Human Immunodeficiency Virus Testing Strategies Research Articles

Gaps and Opportunities in HIV Service Delivery in High Volume HIV Care Centers in Liberia: Lessons From the Field.

Background:Human Immunodeficiency Virus (HIV) infection continues to have a profound humanitarian and public health impact in western and central Africa, a region that risks being left behind in the global response to ending the AIDS epidemic. In Liberia, where the health system is being rebuilt following protracted civil wars and an Ebola virus disease outbreak, the Resilient and Responsive Health System (RRHS) is assisting with quality HIV services delivery through support from PEPFAR and HRSA but gaps remain across the cascade of care from diagnosis to viral load suppression.Objective:To highlight gaps in HIV service delivery in Liberia, identify opportunities and offer recommendations for improving the quality of service delivery.Methods:A narrative review of relevant literature was conducted following a search of all local and online databases known to the authors.Findings:Antiretroviral therapy (ART) has transformed the HIV response in Liberia by averting deaths, improving quality of life, and preventing new HIV infections but critical gaps remain. These include weak HIV prevention and testing strategies; suboptimal ART initiation and retention in care; low viral load testing volumes, commodity supply chain disruptions and a HIV workforce built on non-physician healthcare workers. In the context of the prevailing socioeconomic, heath system and programmatic challenges, these will impact achievement of the UNAIDS targets of 95-95-95 by 2030 and ending the epidemic.Conclusion:Combination prevention approaches are necessary to reach the most at risk populations, while a robust health workforce operating through facilities and communities will be needed to reach people with undiagnosed HIV earlier to provide efficient and effective services to ensure that people know their HIV status, receive and sustain ART to achieve viral suppression to maintain a long and healthy life within the framework of overall health system strengthening, achieving universal health coverage and the sustainable development goal.

HIV Testing Strategies for Health Departments to End the Epidemic in the U.S.

An important goal of the Ending the HIV Epidemic in the U.S. initiative is the timely diagnosis of all people with HIV as early as possible after infection. To end the HIV epidemic, health departments were encouraged to propose new and innovative HIV testing strategies and improve the reach of existing programs. These activities were divided into 3 core strategies: expansion of routine screening in healthcare settings, locally tailored HIV testing initiatives in nonhealthcare settings, and specific efforts to increase the frequency of testing for individuals with increased potential for acquiring HIV. Because HIV testing is such a crucial part of the core activities of the Centers for Disease Control and Prevention's HIV prevention programs, there are many examples of evidence-based programs and best practices for HIV testing in both clinical and nonclinical settings. This article reviews the evidence base for these strategies and some of the activities proposed under the Diagnose pillar to achieve the goal of diagnosing all HIV infections as early as possible. All other Ending the HIV Epidemic in the U.S. activities start with an awareness of HIV status, which is actually the indicator for which most health departments are closest to the proposed targets. There are both proven and emerging approaches to increasing HIV screening and increasing the frequency of HIV screening available. The Ending the HIV Epidemic in the U.S. initiative provides the motivation, the resources, and a coordinated plan to bring them to scale.

Substantial gap in primary care: older adults with HIV presenting late to care

BackgroundLate diagnosis of human immunodeficiency virus (HIV) is associated with increased morbidity and mortality, and represents a serious public health concern.MethodsA retrospective medical record review was conducted on 188 patients with newly diagnosed HIV at a large academic center’s HIV clinic from 1/2010 to 12/2019. Patient demographic data, HIV staging, and response to combination antiretroviral therapy (cART) as measured by HIV viral suppression at 12 weeks (HIV RNA < 50 copies) were collected. Bivariate analyses were applied to compare patients ≥50 years old to those < 50 years old.ResultsOver two-thirds of the older patients with a new diagnosis of HIV presented with a CD4 count < 200, or an AIDS-defining illness. Though not statistically significant, this same group also had a delay to viral suppression with only 59% achieving viral suppression after 12-weeks of cART initiation.ConclusionsThis study suggests that older patients are presenting to care with advanced stages of HIV, and may also have a delay in achieving viral suppression after cART initiation. Future studies should aim to target HIV testing and treatment strategies for this at-risk older adult group.

Bundling Rapid Human Immunodeficiency Virus and Hepatitis C Virus Testing to Increase Receipt of Test Results: A Randomized Trial.

