HIV Testing Strategies Research Articles

HIV among persons incarcerated in the USA

People who are incarcerated have a disproportionately high risk of HIV infection. They also tend to have risk factors associated with underutilization of antiretroviral therapy (ART) such as substance abuse, mental illness, and poor access to care. In this review, we describe how incarceration is a marker of vulnerability for suboptimal HIV care, and also how criminal justice settings may be leveraged as a platform for promoting testing, linkage, and retention in HIV care for a high-risk, marginalized population. In both prisons and jails, routine, opt-out HIV testing strategies are more appropriate for screening correctional populations than traditional, risk-based strategies. Rapid HIV testing is feasible and acceptable in busy, urban jail settings. Although ART is successfully administered in many prison settings, release to the community is strongly associated with inconsistent access to medications and other structural factors leading to loss of viral suppression. Collaborations among HIV clinicians, criminal justice personnel, and public health practitioners represent an important strategy for turning the tide on the HIV epidemic. Success will depend upon scaled-up efforts to seek individuals with undiagnosed infection and bring those who are out-of-care into long-term treatment.

Belief in AIDS-Related Conspiracy Theories and Mistrust in the Government: Relationship With HIV Testing Among At-Risk Older Adults

One in 4 persons living with HIV/AIDS is an older adult (age 50 or older); unfortunately, older adults are disproportionately diagnosed in late stages of HIV disease. Psychological barriers, including belief in AIDS-related conspiracy theories (e.g., HIV was created to eliminate certain groups) and mistrust in the government, may influence whether adults undergo HIV testing. We examined relationships between these factors and recent HIV testing among at-risk, older adults. This was a cross-sectional study among older adults enrolled in a large venue-based study. None had a previous diagnosis of HIV/AIDS; all were seeking care at venues with high HIV prevalence. We used multiple logistic regression to estimate the associations between self-reported belief in AIDS-related conspiracy theories, mistrust in the government, and HIV testing performed within the past 12 months. Among the 226 participants, 30% reported belief in AIDS conspiracy theories, 72% reported government mistrust, and 45% reported not undergoing HIV testing within the past 12 months. Belief in conspiracy theories was positively associated with recent HIV testing (adjusted odds ratio [OR] = 1.94, 95% confidence interval [CI] = 1.05-3.60), whereas mistrust in the government was negatively associated with testing (OR = 0.43, 95% CI = 0.26-0.73). Psychological barriers are prevalent among at-risk older adults seeking services at venues with high HIV prevalences and may influence HIV testing. Identifying particular sources of misinformation and mistrust would appear useful for appropriate targeting of HIV testing strategies.

HIV-2 infection: Where are we today?

Context:The choice of antiretroviral therapy for HIV-2 differs from that for HIV-1, underscoring the importance of differentiating between the two.Aims:The current study was planned to find out the prevalence of HIV-2 infection at our center and to find out the utility of the current diagnostic algorithm in identifying the type of HIV infection.Setting and Design:Retrospective analysis in a tertiary care teaching institute over a period of three years.Materials and Methods:All patients diagnosed as HIV infected using NACO/WHO HIV testing strategy III were included in the study. They were classified as HIV-1 infected, HIV-2 infected and HIV-1 and HIV-2 co-infected based on their test results. For discordant samples, immunoblotting result from National Reference Laboratory was considered as final.Statistical Analysis Used:Comparison between HIV-1, HIV-2 and HIV-1+2 positive groups for age, gender, route of transmission was made using chi squared test. P value < 0.05 was considered as significant.Results:Of the total of 66,708 patients tested, 5,238 (7.9%) were positive for HIV antibodies. 7.62%, 0.14%, 0.08% and 0.004% were HIV-1, HIV-2, HIV-1 and HIV-2 co-infected and HIV type indeterminate (HIV-1 Indeterminate, 2+) respectively. The current algorithm could not differentiate between the types of HIV infection (as HIV-1 or HIV-2) in 63 (1.2%) cases.Conclusion:In areas like the Indian subcontinent, where epidemic of both HIV-1 and HIV-2 infections are ongoing, it is important to modify the current diagnostic algorithms to diagnose and confirm HIV-2 infections.

