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Biomedical Interventions: HIV Testing and Counseling as Prevention
I. Definition of the Prevention Area
As a stand-alone intervention, HIV testing and counseling (HTC) contributes to prevention of HIV transmission by identifying and informing individuals, partners and couples, and families of their HIV status and counseling them to develop appropriate sexual, injection, or other risk-reduction measures. These measures differ according to the serostatus of the individual or of couples, be they seroconcordant (both partners test either HIV-positive or HIV-negative) or serodiscordant (one partner tests HIV-positive and the other tests HIV-negative).
HTC is also a prerequisite to accessing such services as antiretroviral therapy, prevention of mother-to-child transmission, and voluntary medical male circumcision. Successful linkages to clinical and community-based prevention, care and support, and treatment services are important for any effective HTC program.
II. Epidemiological Justification for the Prevention Area
The evidence on whether HTC directly affects HIV incidence is mixed. However, studies show that HTC may have the greatest effect on sexual transmission of HIV for two population groups in particular: adult individuals who test HIV-positive and serodiscordant couples. In addition, some studies show a reduction in sexual risk behaviors for HIV-negative concordant partners who are tested together using couples HTC. Other studies suggest reductions in risk behaviors after HTC (e.g., reduction of unprotected sex or in number of sexual partners).
Studies on HTC among people who inject drugs are usually conducted in the context of other services—such as detoxification or drug treatment centers, and needle and syringe exchange—and reveal mixed results. Findings suggest that safer injection practices following HTC may occur when HTC is available in the context of other harm reduction services. Serosorting, when HIV-positive persons seek sexual partners who are HIV-positive, is another demonstrated behavior following HIV testing. The literature is strongest among men who have sex with men, but recent discussions suggest that individuals in generalized epidemics may also use this strategy.
III. Core Programmatic Components
HTC is available through a wide variety of delivery models. HTC can be accessed through providers or can be initiated by clients. Provider-initiated HTC uses “opt-out” testing, which is when all adults and adolescents (with or without symptoms) are tested for HIV as part of their overall health care unless the patient declines. Informed consent is stressed for this method. Client-initiated HTC is when an individual wants to get tested and searches for the best HTC center for him or her. This could include a stand-alone voluntary counseling and testing site, provider-initiated HTC site, or a community-based HTC site such as a mobile or workplace HTC.
HTC should be specific to the type of epidemic, population, and level of risk. In concentrated epidemics, offering HTC at specific sites, such as outreach centers or mobile facilities, may be the most effective way to reach hard-to-reach populations. The World Health Organization (WHO) states that provider-initiated HTC should be considered for sexually transmitted infection and tuberculosis clinics, for services for most-at-risk populations, and for childbirth, antenatal care, and postpartum services for concentrated and low-level epidemics. In generalized epidemics, WHO recommends providing provider-initiated HTC at all clinical settings, including services for sexually transmitted infections, tuberculosis, and antenatal care, as well as in- and outpatient services. Offering stand-alone, mobile, and home-based testing for harder-to-reach populations—such as rural or higher-risk groups—in generalized epidemics has also demonstrated increased uptake of HTC. For mixed epidemics, HTC programming can use a range of these options based on the epidemiological and social context of the country.
HTC minimum standards follow international guidance and include pre- and post-test counseling or information as well as referral and linkage to HIV prevention, care, support, and treatment services. The type of test (e.g., rapid testing with same-day results) also affects how successful HTC is in delivering high-quality test results and services. WHO guidelines recommend that post-test counseling be provided regardless of test result and should include an explanation of the test result, advice on risk reduction, and the provision of condoms and referrals. For those testing HIV-positive, counseling should also include emotional support, discussion of the patient’s safe disclosure to others of his or her HIV status, and referral of the patient’s partners and children for testing
IV. Current Status of Implementation Experience
To resolve questions about the impact of community- versus clinic-based HTC on the behavior of HIV-negative individuals, the U.S. National Institute of Mental Health sponsored Project Accept, the first randomized controlled study to determine whether behavioral changes encouraged by HTC reduce HIV incidence. The study was conducted in 14 communities in Thailand and 34 communities in sub-Saharan Africa. Each community was randomized to receive both community- and clinic-based HTC or clinic-based HTC alone. The study ended in 2011. Incidence data are not yet available, but interim results show that uptake of first-time testers is greater in the community- and clinic-based HTC sites compared to clinic-based HTC alone. WHO is also coordinating the MATCH Study, a multi-country, mixed-methods study of HTC models evaluating a range of variables, including service quality, uptake, health behavior, and equity. In 2011, data collection was ongoing in four countries: Burkina Faso, Kenya, Malawi, and Uganda.
Changes in Sexual Risk Behavior Before and After HIV Seroconversion in Southern African Women Enrolled in a HIV Prevention Trial
Venkatesh, K. K., de Bruyn, G., Mayer, K. H., et al. Journal of Acquired Immune Deficiency Syndromes (2011), Vol. 57 No. 5, pp. 435-441.
The Correlates of HIV Testing and Impacts on Sexual Behavior: Evidence From a Life History Study of Young People in Kisumu, Kenya
Kabiru, C. W., Luke, N., Izugbara, C. O., et al. BioMed Central Public Health (2010), Vol. 10, p. 412.
This study used data from 600 young people aged 18 to 24 years collected using a 10-year, retrospective life history calendar. It found that 64 percent of females and 55 percent of males had tested for HIV at least once in the previous decade, and that 40 percent of the females were pregnant in the month of their first test. Among women who had ever been pregnant, a recent HIV test was associated with lower odds of unprotected sex, whereas among those who had never been pregnant, it was associated with higher odds of risky and unprotected sex. Among males, a recent HIV test was associated with increased likelihood of concurrent sexual partners. However, repeated HIV tests were associated with lower likelihood of concurrent partners or risky sex six months later. The authors conclude that while HIV testing and counseling (HTC) may not have any immediate impact on behavior, repeated HTC over the long-term may increase the adoption of safer sex practices. A primary weakness of the study was that authors did not know the HIV status of the respondents, which could have shed additional light on the sexual and HTC practices among these youth.
