Attitudes and practices of health care workers toward routine HIV testing of infants in Côte d'Ivoire: the PEDI-TEST ANRS 12165 Project.

OBJECTIVE: We assessed attitudes and practices of health care workers (HCWs) toward HIV counselling and testing (CT) routinely offered to infants in health facilities in Abidjan, Côte d'Ivoire. METHODS: We performed a cross-sectional survey inquiring on systematic HIV CT offered to children aged 6-26 weeks attending postnatal care for either immunization or pediatric care and to their parents in 4 community health centres rolling-out access to antiretroviral therapy. Data were collected using standardized anonymous self-questionnaires directed to all HCWs involved. RESULTS: One-hundred five HCWs were interviewed in 2008: 30% were social workers, 27% physicians, 24% nurses and 19% laboratory technicians. Among immunization staff (n = 45), none trained in child CT versus 26% in pediatric services (n = 60, P < 0001). Almost all staff believed that it is important to offer HIV screening services to children and the best place could be during pediatric consultations. In their daily work, 22% of immunization staff and 48% of pediatric care staff had already been dealing with early HIV CT (P = 0.01). Facing a child suspected to be HIV infected, only 54% of providers in pediatrics and 71% in immunization would offer CT to all family members (P = 0.01). CONCLUSIONS: In Abidjan, although HCWs were generally in favour of pediatric HIV screening, very few had received specific training to do so. Deleguation of CT to the primary care level could improve coverage of CT services. It is urgent to train HCWs to promote early infant HIV diagnosis to improve earlier access to antiretroviral therapy in West African HIV-infected children.

A comparison of patient and staff attitudes about emergency department-based HIV testing in 2 urban hospitals.

OBJECTIVE: This study compares and contrasts emergency department (ED) patient and staff attitudes towards ED-based HIV testing in 2 major hospitals in a single city, with an attempt to answer the following: Should routine ED-based HIV testing be offered? If so, who should be responsible for disclosing HIV test results? And what barriers might prevent ED-based HIV testing? METHODS: Paper-based surveys were presented to a convenience sample of ED patients and staff at 2 urban, academic, tertiary care hospitals between December 2007 and June 2009. Descriptive statistics were derived with SAS and MicroSoft Excel. Data are reported in percentages, fractions, and graphs. RESULTS: A total of 457 patients and 85 staff completed the surveys. The majority of patients favor ED-based HIV testing. Only a minority of ED staff support ED-based HIV testing. In both hospitals, patients prefer to have HIV test results delivered by a physician. This was true for both positive and negative results. However, only about one third of attending physicians feel comfortable disclosing a positive HIV test result. Patients and staff both view privacy and confidentiality as significant barriers to ED-based HIV testing. CONCLUSION: Although ED patients are overwhelmingly in favor of ED-based HIV testing, the staff is not. Patients and staff agree that physicians should deliver HIV test results to patients, but a significant number of physicians are not comfortable doing so. Historical barriers continue to hinder ED-based HIV testing programs.

Patient satisfaction with rapid HIV testing in the emergency department.

OBJECTIVE: Patient satisfaction with HIV screening is crucial for sustainable implementation of the Centers for Disease Control and Prevention (CDC) HIV testing recommendations. This investigation assesses patient satisfaction with rapid HIV testing in the emergency department (ED) of an urban tertiary academic medical center. METHODS: After receiving HIV test results, participants in the Universal Screening for HIV Infection in the Emergency Room (USHER) randomized controlled trial were offered a patient satisfaction survey. Questions concerned overall satisfaction with ED visit, time spent on primary medical problem, time spent on HIV testing, and test provider's ability to answer HIV-related questions. Responses were reported on a 4-point Likert scale, ranging from very dissatisfied to very satisfied (defined as optimal satisfaction). RESULTS: Of 4,860 USHER participants, 2,025 completed testing and were offered the survey: 1,616 (79.8%) completed the survey. Overall, 1,478 (91.5%) were very satisfied. Satisfaction was less than optimal for 34.5% (10 of 29) of participants with reactive results and for 7.5% (115 of 1,542) with nonreactive results. The independent factors associated with less than optimal satisfaction were reactive test result, aged 60 years or older, black race, Hispanic/Latino ethnicity, and testing by ED provider instead of HIV counselor. CONCLUSION: Most participants were very satisfied with the ED-based rapid HIV testing program. Identification of independent factors that correlate with patient satisfaction will help guide best practices as EDs implement CDC recommendations. It is critical to better understand whether patients with reactive results were negatively affected by their results or truly had concerns about the testing process.

