Voluntary Counselling And Testing Programme Research Articles

Review of literature on HIV/AIDS voluntary counselling and testing in Sub-Saharan Africa: Towards a social transformation model

Some estimates indicate approximately 65 million people globally have been infected with HIV since the first case was reported, of whom AIDS has killed more than 25 million and 40 million people were living with HIV/AIDS by the year 2006. Other records show the figure had declined to 33.2 million people living with the disease by 2007 but the cause of the decline is not clear whether because of improved records or increased deaths. AIDS is the fourth leading cause of death worldwide and the leading cause of death in Sub-Saharan Africa yet there is still no vaccine or cure for the disease. Prevention of HIV infections is therefore a key part in fighting the disease. Prevention of HIV infections is a key part in fighting the disease. Therefore voluntary counseling and testing (VCT) centers are crucial in attaining some of the goals towards prevention and management of the disease. Objective of the study: This study reviewed studies on VCT programs focusing on performance of the programs in Sub-Saharan Africa with the aim of coming up with practical suggestions for enhancing VCT towards HIV/AIDS prevention. Method: Literature on VCT services in Sub-Saharan Africa analyzed in the present study was obtained from multiple internet databases. Only those studies that met the selection criteria were included in the analysis. Findings: Major findings included the critical need to understand and integrate male perspective and participation in efforts to promote effective utilization of VCT programs for long-term implications in effectiveness of the programs; that women's economic empowerment is necessary but currently not sufficient in the translation of knowledge into desirable behavior changes; and that there is an urgent need to address the gendered power imbalances and gross marginalization of women in Sub-Saharan Africa. Overall, some VCT programs operate with essential key factors that seem to make a difference in the success of the programs. Based on these findings, the authors recommend existing and developing programs consider the incorporation of a multi-dimensional, social transformation model that is more conducive to large-scale transformational changes and program success in the African culture.

A social cost–benefit criterion for evaluating Voluntary Counseling and Testing with an application to Tanzania

There are many interventions for HIV/AIDS that require that people know their status and hence require a HIV test. Testing that is driven by a desire to prevent the spread of the disease often has an indirect effect on others. These external effects need to be identified, quantified and included as part of the benefits and costs of testing. Pioneering analyses of HIV testing by Philipson and Posner have introduced the economic calculus of individual expected benefits and costs of activities into an understanding of the HIV epidemic. What is required for social evaluations is an extension of the analysis to ensure that external effects are included. The objective of this paper is two-fold. First we seek to formulate cost-benefit criteria that incorporate fully the external effects in the evaluation of Voluntary Counseling and Testing (VCT). We achieve this by recasting the individual calculus of benefits and costs to a couple setting. We can then compare an individual's cost-benefit analysis of being tested with social criteria that look at outcomes from a couple's perspective for both separate and dual/joint testing. Second we aim to apply our social criteria to VCT programs as they currently operate in Tanzania and how these programs might operate in the future when they are scaled up to relate to the general population. We develop social criteria for evaluating separate and dual VCT using a couple's perspective with and without altruism. Therefore, the welfare function is based on two individual expected utility functions viewed as a couple, either married or regular partners. The benefits are the averted lives lost whenever discordant couples are revealed. The costs of VCT are the benefits of unprotected sex that the couple foregoes and the costs of the testing and counseling. The cost-benefit criteria are applied to VCT programs in Tanzania. The four main ingredients estimated are: the foregone benefit of unprotected sex (measured by the compensated wage differentials charged by commercial sex workers); the probability of infection; the cost of an infection (measured by both the value of a statistical life and the human capital approaches) and the cost of a single test (which includes behavior-modifying counseling). We find separate testing in existing VCT programs to be only marginally worthwhile. However, in scaled-up programs the benefit-cost ratio is over three. Dual testing is always more beneficial than separate testing. However, this advantage is reduced in scaled-up programs. VCT should be greatly expanded throughout Tanzania as future returns would be even higher for both separate and joint counseling and HIV testing.

