Confidential Testing Research Articles

Rethinking Contraception in Africa in the Era of HIV / AIDS / Reconsideration de la contraception a l'epoque du VIH / SIDA

Rethinking Contraception in Africa in the Era of HIV / AIDS / Reconsideration de la contraception a l'epoque du VIH / SIDA

Confidential health care for adolescents: position paper of the Society for Adolescent Medicine

Confidential health care for adolescents: position paper of the Society for Adolescent Medicine

Genetic testing for Alpha1-antitrypsin deficiency

Purpose: The Alpha Coded Testing Study investigated the risks, benefits, and psychological impact of home genetic testing for α1-antitrypsin deficiency.Methods: In the study, 996 adult individuals requested and returned a home-administered, confidential, fingerstick blood test.Results: Individuals highly rated the benefits of establishing a diagnosis (82%), helping family members (86%), and anticipating peace of mind (79%). 78% of 239 current smokers reported a high likelihood of smoking cessation if diagnosed with AATD. After testing, more than 60% indicated that they would share the results with family and physicians but < 30% would share results with insurance companies.Conclusions: Confidential home testing for genetic disorders requires a comprehensive program of participant support.

Evaluating the accessibility of HIV testing organizations.

Consumer-based indicators were developed to evaluate the accessibility of private and public nonhospital HIV testing organizations. A comprehensive roster of 148 nonhospital HIV testing organizations in Los Angeles County was constructed from publicly available listings. A telephone survey protocol was used to contact sites and assess consumer relevant accessibility measures. Only 50% of the sites could be contacted and indicated that HIV testing was available. Hence, a consumer who tried to reach one site had only a 50-50 chance of success. HIV testing sites differed with regard to how frequently they offered testing; whether they offered anonymous and/or confidential testing; what types of counseling they provided; how quickly test results were available; and how friendly, helpful, attentive, and knowledgeable about testing procedures their attendants were. HIV testing sites must make their services accessible and be perceived by consumers as responsive if they are to be effective service providers.

Feasibility of testing for Chlamydia trachomatis in a general population sexual behaviour survey in Slovenia.

Our objective was to assess the feasibility of integrating first void urine (FVU) specimens testing for Chlamydia trachomatis genitourinary infection into a general population sexual behaviour survey. A total of 752 randomly selected respondents aged 18 to 54 were enrolled into the survey. Face to face interviewing with self-administered sensitive questions was used. Overall survey response rate was 77.4%. A convenience sub-sample of 83 respondents were invited to provide FVU specimens for confidential testing for C. trachomatis genitourinary infection. Fifty-five complied. This resulted in 66% FVU specimen participation rate among targeted respondents. Two specimens tested positive by Amplicor polymerase chain reaction. High feasibility study overall response rate indicated good acceptability of the survey. It proved feasible to collect FVU specimens for C. trachomatis testing in the small sub-sample. Consequently, we proceeded with integration of testing for C. trachomatis into the ongoing main survey.

Assessment of emergency department health care professionals' behaviors regarding HIV testing and referral for patients with STDs.

The objective of this study was to evaluate human immunodeficiency virus (HIV) counseling, testing, and referral practices of emergency department health care professionals (i.e., medical doctors [MD], physician assistants [PA], nurse practitioners [NP], and registered nurses [RN]) for patients presenting with other sexually transmitted diseases (STD). All health care professionals from 10 emergency departments in a northeastern county were asked to complete an anonymous survey. The surveys were returned by 154 (41%) health care professionals (RN = 99, NP = 5, PA = 7, MD = 39, other = 4). The average years in practice were 11. Only 7% of respondents were certified to provide state mandated HIV pretest counseling (certification not required for MD). Respondents reported caring for an average of 13 patients per week with suspected STD. Fifty-five percent of respondents reported that they always or usually warn STD patients of their HIV risk, yet only 10% always or usually encouraged these patients to consent to HIV testing in their emergency department (RN = 7%, NP = 25%, PA = 0%, MD = 16%). Reasons for not offering HIV testing in their emergency department were follow-up concerns (51%), not certified to provide pretest/posttest counseling (45%), and too time consuming (19%). Twenty-seven percent of respondents indicated HIV testing was not available in their emergency department despite all hospital laboratories reporting HIV testing capability. Ninety-three percent of respondents were aware that confidential testing sites were available, but only 35% always or usually referred patients not tested in the emergency department elsewhere for testing. Emergency department health care professionals frequently fail to provide HIV counseling, testing, and/or referral for patients with suspected STD.