Behavioural Interventions for HIV Positive Prevention in Developing Countries: A Systematic Review and Meta-Analysis
Kennedy, C. E., Medley, A. M., Sweat, M. D., et al. Bulletin of the World Health Organization (2010), Vol. 88 No. 8, pp. 615-623.
This systematic review and meta-analysis of 19 studies assessed whether positive prevention programs in developing countries are effective and looked at the ways in which such programs differ from those targeted at HIV-negative individuals. Nearly all the studies reviewed were conducted in sub-Saharan Africa and examined HIV testing and counseling interventions, including HIV-positive and HIV-negative individuals and serodiscordant couples. Four pooled studies including over 4,000 participants found that condom use increased among HIV-positive individuals, but no change was evident among HIV-negative people. Among interventions targeting HIV-positive people, seven combined studies of 1,800 people found a strong and significant effect on condom use, with the greatest effect on serodiscordant couples. The researchers concluded that positive prevention indeed impacts HIV risk behavior, particularly in serodiscordant couples. Study limitations included few randomized trials, primarily self-reported outcomes, and studies that were generally not very rigorous. Furthermore, all but one study only included heterosexual couples, thus neglecting many important high-risk populations.
Initial Outcomes of Provider-Initiated Routine HIV Testing and Counseling During Outpatient Care at a Rural Ugandan Hospital: Risky Sexual Behavior, Partner HIV Testing, Disclosure, and HIV Care Seeking
Kiene, S. M., Bateganya, M., Wanyenze, R., et al. AIDS Patient Care and STDs (2010), Vol. 24 No. 2, pp. 117-136.
This study assessed behavioral outcomes after provider-initiated, routine HIV testing and counseling (HTC) while people were seeking care in an outpatient center of a rural hospital. The 245 participants underwent routine HTC and were followed up after three months, when they completed an interview about their sexual behavior since they were tested. Regardless of their own HIV status, at follow-up participants were significantly more likely to know their partners’ HIV status than at baseline, but still only a third knew their partners’ HIV status. Married or cohabitating individuals were more likely to find out their partners’ HIV status, but women were two times less likely than men to know their partner’s status after HTC. While HTC had an effect on risky and safe sexual behaviors among certain groups in this study, it was not statistically significant and reached only 4 percent across all study participants, with half of all participants still engaging in risky sex. The authors conclude that provider-initiated HTC has the potential to increase testing, especially among first-time testers. This study only followed participants for six months, limiting the degree to which the findings can be generalized.
Unprotected Sex Following HIV Testing Among Women in Uganda and Zimbabwe: Short- and Long-Term Comparisons with Pre-Test Behavior
Turner, A. N., Miller, W. C., Padian, N. S., et al. International Journal of Epidemiology (2009), Vol. 38, No. 4, pp. 997-1007.
This article presents the long-term findings from a prospective study of the pre- and post-test sexual behavior of 801 participants, of whom 151 were infected with HIV. It found that among women in this subgroup, the percentage who reported any unprotected sex in the previous month dropped from approximately three-quarters before they were diagnosed to just over half 12 to 16 months after diagnosis. This change occurred due to a reduction in overall frequency of sexual intercourse and also an increase in condom use. However, uninfected women did not report a change in their behavior pre- and post-test. One of the report’s strengths is that its results are more generalizable to African women compared to previous research, which has focused on high-risk populations. However, the self-reported nature of the data means that it may be subject to bias.
Serosorting and the Evaluation of HIV Testing and Counseling for HIV Prevention in Generalized Epidemics
Reniers, G., & Helleringer, S. AIDS and Behavior (2010), Vol. 15 No. 1, pp 1-8.
This paper argues that serosorting, whereby people select their sexual partners so that that they share the same HIV status, should be included in evaluation studies on the impact of HIV testing and counseling (HTC). Serosorting as a HIV prevention strategy is typically associated with men who have sex with men, and sexual behavior surveys are not designed to detect this activity in generalized epidemics. The omission of this information so far has undermined the findings of HTC evaluations for two reasons, the authors state. First, it creates a bias by omitting a significant variable, as seroconcordant couples may not take precautionary measures. Second, concentrating on the impact of HTC on individual behavior ignores the potential benefits at the level of sexual networks and populations. Including serosorting in evaluations could overcome this limitation. If serosorting was included in the evaluation process, the impact of HTC interventions on behavioral change could be more accurate, the authors conclude.
HIV Voluntary Counseling and Testing and Behavioral Risk Reduction in Developing Countries: A Meta-Analysis, 1990-2005
Denison, J. A., O’Reilly, K. R., Schmid, G. P., et al. AIDS and Behavior (2008), Vol. 12 No. 3, pp. 363-373.
This paper reviewed the evidence for HIV testing and counseling (HTC) as prevention in developing countries/emerging economies between 1990 and 2005. Seven studies met the inclusion criteria for the meta-analysis. HTC had no effect on the number of sex partners among three pooled studies, but a statistically significant modest reduction in unprotected sex among seven pooled studies. Most of the people adopting condom use were HIV-positive individuals and serodiscordant couples. These studies all had a year or less of follow-up, took place before antiretroviral therapy became widely available, and were not very rigorously designed. The authors conclude that their analysis provides moderate evidence for HTC as an intervention strategy. However, there was no evidence that HTC caused an increase in risky behaviors.
Behaviour Change in Clients of Health Center-Based Voluntary HIV Counseling and Testing Services in Kenya
Arthur, G., Nduba, V., Forsythe, S., et al. Sexually Transmitted Infections (2007), Vol. 83 No. 7, pp. 541-546.