Effectiveness of a training-of-trainers model in a HIV counseling and testing program in the Caribbean Region

ObjectivesTo evaluate the effectiveness and sustainability of a voluntary counseling and testing (VCT) training program based on a training-of-trainers (TOT) model in the Caribbean Region, we gathered data on the percentage of participants trained as VCT providers who were providing VCT services, and those trained as VCT trainers who were conducting VCT training.MethodsThe VCT training program trained 3,489 providers in VCT clinical skills and 167 in VCT training skills within a defined timeframe. An information-monitoring system tracked HIV trainings conducted, along with information about course participants and trainers. Drawing from this database, a telephone survey followed up on program-trained VCT providers; an external evaluation analyzed data on VCT trainers.ResultsAlmost 65% of trained VCT providers could be confirmed as currently providing VCT services. This percentage did not decrease significantly with time. Of the VCT trainers, 80% became certified as trainers by teaching at least one course; of these, 66% taught more than one course.ConclusionA TOT-based training program is an effective and sustainable method for rapid scale-up of VCT services and training capacity in a large-scale VCT program.

Building stakeholder partnerships for an on‐site HIV testing programme

Because of the large number of individuals at risk for HIV infection who visit gay saunas and sex clubs, these venues are useful settings in which to offer HIV outreach programmes for voluntary counselling and testing (VCT). Nevertheless, establishing a successful VCT programme in such a setting can be a daunting challenge, in large part because there are many barriers to managing the various components likely to be involved. Using qualitative data from a process evaluation of a new VCT programme at a gay sauna in California, USA, we describe how the various stakeholders overcame barriers of disparate interests and responsibilities to work together to successfully facilitate a regular and frequent on‐site VCT programme that was fully utilized by patrons.

Advocating for the Improvement of Adolescent VCT Services in Malawi

The focus on adolescent sexual and reproductive health services (ASRHS) in Malawi resulted from the increased risk of adolescents to HIV/AIDS, Sexually Transmitted Infections (STIs) and complications of early pregnancies1. This threatens the health of future generations as close to half of the Malawian population are youths2, making it necessary to focus on adolescents in policy design and programme implementation of sexual and reproductive health (SRH) services and Voluntary Counselling and Testing (VCT). The Ministry of Health (MOH) adopted the concept of comprehensive reproductive health as defined during the 1994 International Conference on Population and Development (ICPD) in Cairo. The ICPD emphasised reproductive health needs for adolescents as well3. The reproductive health unit was established in 1997 within MOH, since then Malawi has developed several policies and guidelines in support of reproductive health service implementation. While MOH is responsible for providing biomedical HIV/AIDS response, the National AIDS Commission (NAC) is the key coordinating body for both government and non governmental HIV/AIDS programmes. Very few young people have gone for testing despite the fact that adolescent VCT programmes have expanded considerably and awareness of available services has increased over the last few years for example in 2000 only 7% of adolescents aged 15–19 had HIV test6. Paradoxically, HIV/AIDS prevalence data shows that 15–24 year olds have the highest rate of new HIV infections2. The fact that many young people contract HIV/AIDS but few present themselves for testing may be because of poor quality of adolescent VCT services. Although another explanation could be that young people consider themselves invulnerable, on the other hand, the adolescents' perception of their vulnerability can be changed by improving VCT services among other things. All in all adolescent VCT services in Malawi leave a lot to be desired about in terms of availability, accessibility and acceptability. Adolescent VCT service enables and encourages adolescents with HIV to access appropriate care and is an effective HIV-prevention strategy4. This article therefore, advocates for improvement of adolescent VCT services in Malawi in terms of availability, accessibility and acceptability through; Analysing current adolescent VCT services in Malawi Discussing what needs to be done Making recommendations for improving adolescent VCT services

