohort study of adult men and women in the Manicaland province of eastern Zimbabwe. Demographic, socioeconomic, sexual behaviour and VCT utilization data were collected at baseline (1998-2000) and follow-up (3 years later). HIV status was determined by HIV-1 antibody detection. In addition to services provided by the government and non-governmental organizations, a mobile VCT clinic was available at study sites. Lifetime uptake of VCT increased from under 6% to 11% at follow-up. Age, increasing education and knowledge of HIV were associated with VCT uptake. Women who took a test were more likely to be HIV positive and to have greater HIV knowledge and fewer total lifetime partners. After controlling for demographic characteristics, sexual behaviour was not independently associated with VCT uptake. Women who tested positive reported increased consistent condom use in their regular partnerships. However, individuals who tested negative were more likely to adopt more risky behaviours in terms of numbers of partnerships in the last month, the last year and in concurrent partnerships. HIV incidence during follow-up did not differ between testers and non-testers. Motivation for VCT uptake was driven by knowledge and education rather than sexual risk. Increased sexual risk following receipt of a negative result may be a serious unintended consequence of VCT. It should be minimized with appropriate pre- and post-test counselling.

Editors’ note: These findings have been the subject of much discussion since they appeared. They suggest that sexual risk is not a strong motivator of decisions to get tested for HIV in this area of Zimbabwe and that there is a tendency to increase the number of sexual partners for those who do decide to get tested and are found negative. This has been seen in other settings in which people appear to interpret an HIV-negative result as evidence of some invulnerability. Community testing literacy programmes to accompany any offer of services are key to changing social norms around sexual behaviour, with access to HIV testing and counselling being the entry point to discussions in communities about the need for change and how to foster it.

Creek TL, Ntumy R, Seipone K, Smith M, Mogodi M, Smit M, Legwaila K, Molokwane I, Tebele G, Mazhani L, Shaffer N, Kilmarx PH. Successful introduction of routine opt-out HIV testing in antenatal care in Botswana. J Acquir Immune Defic Syndr 2007;45:102-7.

Botswana has high HIV prevalence among pregnant women (37.4% in 2003) and provides free services for prevention of mother-to-child transmission (PMTCT) of HIV. Nearly all pregnant women (>95%) have antenatal care (ANC) and deliver in hospital. Uptake of antenatal HIV testing was low from 1999 through 2003. In 2004, Botswana’s President declared that HIV testing should be « routine but not compulsory » in medical settings. Health workers were trained to provide group education and recommend HIV testing as part of routine ANC services. Logbook data on ANC attendance, HIV testing, and uptake of PMTCT interventions were reviewed before and after routine testing training, and ANC clients were interviewed. After routine testing started, the percentage of all HIV-infected women delivering in the regional hospital who knew their HIV status increased from 47% to 78% and the percentage receiving PMTCT interventions increased from 29% to 56%. ANC attendance and the percentage of HIV-positive women who disclosed their HIV status to others remained stable. Interviews indicated that ANC clients supported the policy. Routine HIV testing was more accepted than voluntary testing in this setting and led to substantial increases in the uptake of testing and PMTCT interventions without detectable adverse consequences. Routine testing in other settings may strengthen HIV care and prevention efforts.

Editors’ note: The terminology in this report may be confusing (routine, opt-out, recommended) but the practice does follow the WHO/UNAIDS initiated testing and counselling guidelines. Practitioners are recommending HIV testing to pregnant women so this is provider-initiated testing and although more than three-quarters of women are accepting to be tested, there are some women who are deciding not to be tested, suggesting that it is voluntary testing. Botswana has very high antenatal care coverage which greatly improves the likelihood of higher PMTCT coverage.

Campos-Outcalt D. Time to revise your HIV testing routine. J Fam Pract 2007;56:283-4.

Should all adults and adolescents be screened for HIV? Do all persons at high risk deserve annual screening? The Centers for Disease Control and Prevention (CDC) thinks so, but the US Preventive Services Task Force takes a less aggressive stance. The two agencies looked at the evidence and interpreted it differently-and likewise we must each decide what is best for our own patients and community. Routine screening is one of several recently revised recommendations from the CDC. Though the CDC has historically taken a cautious approach to HIV testing, the winds appear to be changing.

