Articles tagged as "HIV testing"

September
25
2011

HIV testing

Will patients "opt in" to perform their own rapid HIV test in the emergency department?

Gaydos CA, Hsieh YH, Harvey L, Burah A, Won H, Jett-Goheen M, Barnes M, Agreda P, Arora N, Rothman RE. Ann Emerg Med. 2011 Jul;58 Suppl 1:S74-8.

Gaydos and colleagues evaluated the feasibility and accuracy of existing point-of-care HIV tests performed by an untrained patient compared with the routinely used HIV point-of-care test offered to patients in 2 urban emergency departments. From April 2008 through December 2009, patients who had completed a standard HIV oral fluid test performed by a trained health care professional and who were unaware of their results were recruited to perform a rapid point-of-care HIV test. Patients were given a choice of the oral fluid or the fingerstick blood point-of-care test. Evaluation of acceptability to perform the mechanics of the test was accessed by questionnaire. For the "self-test," the participant obtained his or her own sample and performed the test. The patient's results were compared with standard oral fluid results obtained by the health care professional. Overall, 478 of 564 (85%) patients receiving a standard oral fluid HIV test volunteered, with a mean age of 38 to 39 years. Ninety-one percent of participants chose oral fluid and 9% chose blood (P<.05). Self-test results were 99.6% concordant with health care professionals' test results. For the self-testers, 94% of oral fluid testers and 84.4% of blood testers reported trusting the self-administered test result "very much." Furthermore, 95.6% of the oral fluid group and 93.3% of the blood group would "probably" or "definitely" perform a test at home, if available. This study demonstrated that a significant proportion of patients offered a self-HIV point-of-care test volunteered and preferred using oral fluid. Patients' results agreed with standard HIV point-of-care results. The majority of participants trusted their results and would perform a point-of-care HIV test at home, given the opportunity.

For abstract access click here

Editor’s note: This pilot study sought to find out if significant staff time and money could be saved if emergency room patients performed their own HIV test. All the participants had already had blood drawn for an HIV test so willingness to volunteer for HIV testing or to have a first HIV test was not being assessed—85% of those approached agreed to the point-of-care self test. The vast majority chose an oral fluid test over pricking their own finger. The results were 99.6% concordant with those obtained by health care professionals. More than 80% of volunteers reported feeling ‘in control of own health’. Further study is warranted in other settings of self point-of-care HIV testing using clear instructional materials and with proper oversight provided by staff, as was done here.

HIV testing
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August
28
2011

HIV testing

Community-based intervention to increase HIV testing and case detection in people aged 16-32 years in Tanzania, Zimbabwe, and Thailand (NIMH Project Accept, HPTN 043): a randomised study

Sweat M, Morin S, Celentano D, Mulawa M, Singh B, Mbwambo J, Kawichai S, Chingono A, Khumalo-Sakutukwa G, Gray G, Richter L, Kulich M, Sadowski A, Coates T; the Project Accept study team. Lancet Infect Dis. 2011; 11(7):525-532.

In developing countries, most people infected with HIV do not know their infection status. Sweat and colleagues aimed to assess whether HIV testing could be increased by combination of community mobilisation, mobile community-based voluntary counselling and testing (VCT), and support after testing. Project Accept is underway in ten communities in Tanzania, eight in Zimbabwe, and 14 in Thailand. Communities at each site were paired according to similar demographic and environmental characteristics, and one community from each pair was randomly assigned to receive standard clinic-based VCT, and the other community was assigned to receive community-based VCT plus access to standard clinic-based VCT. Randomisation and assignment of communities to intervention groups was done by the statistics centre by computer; no one was masked to treatment assignment because the interventions were community based. Intervention was provided for about 3 years (2006-09). The primary endpoint of HIV incidence is pending completion of assessments after the intervention. In this interim analysis, the authors examined the secondary endpoint of uptake in HIV testing, differences in characteristics of clients receiving their first HIV test, and repeat testing. Analyses were limited to clients aged 16-32 years. This study is registered with ClinicalTrials.gov, number NCT00203749. The proportion of clients receiving their first HIV test during the study was higher in community-based VCT communities than in standard clinic-based VCT communities in Tanzania (2341 [37%] of 6250 vs 579 [9%] of 6733), Zimbabwe (5437 [51%] of 10 700 vs 602 [5%] of 12 150), and Thailand (7802 [69%] of 11 290 vs 2319 [23%] 10 033). The mean difference in the proportion of clients receiving HIV testing between community-based VCT and standard clinic-based VCT communities was 40·2% (95% CI 15·8-64·7; p=0·019) across three community pairs (one per country). HIV prevalence was higher in standard clinic-based VCT communities than in community-based VCT communities, but community-based VCT detected almost four times more HIV cases than did standard clinic-based VCT across the three study sites (952 vs 264; p=0·003). Repeat HIV testing in community-based VCT communities increased in all sites to reach 28% of all those testing for HIV by the end of the intervention period. Community-based VCT should be considered as a viable intervention to increase detection of HIV infection, especially in regions with restricted access to clinic-based VCT and support services after testing.