QUESTIONING MANDATORY HIV TESTING DURING PREGNANCY

Schuklenk and Kleinsmidt’s recent proposal1 to pilot mandatory HIV testing of pregnant women during antenatal care in areas with high HIV prevalence rates provides a plausible ethical justification for compulsory testing and treatment—if such a program were likely to succeed. The authors fail, however, to provide evidence that their program would be successful. In addition, they overlook several basic implementation problems likely to accompany a compulsory program. Three omissions are particularly striking. First, the authors fail to consider the possibility that a compulsory program could deter women from seeking any antenatal care. Presumably, the goal of implementing a mandatory program would be to reach those women who would have opted out of testing if given a choice. Might not these women forgo antenatal care altogether under a mandatory testing approach? “Kids IV,” an oil painting by Marcia Pinho, created in 2005. Printed with permission of Absolute Arts, World Wide Arts Resources, Granville, Ohio. Available at: http://www.absoluteartist.com. Second, there is no discussion of how to enforce mandatory testing and treatment, or of the resources needed for this endeavor. Although voluntary counseling and testing (VCT) has helped reduce risk of HIV infection,2 the authors suggest that VCT programs “divert resources away from testing and [treatment],” concluding that “preserving lives must take priority over counseling.”1(p1182) However, forcing reluctant women to submit to testing and treatment would also consume considerable resources, as the authors acknowledge: “continuing mandatory HAART treatment (after pregnancy) would not be feasible in a coercive regulatory environment.”1(p1182) Finally, there is no discussion of how a compulsory program could affect behavior after pregnancy. Knowing one’s HIV status does not necessarily lead women to engage in treatment, nor does it necessarily lead to change in risk behaviors. Each of these actions or behaviors is guided by complex decisionmaking processes and influenced by social and cultural factors. Even if a successful mandatory program could be imposed during pregnancy, diverting resources away from VCT programs may increase risky behavior after pregnancy. When choosing between a compulsory and a voluntary program, policymakers should heavily favor the program that provides the most personal choice and bodily integrity for women. Those who advocate forced testing and treatment have the burden of proving why the benefits of their proposals will outweigh the inevitable costs. They cannot simply assert that their proposal will save lives; they must provide details of how a compulsory program would be structured and address the very real implementation problems that such a program is likely to face. In short, a much fuller discussion is still needed.

Reaching disenfranchised youth and mobile populations in Ghana through voluntary counselling and testing services for HIV

This paper documents the evaluation of a 20-month project to provide voluntary counselling and testing (VCT) to a mobile population of youth surrounding the Agbogbloshie market in Accra, Ghana. The specific objectives of the evaluation were to determine: 1) to what extent targets for providing VCT services to the specified population were reached; 2) how HIV prevalence among clients compared to that of the general population; 3) to what extent former clients self-reported behaviour change; and 4) whether useful lessons could be drawn regarding fees, hours, and location of services, as well as use of peer educators to increase use of VCT services among the target population. Various methodologies, including questionnaires, focus group discussions, a review of the service statistics and an exit poll of clients were used to evaluate the project. The service statistics demonstrated that the project exceeded the life-of-project target for number of clients by nearly 40%. Prevalence for the VCT client population (aged 15–25) was higher than for the general population (aged 15–24), although the gender differentials were similar. Focus group data suggested that clients may have adopted behaviour changes as a result of VCT. Finally, focus group discussions and VCT service trends showed that the high number of clients was largely influenced by three factors: services being free, location and hours of services being convenient to the target population, and use of peer educators to promote the services. In addition, the evaluation highlighted the importance of the counselling component of VCT, even as counselling can get short-changed at the expense of HIV testing when large numbers of clients are involved. The evaluation stressed the need to appropriately remunerate peer educators for their work whenever possible. Finally, VCT programmes continue to face challenges such as: HIV stigma as a barrier to people coming to be counselled and tested; insufficient availability of medication, support and services for HIVpositive clients; and difficulty of ensuring the sustainability of VCT programmes.

A Social Cost-Benefit Criterion for Evaluating Voluntary Counseling and Testing with an Application to Tanzania