Tuberculosis patients' reasons for, and suggestions to address non-uptake of HIV testing: a cross-sectional study in the Free State Province, South Africa.

BACKGROUND: South Africa endorses the global policy shift from primarily client-initiated voluntary counselling and testing (VCT) to routine/provider-initiated testing and counselling (PITC). The reason for this policy shift has been to facilitate uptake of HIV testing amongst at-risk populations in high-prevalence settings. Despite ostensible implementation of routine/PITC, uptake amongst tuberculosis (TB) patients in this country remains a challenge. This study presents the reasons that non-tested TB patients offered for their refusal of HIV testing and reflects on all TB patients' suggestions as to how this situation may be alleviated. METHODS: In February-March 2008, a cross-sectional survey was conducted amongst 600 TB patients across 61 primary health care facilities in four sub-districts in the Free State. Patient selection was done proportionally to the numbers registered at each facility in 2007. Data were subjected to bivariate tests and content analysis of open-ended questions. RESULTS: Almost one-third (32.5%) of the respondents reported that they had not undertaken HIV testing, with the most often offered explanation being that they were 'undecided' (37.0%). Other self-reported reasons for non-uptake included: fear (e.g. of testing HIV-positive, 19.0%); perception of being at low risk of HIV infection (13.4%); desire first to deal with TB 'on its own' (12.5%); and because HIV testing had not been offered to them (12.0%). Many patients expressed the need for support and motivation not only from health care workers (33.3%), but also from their significant others (56.6%). Patients further expressed a need for (increased) dissemination of TB-HIV information by health care workers (46.1%). CONCLUSIONS: Patients did not undergo HIV testing for various patient-/individual-related reasons. Non-uptake of HIV testing was also due to health system limitations such as the non-offer of HIV testing. Other measures may be necessary to supplement routine/provider-initiation of HIV testing. From the TB patient's perspective, there is a need for (improved) dissemination of information on the TB-HIV link. Patients also require (repeated) motivation and support to undergo HIV testing, the onus for which rests not only on the public health authority and health care workers, but also on other people in the patients' social support networks.

Testing public health ethics: why the CDC's HIV screening recommendations may violate the least infringement principle.

The CDC's HIV screening recommendations for health care settings advocate abandoning two important autonomy protections: (1) pretest counseling and (2) the requirement that providers obtain affirmative agreement from patients prior to testing. The recommendations may violate the least infringement principle because there is insufficient evidence to conclude that abandoning pretest counseling or affirmative agreement requirements will further the CDC's stated public health goals.

A CBPR partnership increases HIV testing among men who have sex with men (MSM): outcome findings from a pilot test of the CyBER/testing internet intervention.

The Internet has emerged as an important tool for the delivery of health promotion and disease prevention interventions. Our community-based participatory research (CBPR) partnership developed and piloted CyBER/testing, a culturally congruent intervention designed to promote HIV testing among men who have sex with men (MSM) within existing Internet chat rooms. Using a quasi-experimental, single-group study design, cross-sectional data were collected from chat room participants, known as "chatters," at pretest (n = 346) and posttest (n = 315). Extant profile data also were collected to describe the demographics of the online population. The intervention significantly increased self-reported HIV testing among chatters overall, increasing rates from 44.5% at pretest to nearly 60% at posttest (p < .001). Furthermore, chatters who reported having both male and female sexual partners had nearly 6 times the odds of reporting HIV testing at posttest. Findings suggest that chat room-based HIV testing intervention may increase testing among MSM who may be difficult to reach in traditional physical spaces.

Use of drawings to explore U.S. women's perspectives on why people might decline HIV testing.

The purpose of this research is to explore through drawings and verbal descriptions women's perspectives about reasons why persons might decline human immunodeficiency virus (HIV) testing. We asked 30 participants to draw a person that would NOT get tested for HIV and then explain drawings. Using qualitative content analysis, we extracted seven themes. We found apprehension about knowing the result of an HIV test to be the most commonly identified theme in women's explanations of those who would not get tested. This technique was well received and its use is extended to HIV issues.