The overlapping human immunodeficiency virus (HIV) and hepatitis C virus (HCV) epidemics disproportionately affect people with substance use disorders. However, many people who use substances remain unaware of their infection(s). The objective of this study was to examine the efficacy of an on-site bundled rapid HIV and HCV testing strategy in increasing receipt of both HIV and HCV test results. Two-armed randomized controlled trial in substance use disorder treatment programs (SUDTP) in New York City. Participants in the treatment arm were offered bundled rapid HIV and HCV tests with immediate results on-site. Participants in the control arm were offered the standard of care, that is, referrals to on-site or off-site laboratory-based HIV and HCV testing with delayed results. A total of 162 clients with unknown or negative HIV and HCV status. The primary outcome was the percentage of participants with self-reported receipt of HIV and HCV test results at 1-month postrandomization. Over half of participants were Hispanic (51.2%), with 25.3% being non-Hispanic black and 17.9% non-Hispanic white. Two thirds were male, and 54.9% reported injection as method of drug use. One hundred thirty-four participants (82.7%) completed the 1-month assessment. Participants in the treatment arm were more likely to report having received both test results than those in the control arm (69% vs. 19%, P<0.001). Seven participants in the treatment arm received a preliminary new HCV diagnosis, versus 1 in the control arm (P=0.029). Offering bundled rapid HIV and HCV testing with immediate results on-site in SUDTPs may increase awareness of HIV and HCV infection among people with substance use disorders.

The Tingathe Surge: a multi-strategy approach to accelerate HIV case finding in Malawi.

Nineteen health facilities in rural, southeastern Malawi. To describe the implementation and results of a 6-week intervention to accelerate human immunodeficiency virus (HIV) case finding. Six HIV testing strategies were simultaneously implemented. Routinely collected data from Ministry of Health registers were used to determine the number of HIV tests performed and of new cases identified. The weekly averages of the total number of tests and new cases before and during the intervention were compared. Testing by age group and sex was described. The percentage yield of new cases was compared by testing strategy. Of 29 703 HIV tests conducted, 1106 (3.7%) were positive. Of the total number of persons tested, 69.5% were women and 75.5% were aged >15 years. The yield of positive test results was 3.5% among women, 4.3% among men, 4.4% among those aged >15 years and 1.5% among those aged ⩽15 years. The average weekly number of tests increased 106.7% from 3337 to 6896 (P = 0.002). The average weekly number of positive cases identified increased 51.9% from 158 to 240 (P = 0.017). The testing strategy with the highest yield resulted in a 6.0% yield; the lowest was 1.3%. The yield for all strategies, except one, was highest in adult men. A multi-strategy approach to HIV testing and counseling can be an effective means of accelerating HIV case finding.

National HIV Testing Day - June 27, 2019.

National HIV Testing Day, observed each year on June 27, highlights the importance of testing in detecting, treating, and preventing human immunodeficiency virus (HIV) infection. Early diagnosis is critical to controlling HIV transmission in the United States (1). With the aim of reducing the number of new infections in the United States by 90% in 10 years, the Ending the HIV Epidemic initiative initially will focus on the 50 local jurisdictions where approximately half of diagnoses made in 2016 and 2017 were concentrated and in seven states with a disproportionate occurrence of HIV in rural areas (2). An analysis of 2016 and 2017 population-based survey data reported in this issue of MMWR found that overall, 38.9% of the U.S. population had ever tested for HIV infection, including 46.9% in the 50 local jurisdictions with the majority of diagnoses and 35.5% in the seven states with disproportionate occurrence of HIV in rural areas. To control HIV transmission, health care providers and public health practitioners need to develop HIV testing strategies to reach segments of the population that have never tested for HIV infection and offer at least annual testing of persons at risk for infection.

The Cost-effectiveness of Human Immunodeficiency Virus (HIV) Preexposure Prophylaxis and HIV Testing Strategies in High-risk Groups in India.