For abstract access click here

Editor’s note: This trial comparing clinic-based versus community-based voluntary HIV counselling and testing in Tanzania, Zimbabwe, and Thailand has yet to report on its primary outcome of HIV incidence. However, the results concerning its secondary outcome of HIV testing uptake are compelling. The numbers of people having a first test ever for HIV was 4 times higher in Tanzania, 10 times higher in Zimbabwe, and 3 times higher in Thailand at community-based sites compared to fixed site clinics in hospitals and health centres. HIV prevalence was higher in the fixed sites but more people found out that they had HIV in the community-based sites because many more people took advantage of the mobile services to find out their status. An amazing 55% of community residents aged 16 to 32 years were mobilised to come forward for testing, underscoring the importance of effective demand creation for high uptake of mobile services linked to post-test community-based support. HIV counselling and testing lowers HIV risk behaviour in people living with HIV and in couples and it is the gateway to life-prolonging HIV treatment and care. Reaching millions of people with the opportunity to learn their serostatus will require multiple strategies. Project Accept demonstrates that offering HIV testing and counselling through mobile services can fill a gap not met by fixed services, particularly in rural areas.

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August
28
2011

HIV testing

Attitudes towards couples-based HIV testing among MSM in three US cities

Stephenson R, Sullivan PS, Salazar LF, Gratzer B, Allen S, Seelbach E. 2011 Apr;15 Suppl 1:S80-7.

Couples-based voluntary HIV counselling and testing-in which couples receive counselling and their HIV test results together-has been shown to be an effective strategy among heterosexual sero-discordant couples in Africa for reducing HIV transmission by initiating behavioural change. This study examined attitudes towards couples-based voluntary HIV counselling and testing among men who have sex with men in three US cities. Four focus group discussions were held with men who have sex with men in Atlanta, Chicago, and Seattle. Although initially hesitant, participants reported an overwhelming acceptance of couples-based voluntary HIV counselling and testing. Couples-based voluntary HIV counselling and testing was seen as a sign of commitment within a relationship and was reported to be more appropriate for men in longer-term relationships. CVCT was also seen as providing a forum for the discussion of risk-taking within the relationship. These results suggest that there may be a demand for couples-based voluntary HIV counselling and testing among men who have sex with men in the United States, but some modifications to the existing African couples-based voluntary HIV counselling and testing protocol may be needed.

For abstract access click here

Editor’s note: The numbers of same-sex couples living in the United States of America has increased substantially, for example by 30% between 2000 and 2005. A study published in 2009 estimated that 68% of new infections among men who have sex with men in the USA are likely attributable to sex with main partners. Among the barriers to the establishment of couples voluntary counselling and testing services in the USA have been provider concerns about confidentiality laws. In African settings, there is no doubt that establishment of such services attracts heterosexual couples and, as this study demonstrates, same-sex male couples in the USA may view such services favourably. The focus group discussions revealed that the idea of mutual disclosure of serostatus and planning safer sex strategies in the company of a trained counsellor was particularly attractive, as was the idea of being able to receive immediate emotional support from the partner or provide it to him. Participants also ventured that couples voluntary counselling and testing services could be offered within a larger package for male couples that could include relationship counselling and financial planning.