This study assessed integrating HIV testing and counseling (HTC) into two rural and one urban government primary health care centers in Kenya. Among 401 adults successfully followed up, there was a significant decrease in sexual partners among those who had two or more sex partners six months after the study. While unprotected sex with any partner decreased significantly from baseline, rates remained high at 89 percent. Although the mean number of sexual encounters remained the same for primary and nonprimary partners alike, there was a trend for increased condom use with nonprimary partners at follow-up. Like all studies using self-reported behavior, there is potential for misreporting, and this study would have been stronger had it used biological endpoints. Furthermore, people who obtain HTC may be different from the general population, limiting the generalizability of the findings. The authors conclude that HTC can be a valuable component in HIV prevention efforts in primary health care health centers.
HIV Incidence During a Cluster-Randomized Trial of Two Strategies Providing Voluntary Counseling and Testing at the Workplace, Zimbabwe
Corbett, E. L., Makamure, B., Chueng, Y. B., et al. AIDS (2007), Vol. 21 No. 4, pp. 483-489.
This analysis compared HIV infection rates among employees in 22 Zimbabwean businesses randomized to intensive HIV testing and counseling (HTC) or standard HTC. Among nearly 3,000 participants initially testing negative, 71 percent underwent HTC in the intervention arm compared to only 5 percent being tested in the standard arm. Despite this significant difference, HIV incidence remained the same in both arms after about 5,000 person-years of follow-up. Limitations of this study that must be considered include virtually all male participants, no couples counseling, and the inability to assess whether HIV-positive individuals transmitted HIV to others. Because this was only the second randomized controlled trial on this subject at publication, the authors concluded that more data are needed to understand the impact of a negative HIV test result on risk behavior so that HTC programs can maximize benefits while minimizing the potential for harm.
Voluntary Counseling and Testing: Uptake, Impact on Sexual Behaviour, and HIV Incidence in a Rural Zimbabwean Cohort
Sherr, L., Lopman, B., Kakowa, M., et al. AIDS (2007), Vol. 21 No. 7, pp. 851-860.
This study assessed HIV testing and counseling acceptance and its impact on the sexual behavior of rural Zimbabweans. Baseline and follow-up data were collected for nearly 6,000 participants who reported having an HIV test two or three years prior to being interviewed. Women who received a positive HIV test reported a significant reduction in risky behaviors, including fewer partners and more condom use than at baseline. Participants with a negative result were significantly more likely to have a partner in the last month, multiple concurrent partners, and a greater total number of partners than they did in the previous year. Despite these self-reported changes in behavior, HIV incidence was the same among all groups. The authors hypothesize that a negative HIV test result may have the unintended consequence of being interpreted as permission for future risky behavior. However, the study is considered to be highly controversial because most of the findings were not statistically significant. Moreover, it is not clear from the paper whether or not partner reduction was a critical message in the counseling process, conducted between 1998 and 2000. To date, the evidence of risk compensation as a result of HIV testing and counseling is inconclusive.
Condom Use After Voluntary Counseling and Testing in Central Mozambique
Mola, O. D., Mercer, M. A., Asghar, K. H., et al. Tropical Medicine & International Health (2006), Vol. 11 No. 2, pp. 176-181.
This longitudinal cohort study of 1,220 men and women looked at whether HIV testing and counseling (HTC) had an impact on risky sexual behavior by comparing responses from those who underwent HTC and those who did not. Participants were asked about condom use in both paid and unpaid sexual encounters. Both groups reported increased condom use at four months versus baseline, and the HTC group reported further increases from four to six months. HIV-positive participants reported a greater increase in condom use. However, those in the non-HTC group only reported an increase from baseline to four months. Moreover, whereas both men and women in the HTC group reported more condom use, only men did so in the non-HTC group. The study was subject to several limitations—sample size was small when the data were broken down by gender, site, or HIV status, for example, and the HTC group was self-selected, making it subject to bias.
Risk Reduction Counseling is Associated with Decreased HIV Transmission-associated Behaviors in High-risk Indian Heterosexuals
Solomon, S. S., Solomon, S., Masse, B. R., et al. Journal of Acquired Immune Deficiency Syndromes (2006), Vol. 42 No. 4, pp. 478-483.
This prospective cohort study conducted in Chennai, India, looked at the effect of risk-reduction counseling on HIV incidence among 500 men and women at high risk of HIV infection. The criteria for being at high risk of HIV were five or more sexual partners in the past six months, history of sexually transmitted infections and/or sexual intercourse once a week with a HIV-positive partner of the opposite sex. The participants received risk-reduction counseling at baseline and again at 6 and 12 months. Both men and women reported reduction in the number of sexual partners and fewer sexual encounters with primary partners. Those with multiple partners and those who engaged in paid sex reported the greatest reductions. The authors conclude that such counseling is a useful tool for reducing risky sexual behavior, but they concede that other factors (timely management of sexually transmitted infections, free condoms, regression to the mean) may have been responsible for the change.
Antenatal Couple Counseling Increases Uptake of Interventions to Prevent HIV-1 Transmission
Farquhar, C., Kiarie, J. N., Richardson, B. A., et al. Journal of Acquired Immune Deficiency Syndromes (2004), Vol. 37 No. 5, pp. 1620-1626.
This study sought to assess the impact of involving partners in antenatal HIV testing and counseling (HTC) to see if this could overcome the reluctance of women who test HIV-positive to inform their partners and lead to increased uptake of perinatal interventions and condom use. The researchers offered women seeking antenatal care in a Nairobi, Kenya clinic information about HIV transmission and encouraged them to inform their partners about HTC. They were invited to return for HTC and other routine antenatal tests with or without their partner. Between 2001 and 2002, about 300 women and their partners went to the clinic for HTC. Although the majority chose individual counseling over couples counseling for their post-test results (62 percent vs. 38 percent), there were benefits to involving men either way: maternal nevirapine uptake, compliance with the nevirapine regimen, and avoiding breastfeeding were highest among those attending couples HTC, and rates were higher for those attending individual HTC than those whose partners did not come in for HTC. Furthermore, couples counseling was associated with a six-fold increase in condom use among HIV-positive women. Male uptake of HTC was poor in this study population, however, with less than one in seven partners coming in for testing.