The human immunodeficiency virus (HIV) epidemic in India is concentrated among 3.1 million men who have sex with men (MSM) and 1.1 million people who inject drugs (PWID), with a mean incidence of 0.9-1.4 per 100 person-years. We examined the cost-effectiveness of both preexposure prophylaxis (PrEP) and HIV testing strategies for MSM and PWID in India. We populated an HIV microsimulation model with India-specific data and projected clinical and economic outcomes of 7 strategies for MSM/PWID, including status quo; a 1-time HIV test; routine HIV testing every 3, 6, or 12 months; and PrEP with HIV testing every 3 or 6 months. We used a willingness-to-pay threshold of US$1950, the 2017 Indian per capita gross domestic product, to define cost-effectiveness. HIV testing alone increased life expectancy by 0.07-0.30 years in MSM; PrEP added approximately 0.90 life-years to status quo. Results were similar in PWID. PrEP with 6-month testing was cost-effective for both MSM (incremental cost-effectiveness ratio [ICER], $1000/year of life saved [YLS]) and PWID (ICER, $500/YLS). Results were most sensitive to HIV incidence. PrEP with 6-month testing would increase HIV-related expenditures by US$708 million (MSM) and US$218 million (PWID) over 5 years compared to status quo. While the World Health Organization recommends PrEP with quarterly HIV testing, our analysis identifies PrEP with semiannual testing as the cost-effective HIV prevention strategy for Indian MSM and PWID. Since nationwide scale-up would require a substantial fiscal investment, areas of highest HIV incidence may be the appropriate initial targets for PrEP scale-up.

Human Immunodeficiency Virus Self-Testing in Adolescents Living in Sub-Saharan Africa: An Advocacy.

Acquired immune deficiency syndrome (AIDS) has become the leading cause of death among adolescents (aged 10–19) in sub-Saharan Africa. Less than 20% of African adolescents know their human immunodeficiency virus (HIV) status, whereas HIV testing remains the gateway to care. To end the AIDS epidemic by 2030 according to the Joint United Nations Programme on HIV/AIDS target, it is necessary to introduce scalable HIV testing strategies specific to different settings such as age groups, populations, and geographical areas. Demonstrated evidence on HIV self-testing (HIVST) in sub-Saharan Africa settings is reported, including data among adolescents. The All In initiative, which is the current international platform for the fight against HIV in adolescents is a good opportunity to address the challenge of HIV testing, including HIVST. Adapted strategies of HIVST such as (i) implementation of several listening and recreation centers for adolescents, (ii) door-to-door HIVST approach, and (iii) reducing the age of consent is urgently needed to promote HIV testing among adolescents living in Africa.

The Effectiveness and Cost-Effectiveness of Screening for HIV in Migrants in the EU/EEA: A Systematic Review.

Migrants, defined as individuals who move from their country of origin to another, account for 40% of newly-diagnosed cases of human immunodeficiency virus (HIV) in the European Union/European Economic Area (EU/EEA). Populations at high risk for HIV include migrants, from countries or living in neighbourhoods where HIV is prevalent, and those participating in high risk behaviour. These migrants are at risk of low CD4 counts at diagnosis, increased morbidity, mortality, and onward transmission. The aim of this systematic review is to evaluate the effectiveness and cost-effectiveness of HIV testing strategies in migrant populations and to estimate their effect on testing uptake, mortality, and resource requirements. Following a systematic overview, we included four systematic reviews on the effectiveness of strategies in non-migrant populations and inferred their effect on migrant populations, as well as eight individual studies on cost-effectiveness/resource requirements. We assessed the certainty of our results using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. The systematic reviews reported that HIV tests are highly accurate (rapid test >90% sensitivity, Western blot and ELISA >99% sensitivity). A meta-analysis showed that rapid testing approaches improve the access and uptake of testing (risk ratio = 2.95, 95% CI: 1.69 to 5.16), and were associated with a lower incidence of HIV in the middle-aged women subgroup among marginalised populations at a high risk of HIV exposure and HIV related stigma. Economic evidence on rapid counselling and testing identified strategic advantages with rapid tests. In conclusion, community-based rapid testing programmes may have the potential to improve uptake of HIV testing among migrant populations across a range of EU/EEA settings.

Cost-Effectiveness of Voluntary HIV Testing Strategies in a Very Low-Prevalence Country, the Republic of Korea.