HIV and hepatitis B surveillance in First Nations alcohol and drug treatment centres in British Columbia, Canada, 1992–2000

We provide ongoing HIV and Hepatitis B surveillance in residential First Nations alcohol and drug treatment centres in British Columbia, Canada. All clients entering the centres are offered confidential viral testing as part of an education program on sexually transmitted diseases. Participation is voluntary and approximately two thirds of clients choose to be tested. Information about risk factors for communicable disease and immunization status is not recorded. The testing program began in January 1992. As of September 2000, 2,345 people have been tested for HIV. Nine tested positive, giving a prevalence of 3.8 per 1,000 (95% confidence interval: 1.3 to 6.3 per 1,000), lower than among all British Columbians who choose to be tested (8.5 per 1,000). Also, 2,166 people were tested for hepatitis B surface antibody, 23% of these were positive, 10% were positive for hepatitis B core antibody (indicating prior infection with hepatitis B). Seven clients (3.2 per 1,000; 95% Cl: 0.8 to 5.6 per 1,000) were positive for hepatitis B surface antigen and are therefore presumed to be chronically infected. The prevalence of hepatitis B markers was intermediate between what has previously been found in high risk groups and that found in the general population.

Pediatric acquired immunodeficiency syndrome in Asia: mother-to-child transmission.

At least 6 million people in the Asia-Pacific region have human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS). The numbers of HIV-infected women and children are increasing at an alarming rate. Important components of infection control that need to be addressed if mother-to-child transmission of HIV is to be prevented successfully include voluntary and confidential counseling and testing, family planning, obstetric care, use of antiretroviral agents, and availability of alternatives to breast-feeding. Many services can aid in the prevention of mother-to-child transmission of HIV and the care of HIV-infected mothers and their children. Each country needs to take into account the features of HIV and AIDS epidemiology that are peculiar to it, its infrastructure, and the resources that are available. Providing services in a stepwise manner can help prevent mother-to-child transmission of HIV.

The proportion and characteristics of adolescents who return for anonymous HIV test results.

The proportion of adolescents who return for HIV test results varies widely, and knowledge of what characteristics affect their return is limited. To quantify the proportion of adolescents who return for results of anonymous HIV tests, and to identify the characteristics that predict their return. This retrospective study evaluated 285 adolescents consenting to anonymous HIV tests in an urban clinic that provides medical services free of charge without eligibility requirements to a mostly working, uninsured population. Of the adolescents studied, 42% returned for test results. Three characteristics independently predicted their return: (1) coming to the clinic only for HIV testing, (2) having private health insurance, and (3) engaging in unprotected sex while using drugs or alcohol. Except for having unprotected sex while using drugs or alcohol, the characteristics that placed adolescents at risk for HIV infection did not predict their return for test results. Given the low return rate for anonymous testing in this setting, confidential testing, which permits follow-up evaluation of those failing to return for test results, should be considered.

Incidence of HIV among injection drug users entering drug treatment programs in four US cities.