Effect of an HIV Counseling and Testing Program on AIDS-Related Knowledge and Practices in Tuberculosis Clinics in Abidjan, Cote d’Ivoire
Wiktor, S. Z., Abouya, L., Angoran, H., et al. International Journal of Tuberculosis and Lung Disease (2004), Vol. 8 No. 4, pp. 445-450.
This study looked at the impact of HIV testing and counseling (HTC) on knowledge of HIV and sexual practices in a cohort of tuberculosis patients in Abidjan, Côte d’Ivoire. After HTC, a significantly higher proportion of participants correctly identified modes of HIV transmission and prevention, and these improvements were sustained after four months. Reported consistent condom use during unpaid sex more than doubled to 24 percent among men, but there was no such change among women. HTC in the setting of a tuberculosis clinic was well accepted, the authors note. They recommend that similar programs should maximize the benefits by targeting subgroups with the lowest knowledge of HIV. The study findings were undermined by loss to follow-up, which was very high, perhaps due to lack of HIV counseling training for tuberculosis clinic staff.
Sexual Behavior of HIV Discordant Couples After HIV Counseling and Testing
Allen, S., Meinzen-Derr, J., Kautzman, M., et al. AIDS (2003), Vol. 17 No. 5, pp. 733-740.
This study of 963 HIV-discordant heterosexual couples in Lusaka, Zambia, looked at the effect of HIV counseling and testing on sexual behavior. The participants self-reported condom use and underwent clinical tests for sperm detected on vaginal smears, pregnancy, and four sexually transmitted infections (HIV, gonorrhea, syphilis, and Trichomonas vaginalis). Prior to HIV counseling and testing, less than 3 percent of couples reported using condoms, whereas the number exceeded 80 percent after. Those who reported 100 percent condom use had reductions in biological markers ranging from 39 to 70 percent. The markers were able to detect under-reporting (e.g., sperm, pregnancies, and HIV transmissions were all detected among couples who reported consistent condom use). DNA sequencing showed that almost 90 percent of new infections were acquired from the spouse. The study shows that biological markers can help identify under-reporting, the authors conclude, and they urge more work on strategies to encourage participants in future studies to honestly report their behavior.
Efficacy of Voluntary HIV-1 Counseling and Testing in Individuals and Couples in Kenya, Tanzania, and Trinidad: A Randomized Trial
The Voluntary HIV-1 Counseling and Testing Efficacy Study Group. The Lancet (2000), Vol. 356 No. 9224, pp. 103-112.
To understand sexual risk behavior following HIV testing and counseling (HTC), over 3,000 individuals and nearly 600 couples in the capitals of Kenya, Tanzania, and Trinidad were randomized to HTC or information about HIV and condoms. At follow-up, approximately 7 and 14 months after baseline, couples and individuals in the HTC arm were both significantly less likely to have unprotected sex with nonprimary partners and less unprotected sex. Among HIV-negative participants, the proportion having unprotected sex fell by roughly a third for women and by a fifth for men, while among participants who were HIV-positive or who had HIV-positive partners, the reductions in unprotected sex were far more dramatic. Participants in the health information group who received HTC at first follow-up and were diagnosed as HIV-positive showed similarly reduced rates of unprotected sex at second follow-up. The authors conclude that HTC indeed helps motivate people to adopt protective behaviors and should be a standard component of HIV prevention strategies in developing countries.
Brief Cognitive Counseling with HIV Testing to Reduce Sexual Risk Among Men Who Have Sex with Men: Results from a Randomized Controlled Trial Using Paraprofessional Counselors
Dilley, J. W., Woods, W. J., Loeb, L., et al. Journal of Acquired Immune Deficiency Syndromes (2007), Vol. 44 No. 5, pp. 569-577.
Personalized cognitive counseling (PCC) targets the thoughts, attitudes, and beliefs that people employ when engaging in high-risk behaviors. This study of men who have sex with men attending publicly funded HIV testing and counseling sites in San Francisco assessed whether a single session of PCC was more effective than standard counseling in reducing unprotected anal intercourse among nonconcordant and nonprimary male partners. Men in the PCC arm reported statistically significant fewer episodes of high-risk sex at six months compared to baseline, with no change in the control group at this time. The PCC arm participants reported the same number of high-risk episodes at 12 months as they did at 6 months. Those in the control arm, however, reported a statistically significant decrease in high-risk sex acts from baseline. While the effectiveness of PCC needs to be validated among other populations, the authors posit that perhaps the emphasis of a specific, recent high-risk exposure was seen as more personally relevant. This may have offered participants the opportunity to understand something new about their decision making, prompting them to take action.
Sexual Risk Reduction in a Cohort of Injecting Drug Users in Bangkok, Thailand
Vanichseni, S., Des Jarlais, D. C., Choopanya, K., et al. Journal of Acquired Immune Deficiency Syndromes (2004), Vol. 37 No.1, pp. 1170-1179.
This study looked at whether the modest gains usually associated with interventions to reduce sexual risk taking among people who inject drugs were better over a longer timeframe. The study cohort comprised 800 HIV-negative people who inject drugs who were offered HIV testing and counseling and free condoms at regular intervals four times over a 16-month period. At each session, the participants self-reported their sexual behavior. There was no change in the proportion of participants—4 out of 10—who reported engaging in vaginal unprotected sex. However, participants who were identified as HIV-positive during the course of the study did report substantial increases in condom use with regular partners. There was an association between unprotected sex with casual partners and amphetamine use. The study shows that even over a longer timeframe, HIV testing and counseling does not reduce sexual risk taking among people who inject drugs, pointing to an urgent need for more effective interventions, the authors conclude.