BackgroundThe Republic of Korea has a very low prevalence of human immunodeficiency virus (HIV) infection, but the number of new HIV diagnoses has steadily risen, strongly indicating a large number of undetected HIV infections. Thus, it is important for Korean public health authorities to adopt and encourage cost-effective HIV detection tools, such as rapid HIV screening tests. In this study, we aimed to evaluate the cost-effectiveness of enzyme-linked immunosorbent assays (ELISA) and rapid tests in a public health center (PHC) setting.MethodsWe developed a decision analytic model to assess the per-examinee cost and the cost-effectiveness of identifying HIV patients in a PHC setting using two HIV testing strategies: conventional HIV screening by ELISA versus rapid HIV testing. Analysis was performed in two scenarios: HIV testing in an average-risk population and in a high-risk population.ResultsCompared to the ELISA, the rapid test was cost-saving and cost-effective. The per-examinee cost was USD 1.61 with rapid testing versus USD 3.38 with ELISA in an average-risk population, and USD 4.77 with rapid testing versus USD 7.62 with ELISA in a high-risk population. The cost of identifying a previously undiagnosed HIV case was USD 26,974 with rapid testing versus USD 42,237 with ELISA in an average-risk population, and USD 153 with rapid testing versus USD 183 with ELISA in a high-risk population.ConclusionRapid testing would be more cost-effective than using conventional ELISA testing for identifying previously undiagnosed HIV-infected cases in Korea, a country with extremely low HIV prevalence.

Evaluating Testing Strategies for Identifying Youths With HIV Infection and Linking Youths to Biomedical and Other Prevention Services

Most human immunodeficiency virus (HIV)-infected youths are unaware of their serostatus (approximately 60%) and therefore not linked to HIV medical or prevention services. The need to identify promising and scalable approaches to promote uptake of HIV testing among youths at risk is critical. To evaluate a multisite HIV testing program designed to encourage localized HIV testing programs focused on self-identified sexual minority males and to link youths to appropriate prevention services after receipt of their test results. Testing strategies were evaluated using an observational design during a 9-month period (June 1, 2015, through February 28, 2016). Testing strategies were implemented by 12 adolescent medicine HIV primary care programs and included targeted testing, universal testing, or a combination. Data were collected from local youth at high risk of HIV infection and, specifically, sexual minority males of color. Proportion of sexual minority males and sexual minority males of color tested, proportion of previously undiagnosed HIV-positive youths identified, and rates of linkage to prevention services. A total of 3301 youths underwent HIV testing. Overall, 35 (3.6%) of those who underwent universal testing in primary care clinical settings, such as emergency departments and community health centers, were sexual minority males (35 [3.6%] were males of color) compared with 236 (46.7%) (201 [39.8%] were males of color) who were tested through targeted testing and 693 (37.8%) (503 [27.4%] were males of color) through combination efforts. Identification of new HIV-positive cases varied by strategy: 1 (0.1%) via universal testing, 39 (2.1%) through combination testing, and 16 (3.2%) through targeted testing. However, when targeted tests were separated from universal testing results for sites using a combined strategy, the rate of newly identified HIV-positive cases identified through universal testing decreased to 1 (0.1%). Rates of new HIV-positive cases identified through targeted testing increased to 49 (6.3%). Youths who tested through targeted testing (416 [85.1%]) were more likely to link successfully to local HIV prevention services, including preexposure prophylaxis, compared with those who underwent universal testing (328 [34.1%]). The findings suggest that community-based targeted approaches to HIV testing are more effective than universal screening for reaching young sexual minority males (especially males of color), identifying previously undiagnosed HIV-positive youths, and linking HIV-negative youths to relevant prevention services. Targeted, community-based HIV testing strategies hold promise as a scalable and effective means to identify high-risk youths who are unaware of their HIV status.

Use of network meta-analysis in clinical guidelines.