We estimated seroincidence of human immunodeficiency virus (HIV) and prevalence of risk behaviors among injection drug users (IDUs) who accepted voluntary HIV testing on entry to drug treatment. Record-based incidence studies were conducted in 12 drug treatment programs in New York City (n = 890); Newark, New Jersey (n = 521); Seattle, Washington (n = 1,256); and Los Angeles, California (n = 733). Records of confidential HIV tests were abstracted for information on demographics, drug use, and HIV test results. More detailed data on risk behaviors were obtained by a standardized questionnaire. Although overall incidence rates were relatively low in this population (<1/100 person-years), there was a high prevalence of risk behaviors. Needle sharing was reported by more than one-third of the participants in each of the cities. HIV seroincidence rates were up to three-fold higher among younger ID Us. We found that HIV continued to be transmitted among ID Us who had received both drug treatment and HIV counseling and testing. HIV/AIDS (acquired immunodeficiency syndrome) prevention education should continue to be an important component of drug treatment.

Future directions.

Despite progress in promotion and support of breastfeeding over the past decade, the HIV pandemic necessitates new actions based on human rights, such as voluntary and confidential testing and counseling, offering HIV-positive women objective information on the risks and costs of all infant feeding options, and providing appropriate support for their decisions. Implementation of the Baby-Friendly Hospital Initiative and the International Code of Marketing are essential components of a rights-based policy response to HIV and will lessen spillover of replacement feeding among HIV-negative women. Protective effects of nevirapine and exclusive breastfeeding, as well as the listed additional topics, require further research. We have yet to make exclusive breastfeeding easy and common when mothers choose to breastfeed.

Access to voluntary counseling and testing for HIV in developing countries.

The counseling that precedes and follows testing of subjects for HIV has become, quite unexpectedly, a focal point for assessment of the ethical propriety, availability, and appropriateness of health services during the AIDS epidemic. It can be anticipated that in the worst affected regions, Voluntary Confidential Counseling and Testing (VCCT) will be an integral component of "...access to comprehensive, essential, quality health care" which is WHO's goal of "Health for All" in the next century. The role, purpose, location, and methods of VCCT, which were reviewed at the previous Global Strategies Conference in 1997, are summarized. Currently understood objectives of VCCT include acceptance of the test, provision of care for HIV-infected individuals (particularly pregnant women), prevention of HIV transmission, and psychosocial support. Many countries in Africa are gradually instituting VCCT as part of their Primary Health Care package. For example "...access to care, counselling and support" for HIV/AIDS and STDs is one of the top 10 national priorities in South Africa. However, closer examination in the country reveals personnel and skill shortages, inability of half the primary health care (PHC) clinics to provide antenatal services, and HIV testing being offered in only 56%. Condom availability is generally good, but termination of pregnancy is undertaken in a bare 27% of hospitals. In other regions of Africa, VCCT is also deficient in many respects: medical services are often unavailable, support is absent, availability is restricted and there are few trained counselors. Consequently, workloads are heavy. Requirements for effective counseling will be listed. The global determinants of inequities in accessing VCCT, such as the GNP and the crushing debt burden borne by poor countries, are discussed. A third of women worldwide receive no antenatal care, and just 60% of the roughly 133 million annual births throughout the world are attended by trained health personnel. Even when VCCT services are available, they are often not acceptable. The overwhelming majority of African women appear to accept HIV testing, but only a proportion (59-61% in recent intervention trials) return for the results. Obstacles to be overcome for provision of VCCT services are identified. Evidence for a positive impact of VCCT services includes facilitated decision-making, acceptance and coping with HIV, improved family and community acceptance, increased condom use, and reduced gonorrhea rates and HIV transmission.

Comprehensive HIV/AIDS Care and Support in Resource-constrained Settings

With the number of people infected with HIV rising globally, care and support for people with AIDS becomes increasingly important. More than 90 per cent of the new HIV infections occur in developing countries, which have limited resources for HIV/ AIDS treatment and care. This paper outlines strategies for provision and access to care in resource-constrained settings within and beyond the health sector. It argues that a comprehensive care and support package along the continuum should include voluntary and confidential counselling and testing, clinical management (including nursing care), psychological and social support. Proposed strategies include the linking of the health sector to community- and home-based care, the reorganisation of service delivery, the integration of prevention of care within national AIDS control programmes, the development of policy and legislation, and the empowerment and facilitation of community acrion.