Disclosure of HIV status between spouses in rural Malawi.

Disclosure of HIV status after HIV voluntary counseling and testing has important implications for the spread of the HIV epidemic and the health of individuals who are HIV positive. Here, we use individual and couples level data for currently married respondents from an ongoing longitudinal study in rural Malawi to (1) examine the extent of HIV status disclosure by HIV serostatus; (2) identify reasons for not sharing one's HIV status with a spouse; and (3) evaluate the reliability of self-reports of HIV status disclosure. We find that disclosure of HIV status is relatively common among rural Malawians, where most have shared their status with a spouse, and many disclose to others in the community. However, there are significant differences in disclosure patterns by HIV status and gender. Factors associated with non-disclosure are also gendered, where women who perceive greater HIV/AIDS stigma and HIV positive are less likely to disclose HIV status to a spouse, and men who are worried about HIV infection from extramarital partners are less likely to disclose their HIV status to a spouse. Finally, we test the reliability of self-reported HIV status disclosure and find that self-reports of HIV-positive men are of questionable reliability.

Development of the Fogg Intent-to-Screen for HIV (ITS HIV) questionnaire.

In this paper, we describe the development and psychometric properties of the Fogg Intent-to-Screen for HIV questionnaire (ITS HIV), which measures peoples' beliefs and intentions toward HIV screening. The ITS HIV was developed using the Theory of Planned Behavior as the framework for a developmental process that included qualitative interviews, a validation phase, two pilot tests, and a field test of the final 55-item questionnaire. The field test involved 312 homeless persons from five New England states. Cronbach alphas of the direct measures scales ranged from .72 to .90. Findings from a path analysis verified the construct validity. The psychometric estimates from these analyses suggest the ITS HIV questionnaire is appropriate for use in clinical practice or to evaluate the effectiveness of interventions.

HIV/AIDS stigma and refusal of HIV testing among pregnant women in rural Kenya: results from the MAMAS Study.

HIV/AIDS stigma is a common thread in the narratives of pregnant women affected by HIV/AIDS globally and may be associated with refusal of HIV testing. We conducted a cross-sectional study of women attending antenatal clinics in Kenya (N = 1525). Women completed an interview with measures of HIV/AIDS stigma and subsequently information on their acceptance of HIV testing was obtained from medical records. Associations of stigma measures with HIV testing refusal were examined using multivariate logistic regression. Rates of anticipated HIV/AIDS stigma were high-32% anticipated break-up of their relationship, and 45% anticipated losing their friends. Women who anticipated male partner stigma were more than twice as likely to refuse HIV testing, after adjusting for other individual-level predictors (OR = 2.10, 95% CI: 1.15-3.85). This study demonstrated quantitatively that anticipations of HIV/AIDS stigma can be barriers to acceptance of HIV testing by pregnant women and highlights the need to develop interventions that address pregnant women's fears of HIV/AIDS stigma and violence from male partners.

The association of HIV counseling and testing with HIV risk behaviors in a random population-based survey in Kisumu, Kenya.

HIV testing has been promoted as a key HIV prevention strategy in low-resource settings, despite studies showing variable impact on risk behavior. We sought to examine rates of HIV testing and the association between testing and sexual risk behaviors in Kisumu, Kenya. Participants were interviewed about HIV testing and sexual risk behaviors. They then underwent HIV serologic testing. We found that 47% of women and 36% of men reported prior testing. Two-thirds of participants who tested HIV-positive in this study reported no prior HIV test. Women who had undergone recent testing were less likely to report high-risk behaviors than women who had never been tested; this was not seen among men. Although rates of HIV testing were higher than seen in previous studies, the majority of HIV-infected people were unaware of their status. Efforts should be made to increase HIV testing among this population.

A comparison of HIV detection rates using routine opt-out provider-initiated HIV testing and counseling versus a standard of care approach in a rural African setting.