The uptake of HIV and syphilis testing in a nurse-delivered service during Gay Pride events

Novel HIV testing strategies may improve the uptake of the test. The aim of the present study was to investigate the uptake of HIV testing during Birmingham Pride events in 2009 and 2010. The project was a collaboration between Whittall Street Clinic and Healthy Gay Life. This was a nurse-delivered service that was offered for nine hours each day during the events (total of 36 hours in two years). The OraSure™ assay for HIV and syphilis testing was used. A total of 405 men visited our marquee during the 2009 (n = 201) and 2010 (n = 204) events. A total of 398 (98%) men accepted HIV testing during the events in 2009 and 2010. Six men (1.5%) were HIV-positive, an incidence of 37.7 cases per 10,000 persons perday. The uptake of syphilis testing was similarly high; 390 (96%) individuals agreed to be tested and one (0.5%) patient was diagnosed with syphilis. The uptake of HIV testing during the Pride event was high. Pride events provide a unique opportunity for testing undiagnosed HIV-infected patients. HIV testing should be provided in other cities during Pride events.

Parallel Rapid HIV Testing in Pregnant Women at Tijuana General Hospital, Baja California, Mexico

The objectives of this study were to evaluate the performance of parallel rapid HIV testing and the presence of HIV-associated risk factors in pregnant women with unknown HIV status in Baja California, Mexico. Pregnant women attending the delivery unit or the prenatal clinic at Tijuana General Hospital had blood drawn for parallel rapid HIV testing with Determine™ HIV-1/2 and Uni-Gold™ Recombigen(®) HIV. The parallel rapid HIV test performance was compared to the enzyme immunoassay (EIA) and western blot. From September 2007 to July 2008, 1,383 (94%) of 1,464 women in labor and 1,992 (96%) of 2,075 women in prenatal care were enrolled. The HIV seroprevalence among women screened during labor (19/1,383, 1.37%, 95% CI: 0.85-2.18%) was significantly higher compared to those seeking prenatal care (5/1,992, 0.25%, 95% CI: 0.09-0.62%; p<0.001). Of 25 pregnant women testing positive by parallel rapid HIV testing 24 had a positive confirmatory western blot and one (0.03%) was confirmed as false positive. Additionally, two (0.06%) women had parallel rapid HIV discordant testing results; both tested negative by western blot. All women who tested negative by rapid testing had negative results on pooled EIA antibody testing. The overall sensitivity, specificity, and positive and negative predictive values of parallel rapid HIV testing were 100%, 99.9%, 96%, and 100%, respectively. These findings document a very high acceptance rate and an excellent performance of the parallel rapid HIV testing strategy during pregnancy.

PHS41 Cost Effectiveness Analysis of Two HIV Counseling and Testing Strategies in Kayunga District (Uganda)

PHS41 Cost Effectiveness Analysis of Two HIV Counseling and Testing Strategies in Kayunga District (Uganda)

HIV testing and counselling for migrant populations living in high-income countries: a systematic review

Background: The barriers to HIV testing and counselling that migrants encounter can jeopardize proactive HIV testing that relies on the fact that HIV testing must be linked to care. We analyse available evidence on HIV testing and counselling strategies targeting migrants and ethnic minorities in high-income countries. Methods: Systematic literature review of the five main databases of articles in English from Europe, North America and Australia between 2005 and 2009. Results: Of 1034 abstracts, 37 articles were selected. Migrants, mainly from HIV-endemic countries, are at risk of HIV infection and its consequences. The HIV prevalence among migrants is higher than the general population’s, and migrants have higher frequency of delayed HIV diagnosis. For migrants from countries with low HIV prevalence and for ethnic minorities, socio-economic vulnerability puts them at risk of acquiring HIV. Migrants have specific legal and administrative impediments to accessing HIV testing—in some countries, undocumented migrants are not entitled to health care—as well as cultural and linguistic barriers, racism and xenophobia. Migrants and ethnic minorities fear stigma from their communities, yet community acceptance is key for well-being. Conclusions: Migrants and ethnic minorities should be offered HIV testing, but the barriers highlighted in this review may deter programs from achieving the final goal, which is linking migrants and ethnic minorities to HIV clinical care under the public health perspective.