Interventions with Injection Drug Users in Ukraine
Booth, R. E., Lehman, W. E., Dvoryak, S., et al. Addiction (2009), Vol. 104 No. 11, pp. 1864-1873.
This study of 1,800 people who inject drugs in Ukraine compared two models of HIV prevention: a standardized counseling and education intervention alone, or the intervention combined with individual outreach by former drug users. Both groups were interviewed using audio computer-administered self-interview to obtain information on demographics, health profile, use of drugs, and risk behaviors related to injection and sex. The participants were followed up after six months with a 90 percent recall rate. In both groups, there were significant reductions in needle and sexual risk behaviors, but younger people who inject drugs and those with a shorter history of injection drug use were more likely to engage in risky practices. While the findings were discouraging because they point to further escalation of the HIV epidemic among people who inject drugs in Ukraine, they were encouraging too because they proved that it is possible to implement community-based interventions in this setting.
Associations between Mode of HIV Testing and Consent, Confidentiality, and Referral: A Comparative Analysis in Four African Countries
Obermeyer, C.M., Neuman, M., Desclaux, A., et al. n.d. PLoS Medicine Vol. 9 No. 10.
The study sought to examine the differences between stand-alone voluntary counseling and testing (VCT), VCT offered through integrated facilities (provider- and client-initiated testing), and VCT offered through prevention of mother-to-child transmission services with regards to the various levels of consent, confidentiality, and referral to care offered by each and to assess if they met quality standards based on World Health Organization and Centers for Disease Control and Prevention guidelines. The study was conducted in four countries—Burkina Faso, Kenya, Malawi, and Uganda—to examine the differences across various settings. A client survey was administered to individuals at facilities who had either accessed VCT or had not. The survey included variables on socio-demographic information, HIV testing and counseling attitudes, and testing status. Those who were tested were asked about their experiences with pre- and post-testing, follow-up care, interaction with providers throughout the process, disclosure, and stigma. Data from 2,116 participants were included in the analysis. It was found that the majority of testers received the necessary components to HIV testing that are within the international guidelines, but improvements could be made. No one type of HIV testing service was found to be significantly better than the others. The study did not find breaches of conduct in terms of consent and confidentiality. In conclusion, based on this study, different types of HIV testing services can be scaled-up in countries to increase knowledge of HIV status and provide referrals to other HIV services.
Voluntary Counseling and Testing (VCT) for Changing HIV-related Risk Behavior in Developing Countries
Fonner, V.A., Denison, J., Kennedy, C.E., et al. Cochrane Database of Systematic Reviews (September 2012), Vol. 9.
Voluntary counseling and testing (VCT) has long been seen as a critical component of HIV prevention strategies worldwide, both as a first step to care and treatment and as a catalyst for behavior change. This systematic literature review and quantitative assessment examined VCT’s efficacy in promoting change in HIV-related risk behaviors in low- and middle-income countries over a 20-year period (1990 to 2010). The authors chose 17 studies for qualitative synthesis (8 of which also underwent meta-analysis); all had either collected data on study participants before and after undergoing VCT, or compared individuals who had received VCT to those who hadn’t. Five HIV-related outcomes were analyzed: HIV incidence, prevalence and incidence of other sexually transmitted infections (STIs), positive and negative life events, condom use and protected sex, and number of sex partners. The authors found no statistically significant differences in HIV incidence or in incidence or prevalence of STIs between participants who received or did not receive VCT. Of the two studies on life events, the authors found that individuals who didn’t undergo VCT experienced a significant increase in negative life events. Other findings show that those who received VCT were more likely to disclose their HIV status, were significantly more likely to reduce their number of sex partners, and were more likely to use condoms.
No “Magic Bullet”: Exploring Community Mobilization Strategies Used in a Multi-Site Community Based Randomized Controlled Trial: Project Accept
Tedrow, V. A., Zelaya, C. E., Kennedy, C. E., et al. AIDS and Behavior (2011), Aug 6 e-publication ahead of print.
The Project Accept randomized controlled trial tested the hypothesis that voluntary HIV counseling and testing together with community mobilization would shift community norms and reduce HIV incidence. This paper is a qualitative examination of the seven community mobilization strategies used in the trial. Using semistructured interviews, the study found that no single strategy (out of stakeholder commitment, community coalition formation, community engagement, participation or awareness raising, involvement of leaders and partnership building) was used alone. The study identified three elements that are crucial to the success of community mobilization efforts. First, strategies evolved over time and were adapted during the process of community involvement. It also took time for acceptance to develop in communities. In addition, each intervention site had unique characteristics requiring tailored community mobilization efforts. Involving lay community members was crucial, the study found.
Community-Based Intervention to Increase HIV Testing and Case Detection in People Aged 16-32 Years in Tanzania, Zimbabwe, and Thailand (NIMH Project Accept, HPTN 043): A Randomised Study
Sweat, M., Morin, S., Celentano, D., et al. The Lancet Infectious Diseases (2011), Vol. 11 No. 7, pp. 525-532.
This paper presents interim analysis of randomized controlled trial, Project Accept. The trial compared the impact on HIV incidence of clinic-based HIV testing and counseling (HTC) versus community-based HTC. The study covered 32 communities, 10 in Tanzania, 8 in Zimbabwe, and 14 in Thailand with the intervention running over three years from 2006 to 2009. Those in the community-based HTC areas had a mean 40 percent higher likelihood of undergoing their first HIV test, compared to those in the community-based HTC areas. Uptake increased 4-fold in Tanzania, 10-fold in Zimbabwe, and 3-fold in Thailand. Almost four times more cases of HIV were detected in the community-based HTC areas, even though HIV prevalence was higher in the clinic-based HTC areas. The study’s ability to mobilize large numbers of people to get tested has important implications for future HIV programming, the authors conclude.