The World Health Organization (WHO) has conducted two major updates to global guidance for the management of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections in 2016. (1,2) Recommendations made by WHO can have an important effect on policy and practice, particularly for low- and middle-income countries. For instance, a 2014 survey found that over three-quarters of all 158 recommendations for HIV and tuberculosis were incorporated into national guidelines. (3) Clinical guidelines are developed through multi-step processes that ensure that guidelines are feasible within the current clinical environment and that they are based on the best available evidence. For the latest HIV and HCV guidelines, WHO used network meta-analysis to inform treatment recommendations. An expansion of conventional pairwise meta-analysis, network meta-analysis includes multiple interventions within a single analysis and estimates the relative treatment effect between each two treatments compared using direct or indirect evidence. Although it is often acknowledged that having the most up-to-date evidence is critical to the development of clinical guidelines, it is equally important that the optimal analytical methods are used to appraise the evidence. We explain here why network meta-analysis lends itself to the development of clinical guidelines and why it may be used more often in this context. WHO has a history of improving the methods it uses for developing its guidelines. Following calls for greater transparency in the use of evidence for decision-making, (4) WHO adopted a process for guideline development in 2007 that included the use of the GRADE approach (grading of recommendations, assessment, development and evaluation) to support decision-making. In addition to clinical evidence, WHO guideline groups take account of factors such as patient preferences, feasibility, costs and human rights. (5) To support decision-making beyond clinical effectiveness, mathematical models have been used to appraise the cost-effectiveness and epidemiological impact of HIV testing and treatment strategies in 2013. (6) WHO guidelines are regularly revised, generally every 3-5 years, to provide up-to-date guidance on interventions to contain or reduce major public health threats. With an ever-growing number of treatment options for HIV and HCV, methods used to synthesize the evidence within the guideline development procedures should maximize the use of all evidence and generate results that can be translated into recommendations. Although the use of network meta-analysis for WHO guideline development is recent, the method is well established within national health technology assessment agencies. It has become essential to formulating recommendations on reimbursements by health care agencies around the world. The method has also recently been adopted by Cochrane, and we found that since 2015, 10% (23/230) of systematic reviews published by this organization used network meta-analysis. The method has numerous qualities that lend themselves to decision-making processes such as clinical guidelines development. In 2015, GRADE working groups published guidance on how to use GRADE in conjunction with network meta-analysis. (7) Furthermore, the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom of Great Britain and Northern Ireland has included recommendations on network meta-analysis within its clinical guidelines manual. (8) However, in 2012 only 8% of 138 NICE clinical guidelines had used network meta-analysis, (9) but the percentage is likely to be higher today. Systematic evidence appraisal, but not the network meta-analysis approach, was used to formulate recommendations in other recent, major guidelines for HIV and HCV disease. (10-12) Network meta-analysis offers several advantages to the process of developing guidelines. One advantage is the ability to make a quantitative comparison of interventions that have not been directly compared in studies. …

Attrition from HIV care among adolescents and adults in a low-income setting.

The global scale-up of antiretroviral therapy (ART) has dramatically reduced mortality among people living with the human immunodeficiency virus (HIV).1 The success of ART programmes, however, relies on patients remaining in care and adhering to treatment. Under programmatic conditions, in addition to mortality, a proportion of patients drop out of treatment programmes without seeking care elsewhere.2 These patients are at high risk of morbidity and death within a short time of attrition.3 A number of studies have examined retention in care, but few have evaluated outcomes by age, particularly among adolescents and youth. This is a very heterogeneous age group with respect to physical, psychological and cognitive development, but studies tend to group adolescents variably as adults aged >16 years or >18 years. The study in this issue of Public Health Action by Matyanga et al., from a public sector clinic in peri-urban Zimbabwe, is the first to compare attrition in a non-research cohort between younger (age 10–14 years) and older (age 15–19 years) adolescents and between younger (age 20–29 years) and older (age ⩾30 years) adults, over a 2-year period.4 The rates of retention in care by 24 months were greater than 80% in all age groups except young adults, where 26% were not in care by the end of 24 months. These rates are higher than those reported in earlier studies, demonstrating that progress has been made in retaining patients in care.5 The significantly lower rates of retention in care in young adults is, however, of concern. This age group has the highest HIV incidence of any age group, and it is highly mobile. The study was conducted in a clinic that serves a population where the majority live in informal housing, and it is likely that there are high levels of migration for work, which may result in interruption of HIV care. More than three-quarters of attrition across all age groups was due to patients being lost to follow-up, a finding also reported by other studies.2 Attrition was associated with late presentation, and it is probable that many of those lost to follow-up died.3 This highlights the need not only to improve tracing of those who default from care but also to implement innovative HIV testing strategies so that timely HIV treatment can be started. Notably, more than a third of patients initiating ART had advanced disease, which is associated with poorer clinical outcomes. Among adolescents, 91% had a body mass index of <17 kg/m2, demonstrating very high rates of stunting and wasting. While this may be partly explained by food insecurity, it is much more likely to be due to late diagnosis of vertically infected children who have slow-progressing disease.6 The 2015 World Health Organization HIV treatment guidelines recommend ART for all HIV-infected individuals, regardless of clinical or immunological stage.7 Much larger numbers of individuals will therefore be eligible for treatment now, many of whom will be a symptomatic. To achieve the ambitious Joint United Nations Programme on HIV/AIDS (UNAIDS) 90–90–90 targets of identifying 90% of HIV-positive persons through testing, initiating 90% of these on ART, and achieving viral suppression in 90% of those on ART, there is now an even more pressing need to develop innovative strategies not only to identify HIV-infected individuals, particularly hard-to-reach groups such as men and adolescents,8 but to focus efforts on retaining those at high risk of attrition. To achieve this, tracing procedures of those who drop-out will need to be strengthened.