The cost-effectiveness of rapid HIV testing in substance abuse treatment: Results of a randomized trial

BackgroundThe President's National HIV/AIDS Strategy calls for coupling HIV screening and prevention services with substance abuse treatment programs. Fewer than half of US community-based substance abuse treatment programs make HIV testing available on-site or through referral. MethodsWe measured the cost-effectiveness of three HIV testing strategies evaluated in a randomized trial conducted in 12 community-based substance abuse treatment programs in 2009: off-site testing referral, on-site rapid testing with information only, on-site rapid testing with risk-reduction counseling. Data from the trial included patient demographics, prior testing history, test acceptance and receipt of results, undiagnosed HIV prevalence (0.4%) and program costs. The Cost-Effectiveness of Preventing AIDS Complications (CEPAC) computer simulation model was used to project life expectancy, lifetime costs, and quality-adjusted life years (QALYs) for HIV-infected individuals. Incremental cost-effectiveness ratios (2009 US $/QALY) were calculated after adding costs of testing HIV-uninfected individuals; costs and QALYs were discounted at 3% annually. ResultsReferral for off-site testing is less efficient (dominated) compared to offering on-site testing with information only. The cost-effectiveness ratio for on-site testing with information is $60,300/QALY in the base case, or $76,300/QALY with 0.1% undiagnosed HIV prevalence. HIV risk-reduction counseling costs $36 per person more without additional benefit. ConclusionsA strategy of on-site rapid HIV testing offer with information only in substance abuse treatment programs increases life expectancy at a cost-effectiveness ratio <$100,000/QALY. Policymakers and substance abuse treatment leaders should seek funding to implement on-site rapid HIV testing in substance abuse treatment programs for those not recently tested.

Alcohol Consumption as a Barrier to Prior HIV Testing in a Population-Based Study in Rural Uganda

Early receipt of HIV care and ART is essential for improving treatment outcomes, but is dependent first upon HIV testing. Heavy alcohol consumption is common in sub-Saharan Africa, a barrier to ART adherence, and a potential barrier to HIV care. We conducted a population-based study of 2,516 adults in southwestern Uganda from November-December 2007, and estimated the relative risk of having never been tested for HIV using sex-stratified Poisson models. More men (63.9 %) than women (56.9 %) had never been tested. In multivariable analysis, compared to women who had not consumed alcohol for at least 5 years, women who were current heavy drinkers and women who last drank alcohol 1-5 years prior, were more likely to have never been tested. Alcohol use was not associated with prior HIV testing among men. HIV testing strategies may thus need to specifically target women who drink alcohol.

Social and individual risk determinants of HIV testing practices among noninjection drug users at high risk for HIV/AIDS

HIV testing services and research among drug users has largely focused on injection drug users (IDUs); yet noninjection drug users (NIDUs) are also at increased risk for HIV due to high-risk sexual behaviors and overlapping networks with IDUs. This study examined drug use, sexual risk, and social network characteristics associated with recent HIV testing (testing within past year) among NIDUs. Interviewer-administered questionnaires were conducted among 418 NIDUs and log-binomial regression models were used to identify correlates of recent HIV testing. Prevalence ratios (PR) with 95% confidence intervals (CI) were reported. Nearly 97% of NIDUs reported having ever been tested for HIV and most participants (85.7%) indicated testing for HIV within the past year. Factors independently associated with recent HIV testing were higher educational attainment (PR: 1.86; 95% CI: 1.03, 3.34) and networks to discuss health and medical services (PR: 1.84; 95% CI: 1.06, 1.20). A prior positive sexually transmitted infection was associated with decreased likelihood of recent HIV test (PR: 0.43; 95% CI 0.25, 0.74). Identifying specific social network characteristics may be effective in facilitating HIV testing and prevention strategies targeting NIDUs.

P13 New HIV diagnoses in a busy inner-city cohort: How far have we come?