HIV testing
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March
27
2011

Discordant couples

HIV-1 transmission among HIV-1 discordant couples before and after the introduction of antiretroviral therapy in Rakai, Uganda

Reynolds SJ, Makumbi F, Nakigozi G, Kagaayi J, Gray RH, Wawer M, Quinn TC, Serwadda D. AIDS. 2011 Feb 20:25(4):473-7

To evaluate the impact of antiretroviral therapy on HIV-1 transmission rates among HIV-1 discordant couples in Rakai, Uganda, Reynolds and colleagues studied HIV-1 discordant couples which were retrospectively identified between 2004 and 2009. Study participants underwent annual screening for HIV-1 and were interviewed to evaluate risk behaviours. Participants were offered voluntary counselling and testing and provided with risk reduction counselling. Free antiretroviral therapy was offered to participants with a CD4 cell count ≤250 cells/ml or WHO stage IV disease. HIV-1 incidence and sexual risk behaviours were compared before and after the HIV-1 positive index partners started antiretroviral therapy. Two hundred and fifty HIV-1 discordant couples were followed between 2004-2009 and 32 HIV-1 positive partners initiated antiretroviral therapy. Forty two HIV-1 transmissions occurred over 459.4 person-years prior to antiretroviral therapy initiation, incidence 9.2/100 person years, (95% CI 6.59, 12.36). In the 32 couples in which the HIV-1 index partners started antiretroviral therapy, no HIV-1 transmissions occurred during 53.6 person-years. The 95% confidence interval (CI) for the incidence rate difference was (-11.91, -6.38, p = 0.0097). Couples reported more consistent condom use during antiretroviral therapy use but there was no significant difference in the number of sexual partners or other risk behaviours. Viral load was markedly reduced in persons on antiretroviral therapy. HIV-1 transmission may be reduced among HIV-1 discordant couples after initiation of antiretroviral therapy due to reductions in HIV-1 viral load and increased consistent condom use.

Abstract

Editors’ note: This observational study of 250 HIV-serodiscordant couples (58% had a male index positive partner) documented no HIV transmission in the 32 couples in which antiretroviral therapy was started at CD4 cell counts under 250. In comparison, the HIV transmission rate in couples where treatment had not yet been initiated was 9.2 per 100 person years. The sample size is small and condom use may have confounded the findings making it unclear how much antiretroviral treatment contributed to the reduction in HIV transmission. Consistent condom use increased significantly in those starting treatment, rising from 14.3% to 53.7% with any partner. Nonetheless, the findings provide support for the hypothesis being tested in the HPTN 052 trial that antiretroviral treatment can prevent HIV transmission in HIV-discordant couples.

HIV testing
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January
29
2011

Economics

The economic burden of late entry into medical care for patients with HIV infection

Fleishman JA, Yehia BR, Moore RD, Gebo KA; for the HIV Research Network. Med Care. 2010 Dec;48(12):1071-9.

A large proportion of people with human immunodeficiency virus (HIV) infection enter care late in the HIV disease course. Late entry can increase expenditures for care. The objective of this study is to estimate direct medical care expenditures for HIV patients as a function of disease status at initial presentation to care. Late entry is defined as initial CD4 test result ≤200 cells/mm, intermediate entry as initial CD4 counts >200, and ≤500 cells/mm; and early entry as initial CD4 count >500. The study included 8348 patients who received HIV primary care and who were newly enrolled between 2000 and 2006 at one of 10 HIV clinics participating in the HIV Research Network. Fleishman and colleagues reviewed medical record data from 2000 to 2007. They estimated costs per outpatient visit and inpatient day, and monthly medication costs (antiretroviral and opportunistic illness prophylaxis). The authors multiplied unit costs by utilization measures to estimate expenditures for inpatient days, outpatient visits, HIV medications, and laboratory tests. They analyzed the association between cumulative expenditures and initial CD4 count, stratified by years in care. Late entrants comprised 43.1% of new patients. The number of years receiving care after enrolment did not differ significantly across initial CD4 groups. Mean cumulative treatment expenditures ranged from $27,275 to $61,615 higher for late than early presenters. After 7 to 8 years in care, the difference was still substantial. Patients who enter medical care late in their HIV disease have substantially higher direct medical treatment expenditures than those who enter at earlier stages. Successful efforts to link patients with medical care earlier in the disease course may yield cost savings.

