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AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
HIV testing, counselling and partner notification R. A. Keenlyside
a
a
University College & Middlesex School of Medicine , London, W1N 8AA, UK Published online: 25 Sep 2007.
To cite this article: R. A. Keenlyside (1991) HIV testing, counselling and partner notification, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 3:4, 413-417, DOI: 10.1080/09540129108251601 To link to this article: http://dx.doi.org/10.1080/09540129108251601
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
413
AIDS CARE, VOL. 3, NO. 4,1991
HIV testing, counselling and partner notification R. A. KEENLYSIDE Downloaded by [Monash University Library] at 07:20 01 February 2015
University College & Middlesex School of Medicine, London W l N 8AA, UK
Introduction Reports detailing HIV counselling practices, serological testing and patient management were plentiful at the conference this year. But while the number of presentations devoted to these issues, at over 100 reports, was similar to last year, the past year has seen these issues recede somewhat in controversy. The conference featured no focused discussion of these matters; rather, relevant reports were scattered throughout the conference programme. The majority of reports were from US investigators. There were some interesting presentations from France and Italy, but disappointingly, contributions from other European countries and less developed countries were noticeably absent. Increasing concern about the spread of HIV/AIDS among heterosexuals, and especially women, was reflected in several papers describing preventive services and testing programmes for HIV in these groups. There were few reports, however, of the results of partner notification programmes, although these were sometimes alluded to in other reports. This review will concentrate on studies of the impact of counselling, the characteristics and attitudes of client populations, partner notification programmes, and opera-
tional research studies of counselling and testing (CT) services. Otten (MC103) evaluated the impact of HIV post-test counselling on behaviour change by comparing the infection rates for sexually transmitted diseases (STD) before and after HIV testing in persons seen at a busy STD clinic in Florida. Surprisingly, STD increased by over 100% in HIV seronegative clients who were told the negative results of their tests and were then counselled. This compares with only a 25% increase in those who did not receive the results of their tests and thus received no counselling. Those who were HIV seropositive showed a decrease. Although it was not possible to differentiate between the effects of counselling and merely being told the test result, this study seems to imply that posttest counselling may not be effective in seronegative persons with high risk behaviour. Perhaps programmes giving continued support for these individuals need to be developed. Rugg (MD4016) studied self reported changes in sexual and drug using behaviour following HIV C T among 139 drug users in methadone treatment centres in New York. Condom use doubled for those who were HIV positive and sharing needles and syringes decreased in all groups. In a similar
Downloaded by [Monash University Library] at 07:20 01 February 2015
414
FLORENCE SUh4MARIES: R. A. KEENLYSIDE
study of 1,016 clients in a New York STD clinic (Bevier, WD4281), overall sexual activity declined, as well as the total number of partners among males and females. Although some of these findings were encouraging, little information was given about how much continuing support was required to sustain these effects. Elsewhere, counselling programmes have been less successful in inducing sustained behaviour change. Gregis (MD4119) in Bergamo, Italy, studied the knowledge, attitudes and behaviour of 462 HIV infected persons; mainly young male injecting drug users. Although most said they were satisfied with the counselling they received, disturbingly, only 57% abstained from needle sharing and 8.4% continued to share frequently after being told of their positive test. Many did not inform their sexual partners of their infection, only 53% always used condoms for sexual intercourse with their seronegative partners and 20% used them rarely or never. Gibson (ThD59) reported the results from a randomized clinical trial to evaluate the relative merits of brief counselling for reducing the risk of infection among 300 injecting drug users in California. Clients were given either brochures or brief counselling at random and followed up at 10 days, three months and one year. Counselling resulted in a significant early decrease in unprotected sexual intercourse, which was partly sustained after a year, and needle sharing was reduced in both groups. Attitudes of clients to testing programmes