BACKGROUND: Routine opt-out provider-initiated HIV testing and counseling (PITC) remains underutilized in sub-Saharan Africa. By selectively targeting clients who either volunteer or have clinical indications of HIV disease, standard approaches to HIV counseling and testing are presumed more cost-efficient than PITC. METHODS: One thousand two hundred twenty-one patients aged 15­ 49 years were seen by 22 practitioners in a mobile clinic in southern Zambia. A random sample of physicians was assigned to administer PITC, whereas the remaining practitioners offered standard non- PITC (ie, voluntary or diagnostic). Questionnaires assessed patient demographics and attitudes toward HIV. HIV detection rates were stratified by referral type, demographics, and HIV-related knowledge and attitudes. RESULTS: HIV prevalence was 10.6%. Infection rates detected using PITC [11.1%; 95% confidence interval (CI): 8.8% to 13.5%] and standard non-PITC (10.0%; 95% CI: 7.5% to 12.5%) did not significantly differ (odds ratio = 1.01; 95% CI: 0.67 to 1.52; P = 0.95). Patients who did not request testing or demonstrate clinical indicators of HIV did not have significantly higher HIV prevalence than those who did (odds ratio = 0.83; 95% CI: 0.55 to 1.24; P = 0.36). Implementation of PITC was highly acceptable and produced a 3-fold increase in patients tested per practitioner compared with standard non-PITC (114 vs. 34 patients per practitioner, respectively). CONCLUSIONS: PITC detected a comparable HIV infection rate as a standard non-PITC approach among rural adults seeking primary care services. Widespread implementation of PITC may therefore lead to significantly more cases of HIV detected.

The inequitable impact of health shocks on the uninsured in Namibia.

The AIDS pandemic in sub-Saharan Africa puts increasing pressure on the buffer capacity of low- and middle-income households without access to health insurance. This paper examines the relationship between health shocks, insurance status and health-seeking behaviour. It also investigates the possible mitigating effects of insurance on income loss and out-of-pocket health expenditure. The study uses a unique dataset based on a random sample of 1769 households and 7343 individuals living in the Greater Windhoek area in Namibia. The survey includes medical testing for HIV infection which allows for the explicit analysis of HIV-related health shocks. We find that the economic consequences of health shocks can be severe for uninsured households even in a country with a relatively well-developed public health care system such as Namibia. The uninsured resort to a variety of coping strategies to deal with the high medical expenses and reductions in income, such as selling assets, taking up credit or receiving financial support from relatives and friends. As HIV-infected individuals increasingly develop AIDS, this will put substantial pressure on the public health care system as well as social support networks. Evidence suggests that private insurance, currently unaffordable to the poor, protects households from the most severe consequences of health shocks.

Patients' attitudes toward and factors predictive of human immunodeficiency virus testing of academic medical clinics.

INTRODUCTION: More than 1,000,000 persons in the United States are living with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome, with 24% unaware of their HIV status. In this study, the authors explored patients' attitudes toward HIV testing in academic medical clinics and investigated the possible impact of the 2006 Centers for Disease Control and Prevention (CDC) HIV screening guidelines. METHOD: Cross-sectional survey study of adult patients in 9 academic internal medicine clinics (response rate 73%). The survey consisted of 76 questions, which assessed demographics, HIV risk factors, knowledge, beliefs, attitudes and characteristics of patient-physician interactions. Patient self-reported HIV testing was the main outcome. Bivariate analyses were performed, and variables with a P-value of <0.1 were included in a logistic regression model to determine characteristics most associated with HIV testing. RESULTS: Four hundred forty-three patients completed the survey (response rate 73%) and 61% reported being screened for HIV. Physician recommendation (P < 0.0001), patient's own request (P < 0.0001), African American race (P < 0.0001) better knowledge about HIV (P = 0.0002), agreement with CDC recommendations (P < 0.0001), being comfortable with their doctor (P < 0.0001) and using street drugs (P < 0.0001) were all strongly associated with testing. In logistic regression, the only factors that remained statistically significant predictors of patients self-reported HIV testing were a patient's request for testing (OR: 103.3) and patient's knowledge about HIV (OR: 1.3). CONCLUSION: In this study, patient request was the strongest predictor for HIV screening and majority of patients accepted the idea of HIV testing in congruence with the CDC recommendations. Therefore, simple waiting room prompts and public education campaigns may represent the most efficient interventions to increase HIV testing rate.

Evaluation of HIV voluntary counselling and testing services in Egypt. Part 1: client satisfaction.