For abstract access click here:

Editors’ note: People present for diagnosis and care late in HIV infection when they fear stigma, mistrust providers, cannot access affordable care, or do not even know that they have been living with HIV. We know that late presentation, defined here as a CD4 cell count at first presentation of less than 200 cells/µl, is associated with a worse prognosis and poorer survival because an immune system weakened to this point does not respond as well to antiretroviral therapy. We also know that late presentation denies people the HIV prevention benefits that effective treatment can bring and denies communities the effects of treatment on HIV transmission. Late presentation also engenders economic burden. This conservative analysis looked only at direct health care costs, excluding nonmedical services and outpatient medical care for non-HIV-related conditions such as comorbidities, psychopathology, or substance use. You would think that shorter survival in late presenters might balance out the economic scorecard but not so – even 8 years after initial presentation, care for the late presenters still cost more. With 43% of people in this USA study presenting late, and that proportion likely even higher in many low- and middle-income settings, it makes economic sense to encourage widespread voluntary HIV testing uptake now – and to make reduction of the percentage of late presenters a national objective in all countries.

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November
23
2010

HIV Testing

Rapid implementation of an integrated large-scale HIV counselling and testing, malaria, and diarrhoea prevention campaign in rural Kenya.

Lugada E, Millar D, Haskew J, Grabowsky M, Garg N, Vestergaard M, Kahn J, Muraguri N, Mermin J. PLoS One. 2010;5(8):e12435.

Integrated disease prevention in low resource settings can increase coverage, equity and efficiency in controlling high burden infectious diseases. A public-private partnership with the Ministry of Health, Centers for Disease Control, Vestergaard Frandsen and CHF International implemented a one-week integrated multi-disease prevention campaign. Residents of Lurambi, Western Kenya were eligible for participation. The aim was to offer services to at least 80% of those aged 15-49. 31 temporary sites in strategically dispersed locations offered: HIV counselling and testing, 60 male condoms, an insecticide-treated bednet, a household water filter for women or an individual filter for men, and for those testing positive, a 3-month supply of cotrimoxazole and referral for follow-up care and treatment. Over 7 days, 47,311 people attended the campaign with a 96% uptake of the multi-disease preventive package. Of these, 99.7% were tested for HIV (87% in the target 15-49 age group); 80% had previously never tested. 4% of those tested were positive, 61% were women (5% of women and 3% of men), 6% had median CD4 counts of 541 cell/µL (IQR; 356, 754). 386 certified counsellors attended to an average 17 participants per day, consistent with recommended national figures for mass campaigns. Among women, HIV infection varied by age, and was more likely with an ended marriage (e.g. widowed vs. never married, OR.3.91; 95% CI. 2.87-5.34), and lack of occupation. In men, quantitatively stronger relationships were found (e.g. widowed vs. never married, OR.7.0; 95% CI. 3.5-13.9). Always using condoms with a non-steady partner was more common among HIV-infected women participants who knew their status compared to those who did not (OR.5.4 95% CI. 2.3-12.8). Through integrated campaigns it is feasible to efficiently  cover large proportions of eligible adults in rural underserved communities with multiple disease preventive services simultaneously achieving various national  and international health development goals. 

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Editors’ note: Talk about integration and meeting people’s needs! This exciting 7-day programme in an area of high malaria incidence, poor sanitation and high diarrhoeal disease, and a low knowledge of HIV serostatus elicited high demand. The population consisted of 51,178 people aged 15-49 years living in 157 villages covering an area of 194 square kilometres. Over 87% of them showed up (along with almost 2800 non-residents) for the MPP (multi-disease prevention package) that consisted of a long-lasting impregnated bednet to prevent night-time mosquito bites, a water purification system, 60 condoms, and testing and counselling for HIV. Uptake was higher for the MPP than had ever been seen for social marketing campaigns for its individual components. Following individual pre-test counselling, fully 99.7% consented to have a test for HIV and receive the results. Unique client numbers delinked from personal identifiers protected confidentiality and micro-planning exercises projected daily demand and matched it to personnel and logistics requirements for 30 service delivery sites. A pre-campaign survey identified appropriate media messages and channels for a health education/community mobilisation programme which began one month before and continued during the 7-day campaign. More ‘outside the facility’ multi-disease integrated campaigns such as this have the potential to achieve rapid, high, equitable coverage to address multiple health challenges on the road to the Millennium Development Goals.

