HIV Testing Policy Research Articles

Simplifying Consent for HIV Testing Is Associated with an Increase in HIV Testing and Case Detection in Highest Risk Groups, San Francisco January 2003–June 2007

BackgroundPopulations at highest risk for HIV infection face multiple barriers to HIV testing. To facilitate HIV testing procedures, the San Francisco General Hospital Medical Center eliminated required written patient consent for HIV testing in its medical settings in May 2006. To describe the change in HIV testing rates in different hospital settings and populations after the change in HIV testing policy in the SFDH medical center, we performed an observational study using interrupted time series analysis.MethodsData from all patients aged 18 years and older seen from January 2003 through June 2007 at the San Francisco Department of Public Health (SFDPH) medical care system were included in the analysis. The monthly HIV testing rate per 1000 hadpatient-visits was calculated for the overall population and stratified by hospital setting, age, sex, race/ethnicity, homelessness status, insurance status and primary language.ResultsBy June 2007, the average monthly rate of HIV tests per 1000 patient-visits increased 4.38 (CI, 2.17–6.60, p<0.001) over the number predicted if the policy change had not occurred (representing a 44% increase). The monthly average number of new positive HIV tests increased from 8.9 (CI, 6.3–11.5) to 14.9 (CI, 10.6–19.2, p<0.001), representing a 67% increase. Although increases in HIV testing were seen in all populations, populations at highest risk for HIV infection, particularly men, the homeless, and the uninsured experienced the highest increases in monthly HIV testing rates after the policy change.ConclusionsThe elimination of the requirement for written consent in May 2006 was associated with a significant and sustained increase in HIV testing rates and HIV case detection in the SFDPH medical center. Populations facing the higher barriers to HIV testing had the highest increases in HIV testing rates and case detection in response to the policy change.

HIV testing and counselling policies and practices in Europe: lessons learned, ways forward

The increasing rate of reported HIV cases in many European countries demonstrates that HIV is still an important public health issue in the World Health Organization (WHO) European Region. In 2006, Eastern European countries reported a rate of newly reported HIV cases that was nearly three times that reported in the West and over 20 times that reported in the Centre of Europe. While the incidence of AIDS has continued to decline in Western and Central Europe, it is increasing in Eastern Europe* [1]. However, the above data concern only reported HIV cases; undiagnosed cases should also be taken into consideration when discussing the extent of the HIV/AIDS epidemic and related trends. In the European Union (EU), the overall level of undiagnosed cases is estimated at 30%, and in some places almost 60% [2,3], and in some non-EU countries half of all injecting drug users (IDUs) – a population that is a driving force of the epidemic there – were unaware of their status when they tested positive in prevalence studies [4].

Changes in HIV Testing Policies and the Implications for Women

The US Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) together with the Joint United Nations Programme on HIV/AIDS (UNAIDS) recently released new guidelines for HIV testing in health care settings. Both sets of guidelines recommend eliminating individual informed consent in favor of an opt-out approach that requires clients to actively decline the HIV test after a pretest information session. The revised guidelines also recommend reducing the amount of counseling that accompanies the HIV test. Women are more likely than men to be affected by efforts to expand access to HIV testing in health care settings because of women's increased vulnerability to HIV and greater contact with the health care system. Women may also be more susceptible to changes to the consent and counseling process for HIV testing because of their marginalized social status in many settings. More research is needed to document women's experiences with provider-initiated, opt-out HIV testing. Understanding women's experiences will help to formulate feasible and effective strategies to support women and ensure they gain access to HIV treatment services.