BackgroundOur service is located in a high HIV prevalence area (6.2/1000), and a large proportion of late presentations. We have widened the availability of HIV testing as a major strategy to reduce HIV related morbidity and mortality in our population.Aims/ObjectivesTo assess the evolving trends in demographics, clinical and laboratory findings of newly diagnosed HIV patients in our busy inner city clinic. To develop HIV testing strategies further with the implementation of current NICE guidance that recommends testing all medical admissions, and assess the potential future impact of this on presentation patterns in our cohort.MethodsRetrospective case note review of 92 consecutive new HIV diagnoses between 2009 and 2011. Data were collected on demographics, clinical stage, CD4 count, source of referrals, and drug resistance. Findings were compared to previous data sets in the same clinic over three audit periods between 2003 and 2011.ResultsThe proportion of males newly diagnosed has increased from 33% (2003) to 51% (2011), and the median age of all diagnoses has crept up to 39.5 years from 36.7 years. The proportion of referrals from primary care is now the largest (51%). Very late presenters (CD4 &lt;200), remain high in our population at 53%, and this is well above the national average of 30%. Primary drug resistance is 16%, currently double the national average.Discussion/ConclusionsThere continues to be a high rate of very late presenters in our cohort. Strengthening current interventions and implementation of NICE guidance will be essential in an effort to reduce late diagnoses.

HIV testing in community settings in resource‐rich countries: a systematic review of the evidence

Community HIV testing represents an opportunity for diagnosing HIV infection among individuals who may not have contact with health services, especially in hard-to-reach groups. The aim of this review was to assess the evidence for feasibility, acceptability and effectiveness of HIV testing strategies in community settings in resource-rich countries. The PubMed database was searched for English language studies of outreach HIV testing in resource-rich countries. Studies were included if they reported one of the following outcome measures: uptake of testing; seropositivity; client acceptability; or provider acceptability. Forty-four studies were identified; the majority took place in the USA and targeted men who have sex with men. Uptake of HIV testing varied between 9 and 95% (in 14 studies). Seropositivity was ≥ 1% in 30 of 34 studies. In 16 studies the proportion of patients who received their test results varied from 29 to 100% and rapid testing resulted in a higher proportion of clients receiving their results. Overall, client satisfaction with community HIV testing was high. However, concern remained over confidentiality, professional standards and the need for post-test counselling. Staff reported positive attitudes towards community testing. In the majority of studies, the reported seropositivity was higher than 1/1000, the threshold deemed to be cost-effective for routinely offering testing. Rapid testing improved the return of HIV test results to clients. HIV testing in outreach settings may be important in identifying undiagnosed infections in at-risk populations, but appropriate data to evaluate these initiatives must be collected.

The Challenges of Testing for HIV in Women: Experience from the Uk and Other European Countries

Strategies for HIV testing vary across Europe, but widespread unacceptably high rates of late diagnosis among women suggest that current testing strategies are not adequately reaching the female population. The only group within the female population that is given specific consideration in guidelines for HIV testing is women who are pregnant, where opt-out testing is often recommended. This article reviews experience from the UK and other European countries with antenatal testing, and trials of routine HIV testing in a range of other settings. Further recommendations for testing strategies for women are required, but need to consider physician barriers to testing, such as constraints on time and training. It is vital to evaluate the motivations that underlie a woman's decision to accept or refuse testing, as these often differ from those of men. Similarly, the consequences of a positive diagnosis for a woman need to be addressed in pre- and post-test discussions.

Educational Gradient in HIV Diagnosis Delay, Mortality, Antiretroviral Treatment Initiation and Response in a Country with Universal Health Care

The aim of this study was to analyse associations between educational level and delayed HIV diagnosis (DD), late initiation of combined antiretroviral therapy (cART), overall and in subjects with timely HIV diagnosis, virological and immunological responses to cART, and mortality from HIV diagnosis and cART initiation. This was a multicentre cohort study of HIV-positive treatment-naive subjects in Spain between 2004-2009. Logistic and Cox regression analyses were used. Of 4,549 subjects, 44.5% had low education level (LOW), 34.4% medium education level (MED) and 21.1% high education level (HIG). In men, DD was more common in MED (OR 1.3 [95% CI 1.0, 1.7]) or LOW [OR 1.8 (95% CI 1.4, 2.3)] compared to HIG. In women, the opposite was observed; women with HIG were 40% more likely to have DD than those with LOW (OR 1.4 [95% CI 0.8, 2.5]). In individuals with timely HIV diagnoses, percentages of late cART initiators were similar (LOW 9.5%, MED 11.4% and HIG 7.0%; P=0.114). Immunological (LOW 68%, MED 76% and HIG 84%) and virological (LOW 76%, MED 83% and HIG 86%) responses to cART increased significantly with educational level; these increases remained significant in multivariate analyses. Mortality for LOW subjects was higher than for HIG, from HIV diagnosis (hazard ratio [HR] 2.3 [95% CI 1.1, 4.9]) and from cART initiation (HR 1.8 [95% CI 0.8, 3.9]). We found important differences by educational level in diagnosis delay, virological and immunological responses to cART and mortality in a country with universal health care. Women with high educational level are at higher risk of having delayed HIV diagnoses. Educational level should be taken into account when designing HIV testing and clinical management strategies.