Preventing mother-to-child transmission of HIV-1 in Africa in the year 2000.

Various approaches to preventing mother-to-child transmission (MTCT) of HIV have recently been, or are being, evaluated in developing countries, especially in Africa. New findings from these trials are now becoming available, the implications of which, for population-based intervention programmes, need urgent consideration. A critical review of 18 randomized trials and other relevant studies from developing and industrialized countries. Most African results relate to trials of antiretroviral agents (ARV). They demonstrate efficacy in reducing transmission in the first 6 months of life with short regimens of zidovudine (ZDV), with or without lamivudine (3TC), and nevirapine (NVP) alone. Preliminary results suggest the long-term efficacy of zidovudine. Antiseptic and nutritional interventions have been shown to reduce maternal and infant mortality and morbidity but not MTCT of HIV. HIV confidential voluntary counselling and testing for pregnant women, a short regimen of peripartum ARV with alternatives to breastfeeding such as early weaning or breast milk substitutes from birth currently represent the best option to reduce MTCTof HIV in Africa. However, the prevention of postnatal transmission requires further research, particularly in view of the consequences of different feeding options and the possibility of post-perinatal exposure prophylaxis of newborns with ARV. Issues relating to the implementation of currently validated strategies are discussed.

HIV testing and its role in fighting the battle against AIDS: a comparison of mandatory, confidential, and anonymous testing

HIV testing and its role in fighting the battle against AIDS: a comparison of mandatory, confidential, and anonymous testing

HIV counselling and testing: overemphasizing high acceptance rates a threat to confidentiality and the right not to know.

To examine factors affecting the readiness for HIV-related voluntary confidential counselling and testing (VCT). In a population-based HIV survey in selected urban and rural areas in Zambia, adults aged > or = 15 years were selected by stratified random cluster sampling. The participants were asked to provide a saliva sample for anonymous HIV testing (n=4812, consent rate 93.5%) and, as a part of an interview, were asked about previous HIV testing experience and if they wished to be counselled and tested for HIV. Those indicating interest (initially willing) were provided with an invitation letter to see a counsellor. In rural areas, VCT was provided by personnel brought in from outside the local community, whereas in urban areas it was provided by locally recruited staff. The overall HIV test rate was 6.5%, but rates appeared to be considerably biased towards higher educational groups. The proportion initially willing was 37% while 3.6% actually came for counselling and were tested (9.3% of those initially willing), of which 47% returned for the result. Actual use was four to five times higher in rural compared with urban areas. Self-perceived risk and high-risk behaviour were positively associated with initial willingness but not with actual use. The readiness for VCT in the general population was found to be very low. Provision factors such as concerns about confidentiality and length of time waiting for the test result contributed to the low utilization rate. Results of this study contrast sharply with reported VCT acceptance rates of 70-90% among women attending antenatal care in Zambian and in other African populations, suggesting an urgent need to evaluate testing policy and practice of antenatal VCT in particular.

Anonymous or Confidential HIV Counseling and Voluntary Testing in Federally Funded Testing Sites--United States, 1995-1997

Human immunodeficiency virus (HIV) counseling and voluntary testing (CT) programs have been an important part of national HIV prevention efforts since the first HIV antibody tests became available in 1985. In 1995, these programs accounted for approximately 15% of annual HIV antibody testing in the United States, excluding testing for blood donation. CT opportunities are offered to persons at risk for HIV infection at approximately 11,000 sites, including dedicated HIV CT sites, sexually transmitted disease (STD) clinics, drug-treatment centers, hospitals, and prisons. In 39 states, testing can be obtained anonymously, where persons do not have to give their name to get tested. All states provide confidential testing (by name) and have confidentiality laws and regulations to protect this information. This report compares patterns of anonymous and confidential testing in all federally funded CT programs from 1995 through 1997 and documents the importance of both types of testing opportunities.