Low HIV-testing rates and awareness of HIV infection among high-risk heterosexual STI clinic attendees in The Netherlands

Since 1999, HIV testing is routinely offered to all attendees of the sexually transmitted infections (STI) outpatient clinic in Amsterdam, the Netherlands. This study evaluates whether this more active HIV-testing policy increased uptake of HIV testing and awareness of an HIV-positive serostatus among heterosexual attendees. In addition to routine data collected at each STI consultation, data from half-yearly HIV surveys were used from 1994 to 2004. During each survey period, 1000 consecutive attendees are enrolled voluntary and anonymously for HIV testing and are interviewed on previous HIV testing and outcome. Trends in and predictors for uptake of HIV testing as offered during routine STI consultation were analysed by logistic regression. Trends in awareness of an HIV-positive serostatus as obtained from the anonymous HIV surveys were likewise analysed. The percentage of heterosexual attendees opting for an HIV test during consultation increased from 13% in 1996 to 56% in 2004. However, the proportion of individuals aware of their HIV infection did not change over time and only a minority (19%) of the 108 attendees found HIV-positive in the anonymous surveys were aware of their HIV infection. Persons being or visiting a commercial sex worker, having a non-Dutch ethnicity, lacking health insurance and having an STI diagnosed were less likely to opt for an HIV test. Although heterosexual attendees increased their uptake of HIV testing during STI consultation over time, uptake of testing by attendees at risk for HIV infection, such as those infected with an STI, remained low. As a result, the percentage of persons aware of their HIV infection remained low, posing a risk for their individual health and for ongoing HIV transmission. Current testing strategies, therefore, misses the group that most needs testing. Based on these results, 'opt-out' HIV testing is now the standard procedure at the Amsterdam STI clinic.

Attitudes About Prenatal Hiv Testing in Turkey

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.

Band-aid for a gaping wound: can mandatory HIV-testing of newborns improve the success of PMTCT?

abstract Recent studies have shown that uptake of Voluntary Counselling and Testing (VCT) services in public sector antenatal settings in South Africa is low, with only half of all pregnant women consenting to HIV test. Out of those who do test, it is estimated that only 30 percent of HIV-positive pregnant women actually receive antiretroviral treatment to prevent HIV transmission during labour. Against this backdrop, arguments are currently being made in favour of radical interventions to reduce vertical transmission. This briefing looks at the proposed policy of mandatory HIV-testing of newborns and presents the case against such an approach, in the interests of women and their babies.

Ethical and Public Health Considerations in HIV Counseling and Testing: Policy Implications

HIV counseling and testing is broadly considered a critical component of HIV transmission-prevention and treatment efforts. Given the severity of the AIDS pandemic in sub-Saharan Africa, the potential societal benefit of testing is invoked to call for its massive expansion and to justify a shift from voluntary to routine testing. Surprisingly little evidence has demonstrated, however, that such a shift will result in the intended benefits to communities, particularly that of reducing the horizontal transmission of HIV. This analysis addresses and critiques the assumptions underlying a serostatus-based approach to behavior change and discusses the ethical consequences of transferring control of the decision to be tested from the individual to the provider. It concludes with a discussion of the implications for HIV counseling and testing policies and proposes alternatives to routine testing that have the potential to be effective while preserving the right to know one's HIV status.

Differences Between Proof-of-Concept Studies and Effective Implementation

Differences Between Proof-of-Concept Studies and Effective Implementation

The HIV/AIDS epidemic in Cuba: description and tentative explanation of its low HIV prevalence

BackgroundThe Cuban HIV/AIDS epidemic has the lowest prevalence rate of the Caribbean region. The objective of this paper is to give an overview of the HIV/AIDS epidemic in Cuba and to explore the reasons for this low prevalence.MethodsData were obtained from the Cuban HIV/AIDS programme established in 1983. This programme has an extensive adult HIV testing policy, including testing of all pregnant women. HIV and AIDS cases have been recorded since 1986. Persons found to be HIV-positive are interviewed on their sexual behaviour and partners. Tracing and voluntary testing of these partners are organised. Epidemiological description of this epidemic was obtained from analysis of this data set. Using elementary mathematical analyses, we estimated the coverage of the detection system (percentage of HIV-positive adults detected) and the average period between HIV infection and detection. Estimated HIV prevalence rates were corrected to account for the coverage.ResultsHIV prevalence has increased since 1996. In 2005, the prevalence among pregnant women was 1.2 per 10,000 (16/137000). Estimated HIV prevalence among 15- to 49-year-olds was 8.1 per 10,000 (4913/6065000; 95%CI: 7.9 per 10,000 – 8.3 per 10,000). Most (77%) of the HIV-positive adults were men, most (85.1%) of the detected HIV-positive men were reported as having sex with men (MSM), and most of the HIV-positive women reported having had sex with MSM. The average period between HIV infection and detection was estimated to be 2.1 years (IQR = 1.7 – 2.2 years). We estimated that, for the year 2005, 79.6% (IQR: 77.3 – 81.4%) of the HIV-positive persons were detected.ConclusionMSM drive the HIV epidemic in Cuba. The extensive HIV testing policy may be an important factor in explaining the low HIV prevalence. To reduce the HIV epidemic in Cuba, the epidemic among MSM should be addressed. To understand this epidemic further, data on sexual behaviour should be collected. Now that antiretroviral therapy is more widely available, the Cuban policy, based on intensive HIV testing and tracing of partners, may be considered as a possible policy to control HIV/AIDS epidemics in other countries.