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October
31
2010

Home-based HIV testing for kids

Acceptance of HIV testing for children ages 18 months to 13 years identified through voluntary, home-Based HIV counselling and testing in Western Kenya.

Vreeman RC, Nyandiko WM, Braitstein P, Were MC, Ayaya SO, Ndege SK, Wiehe SE.  J Acquir Immune Defic Syndr. 2010;55:e3-10.

Home-based voluntary counselling and testing presents a novel approach to early diagnosis. Vreeman and colleagues sought to describe uptake of paediatric HIV testing, associated factors, and HIV prevalence among children offered home-based voluntary counselling and testing in Kenya. The USAID-Academic Model Providing Access to Healthcare Partnership conducted home-based voluntary counselling and testing in western Kenya in 2008. Children 18 months to 13 years were offered home-based voluntary counselling and testing if their mother was known to be dead, her living status was unknown, mother was HIV infected, or of unknown HIV status. This retrospective analysis describes the cohort of children encountered and tested. Home-based voluntary counselling and testing was offered to 2289 children and accepted for 1294 (57%). Children were more likely to be tested if more information was available about a suspected or confirmed maternal HIV infection [for HIV-infected living mothers odds ratio (OR) = 3.20, 95% confidence interval (CI): 1.64 to 6.23), if parents were not in household (OR = 1.50, 95% CI: 1.40 to 1.63), if they were grandchildren of head of household (OR = 4.02, 95% CI: 3.06 to 5.28), or if their father was not in household (OR = 1.41, 95% CI: 1.24 to 1.56). Of the eligible children tested, 60 (4.6%) were HIV infected. Home-based voluntary counselling and testing provides an opportunity to identify HIV among high-risk children; however, acceptance of home-based voluntary counselling and testing for children was limited. Further investigation is needed to identify and overcome barriers to testing uptake.

For abstract access click here

Editors’ note: Early diagnosis of children with HIV infection is critical to their survival: half of children living with HIV die before age 2 and 75% can die by age 5 years. In the context of a division-wide home-based testing programme in the Turbo Division of Uasin Gishu District of the Rift Valley Province of western Kenya, 57,466 household residents were identified. Adolescents above age 13 and adults were offered HIV testing while children aged 18 months to age 13 years were eligible for testing if they met criteria defined by the mother’s risk factors. Overall, 2289 children were eligible but only 57% were tested following parent/guardian consent. Children under the age of 18 months were not eligible for testing, despite the fact that they are most in need of treatment if they have HIV infection, because DNA PCR (polymerase chain reaction) was not available to help distinguish between maternal and child HIV antibodies. For the age group above 18 months, caregivers clearly are the gatekeepers accepting or refusing that a child’s HIV status be learned. Qualitative studies to determine why almost half of caregivers did not consent to have high-risk children tested for HIV in the home and why younger children were less likely to be tested is urgently needed to inform strategies to overcome the barriers that are denying children essential treatment.

 

HIV testing
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August
2
2010

HIV Testing

HIV-1 subtype C-infected individuals maintaining high viral load as potential targets for the "test-and-treat" approach to reduce HIV transmission.

Novitsky V, Wang R, Bussmann H, Lockman S, Baum M, Shapiro R, Thior I, Wester C,  Wester CW, Ogwu A, Asmelash A, Musonda R, Campa A, Moyo S, van Widenfelt E, Mine  M, Moffat C, Mmalane M, Makhema J, Marlink R, Gilbert P, Seage GR 3rd, DeGruttola V, Essex M.  PLoS One. 2010;5:e10148.