Anonymous or Confidential HIV Counseling and Voluntary Testing in Federally Funded Testing Sites—United States, 1995-1997

Anonymous or Confidential HIV Counseling and Voluntary Testing in Federally Funded Testing Sites—United States, 1995-1997

Gonorrhea incidence and HIV testing and counseling among adolescents and young adults seen at a clinic for sexually transmitted diseases.

To determine whether HIV testing and posttest counseling may be associated with an increase in gonorrhea incidence among adolescents and young adults seen at a clinic for sexually transmitted diseases (STD). A historical cohort study with the collection of longitudinal data on the patients' HIV testing and counseling experience. Delgado STD clinic of New Orleans, Louisiana, a public ambulatory primary care center that serves mainly the economically disadvantaged Black population. A record-based inception cohort of 4031 patients aged 15-25 years diagnosed at the clinic between June 1989 and May 1991 with a first lifetime gonorrhea infection. Routine confidential HIV tests and posttest counseling sessions experienced at the clinic during follow-up. Incidence rate of reported gonorrhea reinfection. Of the patients, 51.5% were tested once for HIV antibodies and 25.9% twice or more. Formal posttest counseling occurred after 8.5% of the 4665 HIV-negative and 44.0% of the 49 HIV-positive tests. In the most pessimistic of several models controlling for history of gonorrhea, HIV testing and counseling history, and other potential confounding factors, a significantly lower rate of gonorrhea reinfection was observed after a first HIV-negative test than before [adjusted relative risk (RR), 0.66; 95% confidence interval (CI), 0.59-0.74; P < 0.00011. As compared with the pretest period, significantly higher rates of gonorrhea were observed after respectively a second (RR, 1.18; 95% CI, 1.01-1.37; P = 0.03) and a third (RR, 1.52; 95% CI, 1.22-1.88; P = 0.0001) HIV-negative test. No significant association was found between HIV-positive testing and any variation in gonorrhea rate (RR, 0.95; 95% CI, 0.56-1.62; P = 0.85). Posttest counseling for HIV-negative and HIV-positive results were followed respectively by a significantly higher rate of gonorrhea (RR; 1.27; 95% CI, 1.09-1.48; P = 0.002) and a non-significantly lower rate of gonorrhea (RR, 0.53; 95% CI, 0.17-1.60; P = 0.85). Our results do not exclude the possibility of a modest increase in gonorrhea incidence after routine HIV testing and counseling in an STD clinic. Nevertheless, this conclusion holds only under the least favorable assumptions and applies solely to a minority of patients.

Linking clients from HIV antibody counseling and testing to prevention services.

The effectiveness of HIV antibody counseling and testing as a prevention intervention is limited: persons testing seronegative do not usually change their risk behaviors, some actually increase their risk behaviors, and decreases in risk behaviors are usually short-lived. Referrals to additional prevention and other needed services are therefore recommended, although the extent and determinants of referral provision for persons testing seronegative are unknown. We assessed the prevalence of referrals and the association between risk behaviors and prevention referrals among seronegatives. We reviewed HIV testing and referral data on all persons receiving confidential seronegative test results in San Francisco (SF) in the first 10 months of 1995 (n = 5,595), and gathered more detailed referral information at the municipal STD clinic from November 1995 through May 1996 (n = 747). The overall prevalence of referrals was low: a referral was given to 19.1% of the SF sample and 10.6% of the STD clinic sample; 15.4% of the SF sample and 5.9% of the STD clinic sample received a prevention referral. Injection drug users (IDUs) were the most likely to receive a prevention referral (48.5% of SF IDUs, 36.4% of STD clinic IDUs); men having sex with men and women with high-risk partners were also more likely to get a prevention referral than others. For SF IDUs, unsafe sex and needle sharing were not associated with an increased likelihood of receiving a prevention referral. Opportunities to link high-risk clients from counseling and testing to HIV prevention services are being missed. The referral component of HIV counseling and testing should be improved.