There is little information available about the attitudes of heterosexual men and women toward seeking HIV C T testing. Testing for HIV before first sexual intercourse or first sex without using a condom is now increasingly common among heterosexual couples in France. Allegrhe (MC3328) reported that the couples requesting the test for these reasons were characteristically younger, more highly educated and had
longer relationships than couples tested for other reasons. The women in these relationships were more likely to suggest being tested than their male partners. Among 200 heterosexuals attending an STD clinic in London who opted not to be tested, the commonest reasons for refusal were a fear of loss of confidentiality among males and fear of an inability to cope with the knowledge of a positive test in females (Kell, MD4151). Opposition to testing among homosexual men has been strong in the past, but some indications are that their opinions are changing. Henry (MD56) studied the factors affecting the decision to seek an HIV antibody test and the reasons for not being tested among a sample of 1,295 gay and bisexual men recruited from bars and bathhouses in Canada. The proportion opting for testing (56%) was higher than expected and, of those, 13% were seropositive. Concerns about confidentiality, anonymity and perceived effectiveness of treatment remain substantial, however, among many in this high risk population and present barriers to programmes that aim to promote testing and early identification of HIV infection. Programmes for screening pregnant women for HIV infection have been established in several countries. Reports of seroprevalence rates in these programmes ranged from 28% of women tested in an antenatal clinic in Uganda (Hom, WC3262) to 1.6% of women in Barcelona, Spain (Coll, WC3281) and 0.15% of women delivered in the US (Gwinn, WC34). Recently reported rates in the UK were found to be 0.19% in London and less than 0.01% outside the Thames regions (CDSC PHLS UK). In Sweden and Norway, routine national antenatal HIV screening programmes have been in place since 1987 and have had high acceptance rates of 90-95% (Lindgren, WC3278; Samdal, WC3279). After three years of testing, the seroprevalence rates in Sweden were 0.001% in 324,256 women tested and 0.008% in 276,852 women tested in Norway. There have been concerns about the
Downloaded by [Monash University Library] at 07:20 01 February 2015
HIV TESTING, COUNSELLING 81 PARTNER NOTIFICATION
acceptability of routine testing of pregnant women in the UK, and Meadows (MC3330) questioned 300 London antenatal patients about this. HIV testing was acceptable as a routine test to 54% of the patients. At the same time, 86% believed they were not at risk and only 36% finally elected to be tested. Less than a third of participants were satisfied with their counselling and the knowledge of HIV was particularly poor among persons from ethnic minorities. The authors believed that clients may have refused testing after inadequate pretest counselling, and this should be improved. In a similar study in the US (McGuinness, MC3334), 59% of 219 antenatal patients accepted the test after counselling and 81% returned later for the result. In Switzerland, Weiser (MC3333) examined the effectiveness of communication with patients during routine pretest counselling. Among 105 seronegative women questioned, only 58% recalled being informed of the test when first seen and 4.7% would have refused the test if offered it. Only 56% were given the test result afterward. Again, it was felt that staff should be trained to provide better counselling. A study from Zaire highlighted the need for specific culturally appropriate intervention programmes for prevention of HIV in women. Batter (MD4013) evaluated the impact of counselling women about their infected status on their plans for pregnancy and future family life. Among 365 seropositive women questioned, 30% did not want to tell their partners and 68% said their HIV infection and the known risks of transmission to the child would not affect their future plans for pregnancy. Counselling and partner notification It has now been ten years since the first report of AIDS but the appropriate role for partner notification and referral in prevention and control programmes is still controversial. Bayer (MD4219) discussed the significance and origins of the US debate in a
4 15