The first aim of the study is to assess the distribution of HIV-1 RNA levels in subtype C infection. Among 4,348 drug-naïve HIV-positive individuals participating in clinical studies in Botswana, the median baseline plasma HIV-1 RNA levels differed between the general population cohorts (4.1-4.2 log(10)) and  combination antiretroviral therapy-initiating cohorts (5.1-5.3 log(10)) by about one log(10). The proportion of individuals with high (> or = 50,000 (4.7 log(10)) copies/ml) HIV-1 RNA levels ranged from 24%-28% in the general HIV-positive population cohorts to 65%-83% in  combination antiretroviral therapy-initiating cohorts. The second aim is to estimate the proportion of individuals who maintain high HIV-1 RNA levels for an extended time and the duration of this period. For this analysis, the authors estimate the proportion of individuals who could be identified by repeated 6- vs. 12-month-interval HIV testing, as well as the potential reduction of HIV transmission time that can be achieved by testing and antiretroviral treatment. Longitudinal analysis of 42 seroconverters revealed that 33% (95% CI: 20%-50%) of individuals maintain high HIV-1 RNA levels for at least 180 days post seroconversion and the median duration of high viral load period was 350 (269; 428) days post seroconversion. They found that it would be possible to identify all HIV-infected individuals with viral load > or = 50,000 (4.7 log(10)) copies/ml using repeated six-month-interval HIV testing. Assuming individuals with high viral load initiate combination antiretroviral therapy after being identified, the period of high transmissibility due to high viral load can potentially be reduced by 77% (95% CI: 71%-82%). Therefore, if HIV-infected individuals maintaining high levels of plasma HIV-1 RNA for extended period of time contribute disproportionally to HIV transmission, a modified "test-and-treat" strategy targeting such individuals by repeated HIV testing (followed by initiation of combination antiretroviral therapy) might be a useful public health strategy for mitigating the HIV epidemic in some communities.

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Editors’ note: Viral load studies in sub-type B infection have shown that for most people the initial peak of viral load resolves to a steady-state setpoint in 4 to 6 months, with higher viral setpoint associated with an increased risk of disease progression and onward HIV transmission. Although we do not know what the threshold for HIV transmission is, it is assumed to be between 10,000 and 100,000 copies/ml, with 50,000 copies/ml used in most studies. This study of over 4000 people with sub-type C infection participating in 7 cohort studies in Botswana found that 24-28% of people in the general population studies and 65-83% in the populations staring on antiretroviral therapy had viral loads over 50,000. In the acute infection cohort, the mean and median duration of high viral load was about 12 months, with around 33% of people maintaining high viral loads. Modelling to determine the optimal testing frequency to identify these individuals and offer them immediate treatment revealed that more HIV transmission could be prevented (77%) with 6-monthly viral load testing than with an annual test. Clearly, people in need of life-prolonging treatment should be prioritised for access to therapy. Thereafter, strategies such as offering treatment to people who are not eligible for treatment based on CD4 count but who are most likely to transmit to others could be considered.

HIV testing
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August
2
2010

HIV Testing

Couple-oriented prenatal HIV counseling for HIV primary prevention: an acceptability study.

Orne-Gliemann J, Tchendjou PT, Miric M, Gadgil M, Butsashvili M, Eboko F, Perez-Then E, Darak S, Kulkarni S, Kamkamidze G, Balestre E, Desgrees du Lou A, Dabis F. BMC Public Health. 2010;10:197.

A large proportion of the 2.5 million new adult HIV infections that occurred worldwide in 2007 were in stable couples. Feasible and acceptable strategies to improve HIV prevention in a conjugal context are scarce.  In the preparatory phase of the ANRS 12127 Prenahtest multi-site HIV prevention trial, the authors assessed the acceptability of couple-oriented post-test HIV counselling and men's involvement within prenatal care services, among pregnant women, male partners, and health care workers in Cameroon, Dominican Republic, Georgia, and India. Quantitative and qualitative research methods were used:  direct observations of health services; in-depth interviews with women, men, and health care workers; monitoring of the couple-oriented post-test HIV counselling intervention; and exit interviews with couple-oriented post-test HIV counselling participants. In-depth interviews conducted with 92 key informants across the four sites indicated that men rarely participated in antenatal care services, mainly because these are traditionally and programmatically a woman's domain. However men's involvement was reported to be acceptable and needed in order to improve antenatal care and HIV prevention services. Couple-oriented post-test HIV counselling was considered by the respondents to be a feasible and acceptable strategy to actively encourage  men to participate in prenatal HIV counselling and testing and overall in  reproductive health services. One of the keys to men's involvement within prenatal HIV counselling and testing is the better understanding of couple relationships, attitudes, and communication patterns between men and women, in terms of HIV and sexual and reproductive health; this conjugal context should be taken into account in the provision of quality prenatal HIV counselling, which aims at integrated prevention of mother-to-child transmission and primary prevention of HIV.