Project Accept (HPTN 043): A Community-Based Intervention to Reduce HIV Incidence in Populations at Risk for HIV in Sub-Saharan Africa and Thailand
Khumalo-Sakutukwa, G., Morin, S., Fritz, K., et al. Journal of Acquired Immune Deficiency Syndromes (2008), Vol. 49 No. 4, pp. 422-431.
This paper reports the first year results of a unique study: an international, multisite, community randomized control trial of a multilevel HIV structural prevention intervention. This community-level approach had three strategies: (1) community mobilization to increase HIV testing and counseling (HTC); (2) community-based mobile HTC; and (3) comprehensive post-test services. The study assesses whether, compared to people living in communities with standard HTC, those living in communities where community-based HTC is offered will have lower incidence of HIV and experience less stigma, fewer risk behaviors, higher rates of HIV testing, and more accepting social norms related to HIV. It also assessed the cost-effectiveness of the intervention. In the first year of the intervention, about three times more members living in intervention communities in Tanzania and Thailand sought out HIV testing; in Zimbabwe, the increase was 10-fold. First-year data suggest that this community-level intervention can create changes in social norms about HIV, and because of its low cost, can be replicated in resource-poor settings.
Home-based HIV Voluntary Counselling and Testing in Developing Countries
Bateganya, M. H., Abdulwadud, O. A., & Kiene, S. M. Cochrane Database of Systematic Reviews (2007), Vol. 4, CD006493.
This review looked for randomized and nonrandomized (e.g., cohort and pre-/post-test) controlled trials of home-based voluntary HIV testing and counseling (HTC) in the published literature; the authors found only two studies from developing countries, and none from developed countries, that met inclusion criteria. The randomized controlled trial compared optional location-based and clinic-based HTC, and found that uptake was substantially higher in the optional location group. The pre-/post-test study found similar results: uptake of home HTC was higher than facility-based HTC. The authors conclude that given the lack of methodologically sound evidence, more studies are needed to determine the efficacy and cost-effectiveness of clinic-based testing versus testing on other sites, including the home. The review gives a useful summary of the different modes of HTC, including mandatory, voluntary, opt-out, and home-based testing and counseling.
Promotion of Couples’ Voluntary HIV Counseling and Testing
The Rwanda Zambia Research Group, Rollins School of Public Health, Emory University.
The Rwanda Zambia Research Group at Emory University has several research projects underway to understand factors related to HIV transmission. This webpage summarizes a five-year project to promote HIV testing and counseling among cohabitating couples in Kigali, Rwanda, and Lusaka, Zambia. The group planned two community-oriented interventions to increase couples HIV testing and counseling, and also studied psychosocial and structural factors influencing condom use, regular follow-up, and biological outcomes of unprotected sex in serodiscordant couples, including couple communication, alcohol use, intimacy, and gender roles. Links to the project’s progress reports can also be found from this page.
Scaling up HIV Testing and Counseling in the WHO European Region as an Essential Component of Efforts to Achieve Universal Access to HIV Prevention, Treatment, Care and Support: Policy Framework
World Health Organization. (2010).
This document lays out a policy framework for countries to increase access to HIV testing and counseling (HTC), a key element of attaining the goal of universal access to HIV care. The target audience includes policymakers, national AIDS program planners, health care providers, and nongovernmental organizations in the HIV field in Europe. It is built around 10 principles, such as the position that scaling up of HTC is not only a public health priority but must also be a part of broader HIV prevention, treatment, care, and support efforts, and that HTC must take diverse settings and populations into account. It spells out the need to increase uptake of HTC among most-at-risk populations, the importance of informed consent, confidentiality, and elimination of coercive testing. The document also makes detailed recommendations to World Health Organization member states for each of the principles covered.
Guidance on Testing and Counselling for HIV in Settings Attended by People Who Inject Drugs: Improving Access to Treatment, Care and Prevention
World Health Organization, World Health Organization Regional Office for South-East Asia, & World Health Organization Regional Office for the Western Pacific. (2009).
This document provides policymakers, HIV program planners, care providers, nongovernmental organizations, and civil society groups with information on how health care providers can initiate HIV testing and counseling among people who inject drugs. Developed specifically for the Asia-Pacific context, it can be used to help most-at-risk populations know their HIV status and access treatment and care. The document balances medical ethics and clinical, public health, and human rights objectives for reaching this special population. The primary components of this guidance include recommendations for testing and counseling people who inject drugs; process and elements of HIV testing and counseling; and programmatic considerations.
HIV Testing and Counselling in Prisons and Other Closed Settings
Jürgens, R., World Health Organization, United Nations Office on Drugs and Crime, & Joint United Nations Programme on HIV/AIDS. (2009).
This technical paper systematically reviews the literature to identify best practices and recommendations on HIV testing and counseling (HTC) in prisons and other closed settings. Due to a lack of documentation of this issue in many low-resource settings, the literature review was augmented by findings from a discussion among experts. In addition to providing the findings of the literature review, this document provides 11 recommendations on providing HTC to this population. Recommendations include scaling up HTC, key principles of informed consent, code of conduct for health personnel in prison systems, and continuity of care once prisoners are released back into the community.
Guidance on Provider-Initiated HIV Testing and Counselling in Health Facilities
World Health Organization & Joint United Nations Programme on HIV/AIDS. (2007).
In support of multiple approaches to help people find out about their HIV status, the World Health Organization has published guidance on implementing provider-initiated HIV testing and counseling in health facilities. The guidance is divided by category of HIV epidemic: generalized, concentrated, or low level. It discusses to whom providers should recommend HIV testing and counseling as standard of care. Furthermore, the document covers the enabling environment needed for such a program and provides guidance on post-test counseling, frequency of testing, HIV testing technologies, programmatic considerations, and monitoring and evaluation. Any level audience, from policymaker to health care provider, can find useful information in this document.
