Biomedical Interventions: HIV Testing and Counseling as Prevention

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.