Achieving high acceptability of HIV testing in a population-based survey among immigrants in Finland.

The aim of this study was to assess the acceptability of human immunodeficiency virus (HIV) testing among migrants in Finland and the factors contributing to non-acceptance. The Finnish Migrant Health and Wellbeing Study 'Maamu' was the first national population-based Health Interview and Examination Survey (HIS/HES) among migrants in Finland. A total of 386 Kurdish, Russian and Somali immigrants in Helsinki participated in the study. Despite the participants' different sociodemographic backgrounds, a high rate of test acceptability (92%, 95% CI 90-95) was achieved. HIV test acceptance was associated with pretest counselling, ability to understand spoken Finnish or Swedish and employment status. No participants tested positive for HIV. The results imply that a universal HIV testing strategy is well accepted in a low-HIV prevalence immigrant population and can be included in a general health examination in immigrant population-based surveys.

Cost effectiveness of facility and home based HIV voluntary counseling and testing strategies in rural Uganda

In Uganda, the main stay for provision of human immunodeficiency virus (HIV) voluntary counseling and testing (VCT) has been at health facilities. Home based VCT on the other hand, was initiated in the country to improve service coverage. To evaluate the cost effectiveness of facility- and home-based HIV VCT strategies in rural southwestern Uganda. Data on costs and effectiveness of facility- and home-based HIV VCT intervention strategies was collected in two sub-Counties in rural southwestern Uganda. Costing was performed using the ingredients approach. Effectiveness was measured as the number of HIV sero-positive clients identified. Incremental Cost-Effectiveness Ratios (ICERs) were calculated from the provider perspective. The cost per client tested were US$6.4 for facility based VCT and US$5.0 for home based VCT. The corresponding costs per positive case identified were US$86.5 and US$54.7 respectively. The incremental cost to providers per additional positive case identified by facility based VCT was US$3.5. Home based VCT was the least costly strategy per client tested and was also cost effective in identifying HIV sero-positive clients in rural areas. This strategy should therefore be promoted to improve service coverage and thereby facilitate early and extensive detection of clients eligible for treatment.

A Qualitative Assessment of Emergency Department Patients' Knowledge, Beliefs, Attitudes, and Acceptance Toward Revised HIV Testing Strategies

The objective of this study was to explore emergency department (EDs) patients' knowledge, beliefs, attitudes, and acceptability toward revised human immunodeficiency virus (HIV) testing recommendations. Participants were recruited in proportion to the racial, sex, and ethnic makeup of the study ED. Interviewers presented participants with a stimulus followed by questions about opt-out consent, elimination of separate written consent, and curtailed counseling. Three investigators coded all transcripts using an iterative coding strategy until thematic saturation was achieved. Thirty-four semistructured, in-depth, individual interviews were conducted, including five with patients ages 13 to 17 years and five with Spanish-speaking patients. Nineteen (56%) participants were women. The mean (± SD) age was 31 (± 12) years. Most were Hispanic (38%) or African American/black (44%). Only one (2.9%) participant knew about the revised testing recommendations. Participants believed that opt-out consent would result in increased testing, but this was confounded by misunderstanding of the consent process: "so the opt-out is, you basically don't have a choice." Participants thought eliminating separate written consent was a positive change but that it could result in people being tested without their knowledge. Attitudes diverged over curtailed counseling, but participants felt patients "should have options" for counseling because "everybody isn't the same." Emergency department patients were unaware of revised HIV testing recommendations. Most felt that opt-out consent and elimination of separate written consent were positive changes but could result in a patient being tested without his or her knowledge. The response to curtailed counseling was polarized but participants agreed on the need to accommodate personal preferences. This information may be useful when designing ED-based HIV testing programs.

HIV testing and antiretroviral treatment strategies for prevention of HIV infection: impact on antiretroviral drug resistance

'Test and treat' is a strategy in which widespread screening for human immunodeficiency virus (HIV) is followed by immediate antiretroviral therapy for those testing positive, thereby potentially reducing infectiousness in larger cohorts of infected patients. However, there is a concern that test and treat could lead to increased the levels of transmissible drug-resistant HIV, especially if viral load and/or drug resistance is not routinely monitored. Reviews of the existing literature show that up to now, even in the absence of laboratory tests, drug resistance has not created major problems in sub-Saharan Africa. Here, we discuss the current evidence for the effectiveness of a preventive test and treat approach and the challenges and implications for daily clinical practice and public health.