Home-based HIV Testing and Counseling in Rural and Urban Kenyan Communities
Dalal W., Feikin, D.R., Amolloh, M., et al. 2012. Journal of Acquired Immune Deficiency Syndromes [Epub ahead of print].
A home-based HIV testing and counseling (HBHTC) intervention was implemented in two sites in Kenya to determine the up-take of testing as well as to assess HIV prevalence and referral success rates. Individuals were offered voluntary counseling and testing through counselors and, if they consented, data was collected on any previous testing and access to care and treatment services. All adults received HIV test results in their homes as well as risk reduction counseling. Those who tested positive were counseled and provided information on HIV services, offered a free CD4 count test, referred to the nearest facility for free care and treatment, and visited by a counselor one month after the test. There was an 81.7 percent acceptance rate of HBHTC in the participating communities (19,966 accepted out of 24,450 offered). The motivation for testing by the majority (84.9 percent) of acceptors was their desire to plan for the future. HIV prevalence was 16.3 percent among the participants, and the majority of those found to be HIV-positive were first time testers. About a third (38 percent) of those reporting to be in a couple were counseled and tested together, and 84.3 percent were HIV-concordant negative. Half of those who tested positive were visited one month after their tests. About a half reported attending a patient support center. In conclusion, the intervention was successful in contacting individuals who had never been tested and in identifying newly diagnosed HIV-positive individuals and linking them to care and treatment services.
NIMH Project Accept (HPTN 043) HIV/AIDS Community Mobilization to Promote Mobile HIV Voluntary Counseling and Testing in Rural Communities in Northern Thailand: Modifications by Experience
Kawichai, S., Celentano, D., Srithanaviboonchai, K., et al. 2012. Project Accept Study Team. Collaborators (61) AIDS Care [Epub ahead of print]
The intervention strove to increase the up-take of HIV testing through its mobile voluntary counseling and testing (MVCT) centers by implementing community mobilization (CM) activities. The intervention was implemented in communities in rural Thailand from 2006 to 2009. Communities were randomly selected as control or intervention sites and were similar on measures including ethnicity, livelihoods, and health care services. Community Working Groups were established at each intervention site to increase involvement and facilitate activities. For intervention rounds one to three in the intervention communities, the CM teams went door-to-door and conducted small meetings to educate individuals about HIV and inform them about the MVCT centers. The MVCT services followed a few days later. Since the number of participants accessing MVCT was decreasing, the project’s strategy was modified to implement larger-scale events, coupled with MVCT, during the last rounds of the project. It was found that about 17,000 individuals were tested, with the majority first time testers (61.1 percent). The project identified 136 individuals who were HIV-positive, and the majority did not have any signs or symptoms of AIDS. Participation did increase during the last rounds of the project based on the change of the CM strategy. Participants were younger in the later phases as well. It was found that CM can help educate communities about HIV and reduce stigma. When coupled with MVCT, up-take of testing can increase the identification of new HIV cases.
An Incentivized HIV Counseling and Testing Program Targeting Hard-to-Reach Unemployed Men in Cape Town, South Africa
Nglazi, M.D., van Schaik, N., Kranzer, K., et al. 2012. Journal of Acquired Immune Deficiency Syndromes Vol. 59 No.3, pp. e28-34.
Men access HIV counseling and testing (HCT) services less than women do. Innovative strategies are sought to increase the uptake of HCT services by men. Past studies have demonstrated success in attracting men when HCT services were coupled with a conditional case transfer program. The retrospective observational study combined the use of incentives with a mobile HCT clinic. It then compared the enhanced intervention to a non-incentivized mobile HCT site and a stationary non-incentivized HCT site to explore which service was most accessed by men. All services were operating in poor underserved peri-urban sites. The stationary site included all men who came for testing on their own initiative. The mobile non-incentive site did not advertise or actively recruit clients. The mobile incentive-based HCT partnered with a local organization that worked with unemployed or under-employed men to encourage them to access the services. The incentive to accessing HCT was receiving a food voucher worth about US$10.00. Only men were included in the data analysis. All women, young men under age 15, and those of known HIV status were excluded from the data analysis. A total of 9,416 first-time testers accessed one of the three HCT services, with a higher proportion of self-reported first-time testers using the incentivized site compared to the non-incentivized mobile site. It was found that HIV prevalence among testers was the highest among those who received testing from the incentivized site (16.5 percent) compared to the stationary clinic (10.2 percent) and the non-incentivized site (5.5 percent). The incentive-based mobile HCT was successful in reaching higher-risk men who have never tested for HIV.
A Handbook for Improving HIV Testing and Counseling Services: Field-Test Version
World Health Organization. (2010).
This handbook is a practical guide for those involved in the improvement of HIV testing and counseling (HTC) services. It describes the quality assurance cycle and how to construct a quality improvement framework. To meet the needs of both public health systems and nongovernmental organizations involved in the delivery of HIV services, it spans the whole process of HTC, from point of entry to successful onward referral. Of particular interest to program managers is the outline of the main components of quality improvement in HTC, whereas service providers can make use of its practical tools such as logbooks, interview forms, and site assessment forms. There are also examples of a quality monitoring system and illustrations of the framework in action at service delivery level. A bibliography of recommended core and additional resources, as well as an extensive glossary, completes the document.
HIV Counselling Resource Package for the Asia-Pacific
United Nations Children’s Fund, Family Health International, & World Health Organization. (2009).
This set of resources can help trainers and counselors provide high-quality HIV testing and counseling services. The authors emphasize evidence-based counseling strategies that may reduce HIV transmission and include focused guidance on working with drug users and other most-at-risk populations. The HIV counseling handbook is a comprehensive resource package providing HIV counselors easy reference to key basic counseling processes and procedures. The trainer’s manual has everything needed for an eight-day training course, including seven classroom days and one day for site visits. It contains 16 modules with session plans and interactive sessions and learning activities for the trainees. The toolkit includes useful forms and protocols, client education charts, and screening/assessment tools that can be used while counseling patients.