Evaluation of the Relative Effectiveness of Three HIV Testing Strategies Targeting African-American Men Who Have Sex with Men (MSM) in New York City: Response to Letter from Renaud et al.

Evaluation of the Relative Effectiveness of Three HIV Testing Strategies Targeting African-American Men Who Have Sex with Men (MSM) in New York City: Response to Letter from Renaud et al.

Accurate Comparison of HIV Testing Strategies Requires Verification of Clients’ HIV Status Using HIV Surveillance Registry. A Commentary on Halkitis et al.

In their recently published study, Halkitis et al. [1] compare three HIV testing strategies—alternative venue, partner services, and social network—and conclude that the social network strategy is the most effective in identifying previously undiagnosed HIV-positive African–American men who have sex with men. Though we commend Halkitis and colleagues’ effort to compare testing strategies, we caution readers about their conclusion. Data presented for the three strategies are not comparable because, for two of the strategies, program staff members were unable to check if testers were already known to the health department to be HIV infected. This is because of the legal restrictions in the New York State that protect the confidentiality of persons living with HIV. As staff members within the HIV partner services program within the New York City (NYC) Department of Health and Mental Hygiene, we are, unlike Halkitis et al., able to check if clients have been reported to the NYC HIV Surveillance Registry. When we submitted data to Halkitis et al., we excluded all testers who were previously diagnosed with HIV, regardless of whether they had disclosed their status. Had we included nondisclosers in the numerator, the detection rate for partner services would be 22%, far higher than the 14.3% detection rate reported in the study and also higher than that reported for social networks (19.3%). From our experience, persons living with HIVoften do not disclose their HIV status when testing because of denial, embarrassment, desire for incentives, or other reasons. As noted by Halkitis et al., incentives significantly increased enrollment. Incentives, therefore, may have increased the proportion of known positives who accepted testing. We agree with Halkitis and colleagues’ call for a “rigorous experimental study design to identify the most effective HIV testing strategies” and recommend that such a study include collaboration with local health departments to verify self-reported HIV status with the local HIV surveillance registry. Previously diagnosed repeat testers should be excluded from such analyses.

Failure to test children of HIV-infected mothers in South Africa: implications for HIV testing strategies for preschool children

To assess the uptake of HIV testing among preschool children with HIV-positive mothers in a peri-urban population-based study in KwaZulu-Natal, South Africa, an area of high HIV prevalence. All children 4-6 years old and their primary caregivers from the area were invited to participate. All participants were asked about prior HIV testing and were offered counselling and voluntary HIV testing irrespective of previous testing. Twenty-seven HIV-infected mothers were interviewed to identify barriers to testing their children. One thousand five hundred and eighty-three children (88% of eligible children) and their caregivers participated. Of the biological mothers, 86% were previously tested for HIV (27% tested positive). Among the surviving 244 children born to an infected mother, only 41% had been tested for HIV (23% tested positive). Subsequently, 90% of previously untested children of infected mothers underwent HIV testing (9.3% were positive). Overall seroprevalence among study children was 4.9%. All infected mothers interviewed endorsed the belief that children of HIV-infected women should be tested for HIV. Women who missed opportunities for antenatal HIV testing reported no systematic testing of their children at later ages. In this community with high HIV prevalence, HIV testing of children is infrequent despite high testing coverage among caregivers. The low proportion of children tested for HIV, particularly those of infected mothers, is of great concern as they are at high risk for morbidity and mortality associated with untreated childhood HIV infection. HIV testing programs should strengthen protocols to include children, especially for those who missed PMTCT opportunities in infancy.