Rationale: There are many interventions for HIV/AIDS that require that people know their status and hence require a HIV test. Testing that is motivated by a desire to receive treatment need not directly affect others. However, testing that is driven by a desire to prevent the spread of the disease often has an indirect effect on others, whether they be sex partners, babies of infected mothers or recipients of blood transfusions. These external effects need to be identified, quantified and included as part of the benefits and costs of testing. Pioneering analyses of HIV testing by Philipson and Posner have introduced the economic calculus of individual expected benefits and costs of activities into an understanding of the HIV epidemic. What is required for social evaluations is an extension of the analysis to ensure that external effects are included. Objectives: The objective of this paper is two-fold. First we seek to formulate cost-benefit criteria that incorporate fully the external effects in the evaluation of Voluntary Counseling and Testing (VCT). We achieve this by recasting the individual calculus of benefits and costs to a couples setting. We can then compare an individual's cost-benefit analysis of being tested with social criteria that look at outcomes from a couple's perspective for both separate and dual / joint testing. Second we aim to apply our social criteria to VCT programs as they currently operate in Tanzania and how these programs might operate in the future when they are scaled-up to relate to the general population. Methodology: We develop social criteria for evaluating separate and dual VCT using a couples' perspective. So the welfare function is based on two individual expected utility functions viewed as a couple, either married or regular partners. The benefits are the averted lives lost whenever discordant couples are revealed. The costs of VCT are the benefits of unprotected sex that the couple foregoes and the costs of the testing and counseling. The cost-benefit criteria are applied to VCT programs in Tanzania. The four main ingredients estimated are: the foregone benefit of unprotected sex (measured by the compensated wage differentials charged by commercial sex workers); the probability of infection; the cost of an infection (measured by both the value of a statistical life and the human capital approaches) and the cost of a single test. Conclusions: We find separate testing in existing VCT programs only marginally worthwhile. However, in scaled-up programs (where the probability of infection is related to the general population and not just the current sample of persons in the VCT program) the benefit-cost ratio is over three. Dual testing is always more beneficial than separate testing. However, this advantage is reduced in scaled-up programs. So the policy conclusion that follows from our application of cost-benefit analysis to VCT in Tanzania is that although the existing program is marginally worthwhile, VCT should be greatly expanded throughout Tanzania as future returns would be even higher for both separate and joint counseling and HIV testing.

HIV Voluntary Counseling and Testing among Injection Drug Users in South China: A Study of a Non-Government Organization Based Program

HIV voluntary counseling and testing (VCT) programs are usually delivered by government health agencies in China. This study examined the feasibility of using a Chinese non-government organization (NGO) to deliver a VCT program to injection drug users (IDUs) in a southern Chinese city. The process data indicated the program successfully recruited and served 226 male and female IDUs in 4 months. The HIV prevalence rate of the study population was 57.5% by rapid HIV testing with a secondary rapid test to confirm. Quantitative and qualitative evaluations indicated that the VCT program was implemented appropriately and participants' HIV knowledge and safe drug and sex practices were significantly improved after participation in the VCT program. This study demonstrates the feasibility of a Chinese NGO to provide VCT for IDUs and documents the processes and outcomes of the program. There remains a great need to find additional sources to provide VCT and other HIV prevention services to IDUs and other high-risk populations in China. Chinese NGOs have the potential to fill this need.

Short-Term Effect of a Cultural Adaptation of Voluntary Counseling and Testing Among Female Sex Workers In China: A Quasi-Experimental Trial

This study evaluates the efficacy of cultural adaptation of a voluntary counseling and testing (VCT) intervention, in increasing condom use and decreasing rates of sexually transmitted diseases (STDs) among a group of female sex workers (FSWs) in Guangxi, China. This intervention is modeled after the "state-of-the-science" VCT program that was developed and evaluated by the Center for Disease Control and Prevention's Project RESPECT. Four hundred FSWs were assigned to either an intervention group receiving the VCT intervention or a control group receiving standard of care STD testing and treatment. Data were collected at baseline and 6 months postintervention. Outcome measures included HIV/STD related knowledge and perceptions, condom use, and history of STDs. Five common STDs were screened and tested through clinical examination and laboratory testing to serve as biomarkers. After controlling for potential confounders and baseline differences, the VCT intervention group was significantly higher than the control group in HIV/STD related knowledge (p < .0001) and consistent condom use with clients (odds ration [OR] = 2.23; 95% confidence interval [CI] = 1.26-3.96) at 6 months follow-up. In addition, the intervention group had a significantly lower infection rate of STDs than the control group at follow-up (OR = 0.44; 95% CI = 0.24-0.80). This quasi-experimental trial provides evidence that the brief VCT intervention, through appropriate cultural adaptation, can be efficacious in increasing condom use and reducing STD infection rate among FSWs in China.