HIV voluntary counselling and testing (VCT) services were launched in Egypt in 2005. A study of all functioning VCT centres in Egypt (7 mobile and 9 fixed) aimed to determine the profile of clients and their level of satisfaction to identify strengths and weaknesses in the service. In direct interviews with a sample of 928 clients, the main motive for seeking VCT was risky sexual behaviour (34.2%). More females than males sought services because of partners' risky sexual behaviour. More than 90% of the clients were satisfied with the counselling service. Only 41.4% were willing to discuss the test results with their partners. Male sex, higher education level and attendance at fixed VCT centres were associated with higher satisfaction.

"It is not an easy decision on HIV, especially in Zambia": opting for silence, limited disclosure and implicit understanding to retain a wider identity.

As universal testing moves onto the HIV agenda, there is a need for more understanding of the relatively low uptake of HIV testing and the dynamics of disclosure in Sub-Saharan Africa. Despite the expanding provision of anti-retroviral therapy in Zambia since 2004, disclosure of HIV status - beyond a closed network - remains limited. Drawing on 20 years of living and working in a high HIV prevalence country, research on HIV-related stigma and existing literature on disclosure, this paper explores the reasons that lie behind limited disclosure. Unravelling why HIV disclosure remains "a navigation in a moral field", the pattern of silence around HIV and the routine and often subtle presence of HIV in daily life reveals two key dynamics. The first dynamic is shifting public/private boundaries and retaining a wider identity. People living with HIV juggle the pragmatic advantages of disclosing to a limited circle with the importance of maintaining not only their moral integrity, status and (for some) professional and group identity but also of maintaining their privacy. A more public disclosure ("speaking it" more widely) shifts private-public boundaries and can be threatening, dangerous and can fix identity. Furthermore, disclosure carries obligations which, given high levels of poverty, can be hard to meet. The second dynamic is a pattern of implicit understanding. It can be easier in a context of high HIV prevalence to opt for silence, in its various forms, with the presence of HIV implicitly understood but not often explicitly spoken about. Although this gives more room for manoeuvre and for respect, silence too can be dangerous and certain situations dictate that it is better to breach the silence. More aggressive promotion of HIV testing needs to both respect and consider how to work within these existing dynamics to facilitate safe disclosure.

Negotiating multiple barriers: health workers' access to counselling, testing and treatment in Malawi.

Malawi is facing a severe HIV and AIDS epidemic with an estimated 12% of its population living with the virus. Health workers are on the front lines of the HIV epidemic and they face the risk of HIV infection in both their personal and professional lives. This mixed method study aimed to explore the enablers and barriers to HIV counselling and testing and antiretroviral therapy by health workers in Malawi. After qualitative data were collected through in-depth interviews with health workers in the Mchinji and Nsanje districts, a survey questionnaire was constructed and administered to 906 health workers in eight districts in Malawi. A majority (76%) of health workers surveyed reported having undergone HIV testing and counselling, of whom 74% reported repeat testing. A striking result of the study is that 22% of health workers reported testing after occupational exposure to HIV. The proportions of respondents reporting that they tested after experiencing symptoms, or self-testing for HIV were 11% each. The in-depth interviews and the survey revealed multiple challenges that health workers face to accessing HIV testing, counselling and treatment, including fear of a positive result, fear of stigma and lack of confidentiality. Additional barriers included health workers' personal acquaintance with those conducting testing, along with their perception of being "role models" which could exacerbate their fears about confidentiality. Given health workers' critical role in HIV delivery in Malawi, there is need to develop solutions to help health workers overcome these barriers.

HIV testing among bisexual men in the United States.

Little is known about HIV testing among bisexual men in the United States. Existing studies lack adequate representation, multivariate analytical strategies, and measurement of bisexuality indicators. To address these limitations, this study used the National Survey of Family Growth (N = 3,875). Sexual behavior and identity measures compared bisexual and other men along HIV testing history, reasons for testing, and recency of testing. Multivariate analyses adjusted for sociodemographic and risk factors that covary with testing. Bisexually active men were significantly less likely than homosexually active men to ever test, and they tested less often to know their HIV serostatuses. Bisexual identification decreased the odds of testing among bisexually active men but not others. Findings suggest that bisexual behavior and identity interact to decrease men's likelihoods of HIV testing. Interventions must recognize the potentially mediating roles of bisexual identity and behavior as well as risk factors that increase bisexual men's susceptibility to HIV infection.