Couples HIV Counseling and Testing Intervention and Training Curriculum
U.S. Centers for Disease Control and Prevention. (2008).
Developed primarily for experienced HIV prevention counselors, this curriculum and materials can be adapted to various country contexts when providing couples HIV counseling and testing. There is a manual for participants in training and another for trainers. The materials cover essential topics and activities for those counseling couples, and include prevention messages tailored to couples’ life stages, mitigating tension and diffusing blame, and creating an environment safe for HIV disclosure to partners.
Positive Prevention Counseling: A Training Course for HIV/AIDS Counselors
EngenderHealth, Ministry of Health, Uganda, U.S. Agency for International Development, & Centers for Disease Control and Prevention. (2007).
This manual and related materials form the basis of a comprehensive training course for HIV counselors in positive prevention. The positive prevention program aims to reduce HIV transmission by building the capacity of service providers to scale up HIV prevention counseling skills, integrating family planning and reproductive health needs, and involving people living with HIV as partners in health. This 10-day course includes 8 days of classroom work and 2 days of practicum. Modules address topics such as disclosure counseling, sex and sexuality, counseling serodiscordant couples, alcohol and substance use, and adolescent counseling. Participants develop action plans for integrating positive prevention counseling into their workplace once they return. There are downloadable manuals for trainers and participants.
HIV Counseling and Testing for Youth: A Manual for Providers
Fischer, S., Reynolds, H., Yacobson, I., et al. (2007).
Counseling youth about HIV requires different knowledge and skills than when counseling adults. This manual is a resource of best practices for offering HIV testing and counseling (HTC) services to youth for service providers at all levels. There are chapters on the differences in counseling youth compared to adults and specifically on HTC. Sexually transmitted infections, pregnancy prevention, life skills, and creating a referral network are also covered. A training guide is also available with this manual for use in training experienced HIV counselors on offering HTC to youth. Among other tools, the training guide includes slides, interactive exercises, and practice sessions.
Scaling-up HIV Test and Counseling (TC) Services: TC Toolkit: An Annotated Bibliography of Peer-reviewed Resources and Tools
World Health Organization. (2007).
This toolkit contains resources for those setting up or scaling up HIV testing and counseling services. Developed for program managers, implementers, and their partners, the selected resources offer practical guidance on planning and implementing HIV testing and counseling services in resource-limited settings and also includes tools for monitoring and evaluation. This document will be updated regularly to keep resources current.
Testing and Counselling for Prevention of Mother-to-Child Transmission of HIV (TC for PMTCT): Support Tools
U.S. Centers for Disease Control and Prevention. (2005).
This set of tools was developed to guide the delivery of essential prevention of mother-to-child transmission (PMTCT) messages. Answering the need for more educational resources for resource-constrained settings, they were developed specifically for both clinical and nonclinical health care workers, program managers, and trainers in the field of PMTCT. The goal is to increase the uptake of HIV testing by pregnant women and also their partners, increase the number of women who are aware of their HIV status, and facilitate PMTCT interventions. There are flipcharts, wall charts, brochures, and a reference guide. There are specific support tools for antenatal, labor and delivery, and postnatal PMTCT support. The resources are available on CD-ROM and also for download in low, medium, and high resolution.
Can Couples Testing Contribute to Achieving the AIDS Transition?
Over, M. (2010).
This study examines couples counseling within the context of the economic theory of asymmetric information as well as epidemiologic findings on its efficacy. Using observational data from several different countries, it suggests that the primary hurdle to HIV prevention is the lack of couples counseling. The problem of asymmetric information, when two people engaging in a transaction have differing amounts of information, is a driver to the HIV epidemic, the authors argues. Not knowing one another’s status discourages the formation and survival of monogamous partnerships. Based on data from studies that find lower HIV transmission rates among serodiscordant couples than among couples who do not know their partners’ status and from studies that find the majority of people obtain HIV tests individually, couples testing should be a priority for helping reduce the HIV epidemic, the author writes. In addition, he states that more rigorous research is needed around this issue of couples testing.
Behavioural Strategies to Reduce HIV Transmission: How to Make them Work Better
Coates, T. J., Richter, L., & Caceres C. The Lancet (2008), Vol. 372 No. 9639, pp. 669-684.
This article argues that the radical behavioral change that is needed to reduce HIV transmission requires radical commitment. Reviewing 25 years of HIV prevention efforts, the authors identify successful HIV prevention efforts and ways to improve behavioral strategies to reduce HIV transmission. They argue for the need to combine behavioral, biomedical, and structural approaches to effectively fight HIV transmission. To date, behavioral changes have reduced HIV in certain countries, regions, or subpopulations due to significant behavior changes taking place among a majority of the population; a mix of communication channels providing clear, actionable risk reduction and health-seeking messages that people can choose from; and local involvement in developing, producing, and disseminating the right messages. Sustained changes in risk behavior, however, have not been found anywhere, they note. The authors conclude that behavioral strategies must take place combined with different approaches and at multiple levels of influence.
World Health Organization, Department of HIV/AIDS
World Health Organization. (n.d.).
This webpage of the World Health Organization’s Department of HIV/AIDS lists all testing and counseling publications starting from 2000. Readers can link back from here to the department’s main counseling and testing page, which includes policy and guidance, advocacy, training materials, data on HIV counseling and testing, and more.
Zimbabwe HIV Prevention e-Toolkit
The toolkit offers a selection of different materials including research papers, books, training materials, and behavior change communication materials across the spectrum of HIV prevention topics. Readers can access materials and resources on behavior change communication, condom use, family planning and HIV service integration, male circumcision, multiple and concurrent partners, prevention of mother-to-child transmission, and voluntary counseling and testing.