poster titled ‘The two faces of partner notification’. He concluded that ‘public health authorities have an ethical obligation to create the institutional mechanisms to assure that such notification takes place’. The epidemic has now encircled the globe and was first detected in the Eskimo population of Greenland in 1985, where it prompted an aggressive public health response (Melbye MC3276). Although the number of cases reported so far is small, the proportion that are heterosexually acquired is high (71% of cases in 1990) and seropositivity rates were comparable to those found in large cities in Europe. In response to this, a national registry of cases that identifies individuals has been established and there is active tracing of the contacts of all positive patients over the previous two years. The system has already uncovered a cluster of 8 infected persons in a chain with another 19 uninfected persons with known exposure to the infection. One report from the US detailed the success of a partner notification programme in which intensive counselling was a foundation for a combined patient/provider approach to referral. (Daniell, MC3327). Only 53% of 531 HIV positive index patients gave adequate information. for identifying contacts. Among these, 33 (88%) of 43 regular contacts of the past year were traced (11 were found to be infected) and 64 (28%) of 229 regular contacts of more than one year ago were traced, of whom one was found to be infected. Approximately a third of the partners named by the index case were notified within a year; of these, 86% required long distance notification through other agencies. It appears, however, that this programme was only moderately successful in achieving its goals. The numbers of successful notifications were relatively small; only 37% of all the potentially identifiable contacts were traced. Twelve percent of the contacts were found to be infected, but unfortunately, there was no inforrnation about the risk categories of patients and their contacts and
Downloaded by [Monash University Library] at 07:20 01 February 2015
4 16 FLORENCE SUMMARIES: R. A. KEENLYSIDE whether the latter already knew of their infection or could have been identified by other means. The overall cost of the programmes was $1 15 per index person and $75 for each reportable contact. The UK has no national guidelines for partner notification (PN) for patients with HIV infection. Keenlyside (MC3335) surveyed physicians and health advisers in STD clinics to determine their attitudes and practices regarding PN. Overall, 62% of all staff discussed PN during pretest counselling and 89% encouraged infected persons to notify their contacts; only 56%,however, would offer the services of the clinic staff for this purpose. Health advisers, especially in the London regions, were generally more opposed than physicians to informing partners of infected persons and more likely to agree that programmes for PN would deter clinic attendance, undermine patient confidentiality and make contacts unnecessarily anxious. They also questioned the importance of PN in epidemic control; the rights of contacts to know of their exposure; the value of early interventions and the ability of existing services to cope with a demand for more counselling. The difficulties in providing appropriate counselling services in areas of high seroprevalence in Thailand were described by Taywaditep (MC3329). In a survey of 168 physicians, nurses and social workers in a large medical centre, almost all staff thought that pre and post test counselling was necessary but less than half gave it routinely. Test results were frequently not given to patients and almost all seropositive patients had no follow up counselling. These failures were ascribed to lack of time and opportunities for counselling and poor coordination between professionals. The authors suggested that a single centralised counselling service may be more effective than several scattered throughout the institution. Impact of services for counselling and testing
A total of 2.3 million HIV tests were re-
ported from publicly supported STD and HIV C T clinics in the US during 1989-90. Investigators from the Centers for Disease Control analysed the data from these sites to estimate the extent of CT nationwide, the characteristics of the clients using these services and those who failed to return for a test result. (West, MC3339; Moore, MC3342; Anderson, MC3337; Campbell, MC3341; Kirby, WC38). Using data from the National Health Interview Surveys and publicly funded C T sites, they estimated that 24% of the US adult population had been tested for HIV by 1990, two thirds of whom were tested in relation to blood donation/transfusion. Those in high risk categories were more likely to use public clinics and were tested at higher rates. Even so, 66% of these persons in high risk categories had not been tested and services in STD clinics in cities with high rates of syphilis and HIV infection were seen to be failing to reach these groups. Females, AfroAmericans and residents of the Mid-West region had lower rates of voluntary testing. Overall, 36% of those tested failed to return for the test result. The failure to return rate (FTRR) was lowest in anonymous test sites and highest in STD clinics. Those least likely to return were young black women, those who were seronegative, heterosexuals, prostitutes and those who had received no pretest counselling. The FTRR was lowest among persons who had symptoms, an HIV positive partner or who were anxious about being infected. The quality of services for women has received more attention recently. Women appear to present with more advanced disease with a worse prognosis, and this has been attributed to poor access to medical care and underdiagnosed HIV infections. In 1989-90, over 1 million women were counselled and tested in public C T sites in the US, representing 48% of all consultations (Cahil, MC3336). Schoenbaum (WC3093) reported that among patients seeking care in an emergency room in New York City, HIV infection, when present, was 33% less likely