Routine offer of antenatal HIV testing ("opt-out" approach) to prevent mother-to-child transmission of HIV in urban Zimbabwe.

To assess the impact of routine antenatal HIV testing for preventing mother-to-child transmission of HIV (PMTCT) in urban Zimbabwe. Community counsellors were trained in routine HIV testing policy using a specific training module from June 2005 through November 2005. Key outcomes during the first 6 months of routine testing were compared with the prior 6-month "opt-in" period, and clients were interviewed. Of the 4551 women presenting for antenatal care during the first 6 months of routine HIV testing, 4547 (99.9%) were tested for HIV compared with 3058 (65%) of 4700 women during the last 6 months of the opt-in testing (P < 0.001), with a corresponding increase in the numbers of HIV-infected women identified antenatally (926 compared with 513, P < 0.001). During routine testing, more HIV-infected women collected results compared to the opt-in testing (908 compared with 487, P < 0.001) resulting in a significant increase in deliveries by HIV-infected women (256 compared with 186, P = 0.001); more mother/infant pairs received antiretroviral prophylaxis (n = 256) compared to the opt-in testing (n = 185); and more mother/infant pairs followed up at clinics (105 compared with 49, P = 0.002). Women were satisfied with counselling services and most (89%) stated that offering routine testing is helpful. HIV-infected women reported low levels of spousal abuse and other adverse social consequences. Routine antenatal HIV testing should be implemented at all sites in Zimbabwe to maximize the public health impact of PMTCT.

Costs and Consequences of the US Centers for Disease Control and Prevention's Recommendations for Opt-Out HIV Testing

BackgroundThe United States Centers for Disease Control and Prevention (CDC) recently recommended opt-out HIV testing (testing without the need for risk assessment and counseling) in all health care encounters in the US for persons 13–64 years old. However, the overall costs and consequences of these recommendations have not been estimated before. In this paper, I estimate the costs and public health impact of opt-out HIV testing relative to testing accompanied by client-centered counseling, and relative to a more targeted counseling and testing strategy.Methods and FindingsBasic methods of scenario and cost-effectiveness analysis were used, from a payer's perspective over a one-year time horizon. I found that for the same programmatic cost of US$864,207,288, targeted counseling 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 counseling and testing scenario).ConclusionsWhile opt-out testing may be able to newly diagnose over 56,000 persons living with HIV in one year, abandoning client-centered counseling has real public health consequences in terms of HIV infections that could have been averted. Further, my analyses indicate that even when HIV seropositivity rates are as low as 0.3%, targeted counseling and testing performs better than opt-out testing on several key outcome variables. These analytic findings should be kept in mind as HIV counseling and testing policies are debated in the US.

Routine HIV-testing policies

Routine HIV-testing policies

Is it time to change our HIV testing policy in health care facilities?