Immunisation coverage among children born to HIV-infected women in Rakai district, Uganda: effect of voluntary testing and counselling (VCT)1

To evaluate the impact of maternal HIV-infection on routine childhood Immunisation coverage, we compared the Immunisation status of children born to HIV-infected and HIV-uninfected women in rural Uganda. The study population was 214 HIV(+) and 578 HIV(−) women with children aged 6 to 35 months previously enrolled in a community study to evaluate maternal and child health in Rakai District, Uganda. Sampling of subjects for interview was stratified by the use of voluntary counselling and testing (VCT) service so that the final sample was four groups: HIV + /VCT+ (n = 98); HIV + /VCT− (n = 116); HIV − /VCT+ (n= 348); HIV − /VCT− (n = 230). The main outcome measure was the percent of complete routine childhood Immunisations recommended by the WHO as assessed from Immunisation cards or maternal recall during household interviews. We found that Immunisation coverage in the overall sample was 26.1%. For all vaccines, children born to HIV-infected mothers had lower Immunisation coverage than children born to HIV-negative mothers (21.3 vs. 27.7%). There was a statistically significant interaction between maternal HIV-infection and maternal knowledge of HIV-infection (p = 0.034). The children of mothers who were HIV-infected and knew their serostatus (HIV + /VCT + ) had a more than two-fold odds of underImmunisation (OR = 2.21, 95% CI: 1.14, 4.29) compared to children of mothers who were HIV − /VCT−. We conclude that maternal HIV-infection was associated with childhood underImmunisation and this was mediated by a mother's knowledge of her HIV status. HIV VCT programmes should encourage HIV-infected mothers to complete childhood Immunisation. Improving access to Immunisation services could benefit vulnerable populations such as children born to HIV-infected mothers.

Social marketing as a means of raising community awareness of an HIV voluntary counselling and testing site in Soweto, South Africa

In order for HIV voluntary counselling and testing (VCT) to be successful, the approval of and attendance at the VCT centre by the community it serves is necessary. To this end, the Township AIDS Project (TAP), which has VCT sites serving the greater Soweto area, attempts to maintain a high degree of visibility in the community through campaigning and various forms of advertising. To determine whether the social marketing strategies employed by the organisation encouraged attendance, pre-test questionnaires completed by volunteers attending the TAP VCT site located in the Meadowlands district of Soweto were retrospectively analysed. During 2003, approximately 34% of volunteers were made aware of the VCT site through marketing. However, a more important factor in volunteer awareness was word of mouth, with about 46% of volunteers informed of TAP VCT by a friend, partner or relative. This attests to the success of the marketing strategies employed by the TAP organisation in raising community awareness and attendance at the VCT site investigated in this study. In total, 1 141 volunteers completed a questionnaire and 1 054 of these consented to being tested for HIV antibodies. The level of infection among the sample of individuals tested at this clinic-based VCT programme was 29.9%.

Using HIV voluntary counseling and testing data for monitoring the Uganda HIV epidemic, 1992-2000.

To assess trends in the prevalence of HIV infection among voluntary counseling and testing (VCT) clients in Uganda and to describe the utility of VCT data for monitoring the HIV epidemic in 1992-2000. We analyzed routinely collected data from first-time VCT clients not reporting illness as a reason for testing. We developed a model adjusting for test site, couple testing, and premarital testing, assessed trends in adjusted prevalence of HIV infection and shifts in age-specific peak prevalence, and compared antenatal clinic (ANC) surveillance data and VCT prevalence trends. Among 201,741 clients, adjusted prevalence of HIV infection declined from 23% in 1992 to 13% in 2000 (P < 0.001) (men, 17%-9% [P < 0.001]; women, 31%-18% [P < 0.001]). The prevalence declined for all age groups except men older than 39 years and women older than 34 years. The prevalence increased for women older than 39 years (P < 0.003). Between 1992 and 2000, peak prevalence declined for both men (31% to 24%) and women (44% to 41%), whereas the age at which the peak occurred increased for both men (36 to 41 years) and women (31 to 36 years). VCT and ANC prevalence trends were similar. In Uganda, the prevalence of HIV infection among male and female VCT clients declined from 1992 to 2000, similar to ANC surveillance data, but did not decline in older age groups. In regions with well-established VCT programs, VCT data may provide a useful and convenient tool for monitoring the HIV epidemic.

Antenatal voluntary counseling and testing for HIV in Barbados. Success and barriers to implementation.