Downloaded by [Monash University Library] at 07:20 01 February 2015
HIV TESTING, COUNSELLING 8 PARTNER NOTIFICATION
4 17
to be diagnosed in women than in men. Conclusions and future needs Their infection was most commonly identiThis year’s presentations of C T programmes fied only when they developed AIDS. Called have provided valuable information on the for are improved services for women and a characteristics and attitudes of clients and greater awareness among health professiontheir use of different services and have docals that women are likely to be infected. umented some success in achieving shortIn a report from France, Serafy term changes in high risk behaviour. They (WD4289) described the establishment of have also raised concerns about the quality free and anonymous C T sites in 119 departand coverage of counselling services and the ments since 1988. Since then, 600,000 HIV impact of health education. Notably, these tests have been done in France, 60,000 of concerns were that clients in high risk categwhich were performed in these centres. The ories are not receiving counselling; that serprevalence of HIV carriers in France is apvices for women are inadequate; that imporproximately 100-200,000, but those who are tant facts about HIV are misunderstood by tested are not those at the highest risk. T o certain groups; counselling before and after investigate this, Dab (MD4148) studied the HIV testing is often overlooked, and that knowledge and practices of persons over 18 counsellors communicate poorly with clients years old in the Paris region in 1987 and and need more training. More detailed studagain in 1990. The percentage of persons ies of the performance of programmes are who had been tested for HIV in the previous needed to confirm these impressions and to 12 months increased from 11.2% in 1987 to develop interventions to correct these prob21.7% in 1990; 36% were self initiated, 28% lems. In particular, more studies are refollowed medical advice and others were quired of the efficacy and cost benefit of associated with blood donation. Factors asalternative counselling techniques and the sociated with being tested were knowledge resources needed to monitor and sustain about transmission, disagreement with coerlong term behaviour change need to be cive attitudes, self perception of being at identified. Health care providers should be high risk, use of condoms, having more than encouraged to study and report on the one sexual partner and a positive opinion effectiveness and cost benefit of different about education campaigns. The authors approaches to partner notification and refersuggested that voluntary testing may be effiral in order to inform discussion about the cient if confidentiality and absence of disrole of this in prevention programmes. crimination could be guaranteed.
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
HIV testing, counselling and partner notification R. A. Keenlyside
a
a
University College & Middlesex School of Medicine , London, W1N 8AA, UK Published online: 25 Sep 2007.
To cite this article: R. A. Keenlyside (1991) HIV testing, counselling and partner notification, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 3:4, 413-417, DOI: 10.1080/09540129108251601 To link to this article: http://dx.doi.org/10.1080/09540129108251601
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
413
AIDS CARE, VOL. 3, NO. 4,1991
HIV testing, counselling and partner notification R. A. KEENLYSIDE Downloaded by [Monash University Library] at 07:20 01 February 2015
University College & Middlesex School of Medicine, London W l N 8AA, UK
Introduction Reports detailing HIV counselling practices, serological testing and patient management were plentiful at the conference this year. But while the number of presentations devoted to these issues, at over 100 reports, was similar to last year, the past year has seen these issues recede somewhat in controversy. The conference featured no focused discussion of these matters; rather, relevant reports were scattered throughout the conference programme. The majority of reports were from US investigators. There were some interesting presentations from France and Italy, but disappointingly, contributions from other European countries and less developed countries were noticeably absent. Increasing concern about the spread of HIV/AIDS among heterosexuals, and especially women, was reflected in several papers describing preventive services and testing programmes for HIV in these groups. There were few reports, however, of the results of partner notification programmes, although these were sometimes alluded to in other reports. This review will concentrate on studies of the impact of counselling, the characteristics and attitudes of client populations, partner notification programmes, and opera-