The annual number of AIDS deaths declined substantially in the USA following introduction of highly active antiretroviral therapy (HAART) in 1995 but has remained stable from 1999 to 2004. There are approximately 1.0 - 1.2 million persons estimated to be living with HIV of whom 25% are unaware of their infection and likely to have transmitted their infection unknowingly. Despite considerable survival benefits if treatment is initiated early before symptoms develop 40% of patients receive their HIV diagnosis less than 12 months before developing AIDS. Early HIV diagnosis may therefore be of both public health and individual survival benefit. On 22 September 2006 the United States National Center for HIV/ AIDS published revised recommendations for HIV testing of adults adolescents and pregnant women to facilitate HIV testing as a normal part of medical practice similar to screening for other treatable conditions. HIV screening for all patients in US health care settings is now recommended unless the patient declines (i.e. opt-out screening). Separate written consent for HIV testing is no longer required and general consent for medical care will be considered sufficient to encompass consent for HIV testing. Prevention counselling will not be required with HIV diagnostic testing or as part of HIV screening programmes in health care settings. The objective of the revised policy is to increase HIV screening of patients and pregnant women in health care settings to foster earlier detection of HIV infection identify and counsel individuals with unrecognised HIV infection and link them to clinical and prevention services. (excerpt)

High HIV prevalence among patients choosing anonymous and free testing in Belgium, 1990–2002

From 1990 through 2002, 25,250 anonymous and free HIV tests were performed at a testing site, which carried out the majority (85%) of anonymous testing in Belgium. During the same period, approximately 7.3 million confidential tests were registered nationwide. The rate of new HIV infections diagnosed at the anonymous testing site was 11.1/1000 tests; it was significantly higher than the rate observed among confidential tests (relative risk = 7.41; P < 0.0001). New HIV cases diagnosed through anonymous testing include a higher proportion of young adults (42.0% versus 32.5% in confidential testing; P < 0.001) and a higher proportion of men who have sex with men (32.7% vs. 25.9% in confidential testing; P < 0.02). Anonymous and free HIV testing was particularly sought by persons with higher infection risk, and efficiently contributed to HIV diagnosis in this population. Anonymous and free testing should be and remain an accessible alternative integrated in HIV testing policies.

High-Risk Groups for Late Diagnosis of HIV Infection: A Need for Rethinking Testing Policy in the General Population

The aim of the study was to identify high-risk groups and the determinants of late HIV diagnosis in France in the era of highly active antiretroviral therapy (HAART), from January 1996 to June 2005. Informations were collected from an electronic medical record of all HIV- 1-infected patients who sought care in six HIV reference centers in France, constituting a prospective multicentric cohort. Patients were defined as "late testers" if they had presented with either symptoms of clinical AIDS or a CD4 cell count less than 200/mm(3) during the year of diagnosis, as "nonlate" if their CD4 count was above 200, and as "unknown" if CD4 cell count in the year at the time of diagnosis was not documented. Among the 4516 patients available for analysis, the percentage of late testing was 38% (n = 1718) and decreased after 2003 (31.5% in 2004-2005). This percentage was higher in heterosexual men (48.2%) than in homosexual men (31.7%) or heterosexual women (32.6%) and was higher for patients older than 30. Heterosexual men living in a couple with children had a higher risk of late testing (odds ratio [OR] = 1.65, 95% confidence interval [CI]: 1.03 to 2.66), while heterosexual women in a couple without children had a lower risk (OR = 0.46, 95% CI: 0.25 to 0.83). Among homosexual men, unemployment was associated with late testing (OR = 2.23, 95% CI: 1.14 to 4.36). The proportion of late testing was still high. Groups classically identified as low risk for HIV infection, particularly heterosexual men in a couple with children, were found to be at high risk for late testing. It seems necessary to improve HIV testing policy in the heterosexual population.

The evidence for a change in antenatal HIV screening policy in Australia

Australia is one of the few developed countries without routine antenatal HIV screening, despite having the resources to undertake such a screening program and the availability of antiretroviral therapy. National policy recommends that only women with identified risk factors should be offered testing; however, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists recommends that all pregnant women be offered HIV testing as part of their antenatal care. Knowledge of a woman's HIV status during pregnancy allows interventions to improve her health and reduce the risk of transmission of HIV to her child. A universal antenatal HIV screening program meets many of the Wilson and Jungner criteria for population-based screening programs. This should be considered in the current review of Australia's HIV testing policy.