To determine the success of voluntary counseling and testing (VCT) for HIV and to identify the barriers to implementation when VCT is offered as a package integrated with antenatal care. In this descriptive study we investigated antenatal VCT and HIV testing in all post-parturient women at the Queen Elizabeth Hospital, Bridgetown, Barbados, who gave birth between April and September 2002. Data were collected retrospectively from the antenatal care record and by recall during one-on-one interview. Of 1 342 women surveyed, 954 (71.1%) received antenatal counseling and were offered an HIV test. Of the 954 women offered HIV test after counseling, 914 (95.8%) agreed to have the test. Among the women surveyed, 1 106 (82.4%) had a documented HIV test, 914 (85.7%) were tested after documented pretest counseling, and another 192 (14.3%) were tested without documented pretest counseling. Overall, 822 of the 1 342 women surveyed (61.2%) had a documented HIV test result in their antenatal case record at the time of delivery. Of the 1 106 women who had a documented HIV test, the test results were unavailable at the time of delivery in only 284 (21.2%). Among the reasons for unavailability of a documented HIV test result, the most common (45.0%) was that no test was done, followed by unclear documentation of the result. Twenty-nine percent of surveyed women failed to receive antenatal VCT and this is a cause of concern, for both the high coverage and good quality counseling are key to the overall success and cost effectiveness of the VCT program. Fourteen percent of the women surveyed who did not receive VCT were tested for HIV, a situation that is undesirable because some women may be tested without understanding the full implication of this policy, and as a result the overall impact of VCT may be reduced.

“What is the Point of Knowing?”: Psychosocial Barriers to HIV/AIDS Voluntary Counselling and Testing Programmes in South Africa

Voluntary Counselling and Testing (VCT) programmes are regarded as an important strategy in the management of the HIV/AIDS pandemic worldwide. Such programmes, however, often have limited success due to various problems such as the existence of attitudes and beliefs that act as psychosocial barriers. This article, which presents a study of attitudes towards VCT in South Africa, attempts to ascertain the reasons for people's continued resistance to VCT programmes. A semi-structured questionnaire was used to survey the views of 1422 people. The results indicate that while the research participants, in principle, were not opposed to VCT, they professed a deep mistrust of health-care professionals, and feared discrimination and rejection by the latter, their sexual partners, and their communities. Participants did not know how to disclose their HIV-positive status, and were concerned about testing that did not include treatment and/or follow-up support, as well as their ability to deal with the ensuing psychological turmoil in the event of testing HIV-positive. The authors proposed various suggestions concerning how to improve VCT services in South Africa.

Women's barriers to HIV-1 testing and disclosure: Challenges for HIV-1 voluntary counselling and testing

In view of the ever-increasing HIV/AIDS epidemic in sub-Saharan Africa, the expansion of HIV-1 voluntary counselling and testing (VCT) as an integral part of prevention strategies and medical research is both a reality and an urgent need. As the availability of HIV-1 VCT grows two limitations need to be addressed, namely: low rates of HIV-1 serostatus disclosure to sexual partners and negative outcomes of serostatus disclosure. Results from a study among men, women and couples at an HIV-1 VCT clinic in Dar es Salaam, Tanzania are presented. The individual, relational and environmental factors that influence the decision to test for HIV-1 and to share test results with partners are described. The most salient barriers to HIV-1 testing and serostatus disclosure described by women include fear of partners' reaction, decision-making and communication patterns between partners, and partners' attitudes towards HIV-1 testing. Perception of personal risk for HIV-1 is the major factor driving women to overcome barriers to HIV-1 testing. The implications of findings for the promotion of HIV-1 VCT programmes, the implementation of partner notification policies and the development of post-test support services are discussed.

Voluntary counseling, testing, and referral for HIV: new technologies, research findings create dynamic opportunities.

Programs for voluntary counseling and testing (VCT) for HIV play an increasingly important role in comprehensive prevention and care strategies. New technological advancements and behavioral interventions can improve the effectiveness of VCT as a tool for preventing new HIV infections and helping HIV-positive individuals access appropriate care. With growing consensus that early access to HIV therapy increases its effectiveness, and that individuals diagnosed with HIV reduce risk behavior, VCT has become integral to the continuum of HIV primary care. However, federal funding of VCT has declined, with concomitant decreases in numbers of people being tested. An estimated 200,000 people in the United States remain unaware that they are HIV positive, and many at-risk individuals do not seek out standard HIV counseling and testing services. To increase the acceptability and effectiveness of VCT, the authors recommend that VCT programs employ outreach programs offering anonymous testing to reach those at heightened risk of HIV infection, and to make rapid use of new technologies and counseling strategies to improve the reach and efficacy. Given the important role that VCT can play in both prevention and early treatment, the authors recommend significant increases in federal support.