Editors’ note: These questions have been preoccupying WHO and UNAIDS over the past year as guidance for provider-initiated testing and counselling based on the UNAIDS/WHO 2004 Policy Statement on HIV Testing and Counselling has been developed. The guidance, which was developed through extensive consultations with stakeholders, will be released June 1.

Erasmus U. Morah. Are people aware of their HIV-positive status responsible for driving the epidemic in sub-Saharan Africa? The case of Malawi. Development Policy Review 2007;25:215-242

Many have alleged that those who are now aware that they are HIV positive are driving the epidemic. This article reports the results of a study in Malawi that provides empirical evidence of differences in knowledge, attitudes and behaviour between HIV-positive people and those unaware of their sero-status. It comes to three conclusions: HIV-positive people report better knowledge and attitudes; there is substantially higher safer-sex practice among those aware of their HIV-positive status; and the assertion that the epidemic is spread by those aware of their positive sero-status is unsubstantiated. The overall message is that there is a need to accelerate both HIV testing and positive-prevention work.

Editors’ note: Although as many as half of new infections may be acquired from people who themselves are in the primary infection stage of the first 6 months (see lead item in issue 30 of HIV This Week), people who have been living with HIV longer and who know their status are clearly keen to prevent onward transmission as this report from Malawi shows. Poz-prevention, as some call it, can support safer sex by HIV-positive people but effective anti-stigma campaigns are essential components to any ‘know your HIV status’ programme.

Dilley JW, Woods WJ, Loeb L, Nelson K, Sheon N, Mullan J, Adler B, Chen S, McFarland W. Brief cognitive counseling with HIV testing to reduce sexual risk among men who have sex with men: results from a randomized controlled trial using paraprofessional counselors. J Acquir Immune Defic Syndr 2007 Feb 15; [Epub ahead of print]

Dilley and colleagues test the efficacy and acceptability of a single-session personalized cognitive counselling (PCC) intervention delivered by paraprofessionals during HIV voluntary counselling and testing. HIV-negative men who have sex with men (MSM; n = 336) were randomly allocated to PCC or usual counselling (UC) between October 2002 and September 2004. The primary outcome was the number of episodes of unprotected anal intercourse (UAI) with any non-primary partner of non-concordant HIV serostatus in the preceding 90 days, measured at baseline, 6 months, and 12 months. Impact was assessed as “intent to treat” by random-intercept Poisson regression analysis. Acceptability was assessed by a standardized client satisfaction survey. Men receiving PCC and UC reported comparable levels of HIV non-concordant UAI at baseline (mean episodes: 4.2 vs. 4.8, respectively; P = 0.151). UAI decreased by more than 60% to 1.9 episodes at 6 months in the PCC arm (P < 0.001 vs. baseline) but was unchanged at 4.3 episodes for the UC arm (P = 0.069 vs. baseline). At 6 months, men receiving personalized cognitive counselling (PCC) reported significantly less risk than those receiving usual counselling (UC) (P = 0.029 for difference to PCC). Risk reduction in the PCC arm was sustained from 6 to 12 months at 1.9 (P = 0.181), whereas risk significantly decreased in the UC arm to 2.2 during this interval (P <0.001 vs. 6 months; P = 0.756 vs. PCC at 12 months). Significantly more PCC participants were “very satisfied” with the counselling experience (78.2%) versus UC participants (59.2%) (P = 0.002). The authors conclude that both interventions were effective in reducing high-risk sexual behaviour among MSM repeat testers. PCC participants demonstrated significant behavioural change more swiftly and reported a more satisfying counselling experience than UC participants.

Editors’ note: These findings from a randomised controlled trial highlight that the process of repeat HIV testing accompanied by counselling can lead to reductions in risk behaviours among men who have sex with men, particularly when counselling is personalised to each man’s individual situation. Both the sustainability of these behaviour changes and the extent to which these men remain HIV-negative following the intervention are important questions.