Knowledge and attitudes of Korean dentists towards human immunodeficiency virus/acquired immune deficiency syndrome

PurposeInfection with human immunodeficiency virus (HIV) remains a major global threat, and although the prevalence is comparatively still very low, the number of HIV-positive Koreans is increasing. However, there are no official guidelines as to how to treat people living with HIV/acquired immunodeficiency syndrome (AIDS) (PLWHA) or how to screen for potentially infectious people. This study assessed the level of knowledge and attitudes of dentists in Korea toward PLWHA, and their attitudes to screening patients for HIV infections.MethodsA cross-sectional prospective survey targeting dentists working in Korea was conducted using a self-administered questionnaire.ResultsA satisfactory level of knowledge about HIV/AIDS and a relatively positive attitude toward PLWHA was found. Most of the respondents preferred rapid HIV testing using oral fluid as a specimen. The general attitude of dentists toward HIV/AIDS is sufficiently positive to enable provision of the best treatment to the patients in need.ConclusionsMost of the dentists require HIV testing in dental clinics. In spite of their needs, there are several obstacles. It is hoped that financial considerations and official legal requirements related to HIV testing strategies will be considered.

Contraception and family planning among HIV-seroconcordant and -serodiscordant couples in the US and Zambia

With the advent of antiretroviral therapy remarkable progress has been made in the reduction of morbidity and mortality associated with the human immunodeficiency virus (HIV). As a result in both the developed and developing world reproductive decision-making and family planning has re-emerged as an important health issue among HIV-seroconcordant and -serodiscordant couples. This study sought to explore contraceptive attitudes and practices among HIV-seropositive and -serodiscordant couples in the US and Zambia and to compare contraceptive decision-making between seroconcordant and discordant couples. Study results suggest that while most participants expressed a willingness to use protection to prevent pregnancy the majority were not using protection consistently. Similarly among seropositive younger men in both the US and Zambia more men expressed a desire to have children than women of either serostatus group. Study outcomes also suggest that male and female condom use to reduce HIV transmission within couples is limited. Thus as males are largely the sexual decision makers regarding condom use women’s attitudes or plans regarding child bearing may be eclipsed by those of their male partners and recent reductions in provision of female condoms in the developing world may further reduce women’s options to protect themselves and prevent pregnancy. Education and counseling on vertical and horizontal transmission of HIV among both seropositive and serodiscordant couples should be an element of family planning efforts. Conversely family planning should be a critical element of HIV counseling and testing strategies to realistically respond to the desires of both members of the couple.

HIV Seropositivity And CD4 T-Lymphocyte Counts Among Infants And Children In Port Harcourt, Nigeria

Most published reports on HIV prevalence are centered on adults of sexually active age and antenatal mothers with little or no regard to infants and children. A total of one thousand (1000) children aged 1 to less than 15 years attending the various clinics at the Braithwait Memorial Specialist Hospital (BMSH), Port Harcourt were recruited into the study. Blood samples (3 millilitres of blood) were collected into a five millilitres syringe and the serum was used for serological testing of antibodies to human immunodeficiency virus (HIV) and CD4 cell counts from EDTA blood. The WHO HIV testing strategy III was adopted for defining the HIV status. The CD4 cell count was estimated using the Dynamal Quant Kit (Dynal Biotechn, ASA, Oslo, Norway). The overall HIV prevalence rate in this study was 23.2%. The distribution of HIV prevalence among different age group revealed a high prevalence rate among the under fives (24.1% for males and 26.4% for females). There was a significant negative correlation between age and HIV status of children (r = -0.94, P <0.01). The mean CD4 count of the infected children was 647.25 +/- 340.1 (95% CI 603.3 - 691.1). Logistic regression analysis showed that both age and sex exert an influence of the CD4 count only in the under fives (0 - <5 yrs). 10.3% of the children were immuno compromised with CD4 count below 200 cells, 27.9% fell into the moderate category while 61.8% had normal CD4 counts of 500 cells and above. The seroprevalence of HIV among infants and children is high in this part of the world and this call for urgent intervention through voluntary counseling of antenatal mothers and proper monitoring in order to reduce the paediatric HIV prevalence.