 

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Editors’ note: The Prenahtest trial assessing the impact of couple-oriented post-test counselling, underway in 4 low-to-medium HIV prevalence countries, will be completed in 2011. This preparatory study revealed support for the idea of increasing men’s involvement but identified a number of barriers that first must be overcome. These include making antenatal care services more physically and interpersonally receptive to male participation and challenging gender norms to address the social barriers to male involvement. This process can help change the paternalistic, unidirectional nature of relationships between most health care providers and patients which can reveal itself as lectures without opportunities for personalised prevention messages. Testing options for men are limited to sexually transmitted disease clinics, voluntary counselling and testing services, and male circumcision programmes. Couple counselling and testing in the context of pregnancy is an opportunity to increase the testing options for men while decreasing the likelihood of transmission to infants. It is an opportunity that should not to be missed – most men and women living in a serodiscordant couple do not know their status nor that of their partner.

HIV testing
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April
11
2010

Prisons

Undiagnosed HIV Infection Among New York City Jail Entrants, 2006: Results of a Blinded Serosurvey.

Begier EM, Bennani Y, Forgione L, Punsalang A, Hanna DB, Herrera J, Torian L, Gbur M, Sepkowitz KA, Parvez F. J Acquir Immune Defic Syndr. 2009 Dec 29. [Epub ahead of print]

Since 2004, when all New York City jail entrants began being offered rapid testing at medical intake, HIV testing has increased 4-fold. To guide further service improvement, the authors determined HIV prevalence among jail entrants, including proportion undiagnosed. Remnant serum from routine syphilis screening was salvaged for blinded HIV testing in 2006. Using HIV surveillance data and electronic clinical data, they ascertained previously diagnosed HIV infections before permanently removing identifiers. They defined "undiagnosed" as HIV-infected entrants who were unreported to surveillance and denied HIV infection. Among the 6411 jail entrants tested (68.9% of admissions), HIV prevalence was 5.2% overall (males 4.7%; females: 9.8%). Adjusting for those not in the serosurvey, estimated seroprevalence is 8.7% overall (6.5% males, 14% females). Overall, 28.1% of HIV infections identified in the serosurvey were undiagnosed at jail entry; only 11.5% of these were diagnosed during routine offer testing. Few (11.1%) of the undiagnosed inmates reported injection drug use or being men who have sex with men. About 5%-9% of New York City jail entrants are HIV infected. Of the infected, 28% are undiagnosed; most of whom denied recognized HIV risk factors. To increase inmate's acceptance of routine testing, the authors are working to eliminate the required separate written consent for HIV testing to allow implementation of the Centers for Disease Control and Prevention-recommended opt out testing model.

For abstract access click here: http://www.ncbi.nlm.nih.gov/pubmed/20042868
Editors’ note:  There is virtually no other setting in low prevalence countries in which HIV prevalence levels this high can be found - 2.5-3.5 times higher in men and 14-20 times higher in women than in the general population. The authors indicate that these are conservative estimates with the prevalence likely closer to 8.7% overall. They state that recommending HIV testing through a provider-initiated HIV testing approach could increase the testing uptake beyond the 69 per cent achieved here by their current routine offer of testing that requires a written consent. Unfortunately, they give no indication of what the package of care is for those who are diagnosed as HIV-positive nor what the prevention package is for any inmate undergoing testing. The blinded serosurvey is used simply to assess the level of undiagnosed HIV infection. This is a captive audience but a captive audience with basic human rights and prisons have an obligation to care for prisoners with a standard of care commensurate to that available in the community. Although a provider clinical staff survey has been done, no information is provided on inmates’ views of what motivates them to accept or decline HIV testing – information that is critical to the design of effective, rights-based programmes.

 

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