Uptake of antenatal HIV testing in the United Kingdom: 2000–2003

A policy for routine antenatal HIV testing was introduced in England in 1999, with uptake targets for 2000 and 2002; similar policies were subsequently introduced throughout the UK. Date of implementation of the policy and data for estimating annual uptake of testing 2000-2003 were collected through postal survey of unit-based obstetric respondents to the National Study of HIV in Pregnancy and Childhood (NSHPC). Implementation date was reported for every unit; uptake data were provided for about three-quarters of implementing units each year. The policy was implemented in 78% (152/195) of English units by end of 2000; 78% (89/114) of units providing data achieved at least 50% uptake that year. By 2002, almost one-third (46/151) of English units reported 90% uptake or more, and over half (84/151) 80%. All but three UK units introduced the policy by the end of 2003, and of those providing adequate uptake data, 38% (66/175) reported at least 90% uptake and 69% (121/175) at least 80%; however, 19% (41/216) of respondents still had difficulty providing adequate data for estimating uptake. High uptake of HIV testing was reported from most UK units for 2003, but simple, robust and uniform methods for monitoring uptake at local and regional levels are still required.

Chemoprophylaxis and HAART Therapy in Botswana

Botswana has one of the highest rates of HIV infection in the world, with 37.4% of adults infected in 2003 according to UNAIDS. To address the problems of widespread infections, the government of Botswana instituted aggressive programs for the use of antiretroviral (ARV) drugs in both chemoprophylaxis for pregnant women and HAART therapy for treatment of clinical AIDS. At present, about 25% of AIDS patients receive HAART, and about 40% of HIV positive pregnant women receive chemoprophylaxis. After the country adopted an opt out policy for HIV testing in early 2005, these numbers are rapidly rising. Both the chemoprophylaxis regimen and the first line regimen for AIDS, include nevirapine (NVP). This is likely to cause problems with drug resistance when mothers with young infants need therapy, as about half of the mothers who receive NVP during labor reveal genotypic resistance when analyzed. In a recent trial we showed that NVP given only to newborn infants is as effective as when given to the mother during labor and the newborn infant, at least when used on a background of zidovudine (ZDV). This may provide a mechanism to avoid the establishment of NVP-resistance in HIV-positive mothers. HIV-1C, the subtype of southern Africa, shows higher rates of NVP-resistance as compared to HIV-1A or HIV-1D.

Contesting Motherhood in the Age of AIDS: Maternal Ideology in the Debate over Mandatory HIV Testing

I N T H E M I D -I980 s, with licensing of first Human Immuno Deficiency Virus (HIV) antibody test, it became possible to identify individ uals with HIV infection. Around same time, it became clear that approximately one out of four HIV-positive pregnant women, majori ty of whom were poor women of color, would transmit virus to their newborns perinatally (in utero, during delivery, or through breastmilk). As numbers of HIV-infected women rose rapidly, so too did fears that an impending deadly crisis in United States would leave more than 3,000 babies infected with HIV every year. In response to these fears, Surgeon General C. Everett Koop called on medical professionals to craft a policy that would alleviate the tremendous burden of this devastating condition, especially among children;' but just how to alleviate this bur den, just how to respond to problem of mother-to-child HIV transmis sion, has been subject of contentious debate for almost two decades. At heart of this debate are mandatory HIV-testing policies that raise con cerns not only about role of state and rights of individuals in times of health crisis, but also about meaning of motherhood in age of Acquired Immuno-Deficiency Syndrome (AIDS). Policymakers responded to Koop's call by proposing various measures

Trends in voluntary HIV testing in general practices in France between 1987 and 2002

To measure the level of voluntary HIV testing and to assess its changes in the French general population according to the evolution of HIV testing policies. When general practitioners belonging to the Sentinelles network (SGP) offer HIV testing to their patients, they send the network an anonymous description of the patient and a report of the test results. The number of HIV tests peaked in 1993 at 1760 per 100,000 inhabitants. Since 1995 the rate has fallen slightly, from 1474 to 810 per 100,000 in 2002. Between 1987 and 2002 there was a significant fall in the proportion of persons with a history of STD (31.4-5.1%, p = 0.0001), clinical signs of HIV infection (9.1-4.5%, p = 0.0002) and a history of prior testing (19.3-13.6%, p = 0.0005). Our results show that demand for HIV testing among the French general practice patient population has fallen since 1995, along with the frequency with which GPs offer HIV testing.