Evaluation of the Relative Effectiveness of Three HIV Testing Strategies Targeting African American Men Who Have Sex with Men (MSM) in New York City

African American men who have sex with men (MSM) are disproportionately affected by HIV and constitute more than half of all HIV-infected MSM in the USA. Data from the New York City location of a multi-site study were used to evaluate the effectiveness of three HIV testing strategies for detecting previously undiagnosed, 18 to 64-year-old African American MSM. Effectiveness was defined as the identification of seropositive individuals. Using a quasi-experimental design (N = 558), we examined HIV-positive test results for men tested via alternative venue testing, the social networks strategy, and partner counseling and referral services, as well as behavioral risk factors for 509 men tested through alternative venue testing and the social networks strategy. Detection rates of HIV-positives were: alternative venue testing-6.3%, the social networks strategy-19.3%, and partner services-14.3%. The odds for detection of HIV-positive MSM were 3.6 times greater for the social networks strategy and 2.5 times greater for partner services than alternative venue testing. Men tested through alternative venue testing were younger and more likely to be gay-identified than men tested through the social networks strategy. Men who tested through the social networks strategy reported more sexual risk behaviors than men tested through alternative venue testing. Findings suggest differential effectiveness of testing strategies. Given differences in the individuals accessing testing across strategies, a multi-strategic testing approach may be needed to most fully identify undiagnosed HIV-positive African American MSM.

HIV TESTING OF PREGNANT WOMEN: AN ETHICAL ANALYSIS

Recent global advances in available technology to prevent mother-to-child HIV transmission necessitate a rethinking of contemporary and previous ethical debates on HIV testing as a means to preventing vertical transmission. In this paper, we will provide an ethical analysis of HIV-testing strategies of pregnant women. First, we argue that provider-initiated opt-out HIV testing seems to be the most effective HIV test strategy. The flip-side of an opt-out strategy is that it may end up as involuntary testing in a clinical setting. We analyse this ethical puzzle from a novel perspective, taking into account the moral importance of certain hypothetical preferences of the child, as well as the moral importance of certain actual preferences of the mother. Finally, we balance the conflicting concerns and try to arrive at an ethically sound solution to this dilemma. Our aim is to introduce a novel perspective from which to analyse testing strategies, and to explore the implications and possible benefits of our proposal. The conclusion from our analysis is that policies that recommend provider-initiated opt-out HIV testing of pregnant mothers, with a risk of becoming involuntary testing in a clinical setting, are acceptable. The rationale behind this is that the increased availability of very effective and inexpensive life-saving drugs makes the ethical problems raised by the possible intrusiveness of HIV testing less important than the child's hypothetical preferences to be born healthy. Health care providers, therefore, have a duty to offer both opt-out HIV testing and available PMTCT (preventing mother-to-child transmission) interventions.

Provider-initiated HIV testing increases access of patients with HIV-associated tuberculosis to antiretroviral treatment

Timely initiation of antiretroviral treatment (ART) is a critical component of the case management of patients with HIV-associated tuberculosis (TB) and advanced immunodeficiency. We sought to determine the impact of the introduction of provider-initiated HIV-testing in TB clinics in 2005 on subsequent referrals of patients with HIV-associated TB at a community-based ART service in Cape Town. Retrospective analysis of an ART cohort database (2002 - 2008) stratified by calendar periods. Between 2002 and 2008, 3 770 ART-naive adults enrolled in the ART service. Overall, 27.4% of these patients had been referred from TB clinics with a diagnosis of HIV-associated TB. This proportion increased from 16.0% of referrals in the period 2002 - 2005 prior to the introduction of provider-initiated HIV testing, to 34.7% in 2007 - 2008 (p<0.001). The median duration of TB treatment completed prior to referral decreased from 3 months to 1 month (p<0.001) and patients enrolled with higher median CD4 cell counts (71 cells/microl v. 95 cells/microl; p<0.001). Moreover, the proportion with recurrent TB epiSodes decreased from 8.6% to 3.2% (p<0.001). Introduction of provider-initiated HIV testing by the TB control programme was temporally associated with a major increase in referrals of patients with HIV-associated TB to this ART service, a progressive decline in referral delay, improvements in baseline CD4 cell counts, and fewer recurrent TB episodes. Such trends are likely to be associated with improved survival, and these data strongly support this HIV-testing strategy.