tional research studies of counselling and testing (CT) services. Otten (MC103) evaluated the impact of HIV post-test counselling on behaviour change by comparing the infection rates for sexually transmitted diseases (STD) before and after HIV testing in persons seen at a busy STD clinic in Florida. Surprisingly, STD increased by over 100% in HIV seronegative clients who were told the negative results of their tests and were then counselled. This compares with only a 25% increase in those who did not receive the results of their tests and thus received no counselling. Those who were HIV seropositive showed a decrease. Although it was not possible to differentiate between the effects of counselling and merely being told the test result, this study seems to imply that posttest counselling may not be effective in seronegative persons with high risk behaviour. Perhaps programmes giving continued support for these individuals need to be developed. Rugg (MD4016) studied self reported changes in sexual and drug using behaviour following HIV C T among 139 drug users in methadone treatment centres in New York. Condom use doubled for those who were HIV positive and sharing needles and syringes decreased in all groups. In a similar
Downloaded by [Monash University Library] at 07:20 01 February 2015
414
FLORENCE SUh4MARIES: R. A. KEENLYSIDE
study of 1,016 clients in a New York STD clinic (Bevier, WD4281), overall sexual activity declined, as well as the total number of partners among males and females. Although some of these findings were encouraging, little information was given about how much continuing support was required to sustain these effects. Elsewhere, counselling programmes have been less successful in inducing sustained behaviour change. Gregis (MD4119) in Bergamo, Italy, studied the knowledge, attitudes and behaviour of 462 HIV infected persons; mainly young male injecting drug users. Although most said they were satisfied with the counselling they received, disturbingly, only 57% abstained from needle sharing and 8.4% continued to share frequently after being told of their positive test. Many did not inform their sexual partners of their infection, only 53% always used condoms for sexual intercourse with their seronegative partners and 20% used them rarely or never. Gibson (ThD59) reported the results from a randomized clinical trial to evaluate the relative merits of brief counselling for reducing the risk of infection among 300 injecting drug users in California. Clients were given either brochures or brief counselling at random and followed up at 10 days, three months and one year. Counselling resulted in a significant early decrease in unprotected sexual intercourse, which was partly sustained after a year, and needle sharing was reduced in both groups. Attitudes of clients to testing programmes
There is little information available about the attitudes of heterosexual men and women toward seeking HIV C T testing. Testing for HIV before first sexual intercourse or first sex without using a condom is now increasingly common among heterosexual couples in France. Allegrhe (MC3328) reported that the couples requesting the test for these reasons were characteristically younger, more highly educated and had
longer relationships than couples tested for other reasons. The women in these relationships were more likely to suggest being tested than their male partners. Among 200 heterosexuals attending an STD clinic in London who opted not to be tested, the commonest reasons for refusal were a fear of loss of confidentiality among males and fear of an inability to cope with the knowledge of a positive test in females (Kell, MD4151). Opposition to testing among homosexual men has been strong in the past, but some indications are that their opinions are changing. Henry (MD56) studied the factors affecting the decision to seek an HIV antibody test and the reasons for not being tested among a sample of 1,295 gay and bisexual men recruited from bars and bathhouses in Canada. The proportion opting for testing (56%) was higher than expected and, of those, 13% were seropositive. Concerns about confidentiality, anonymity and perceived effectiveness of treatment remain substantial, however, among many in this high risk population and present barriers to programmes that aim to promote testing and early identification of HIV infection. Programmes for screening pregnant women for HIV infection have been established in several countries. Reports of seroprevalence rates in these programmes ranged from 28% of women tested in an antenatal clinic in Uganda (Hom, WC3262) to 1.6% of women in Barcelona, Spain (Coll, WC3281) and 0.15% of women delivered in the US (Gwinn, WC34). Recently reported rates in the UK were found to be 0.19% in London and less than 0.01% outside the Thames regions (CDSC PHLS UK). In Sweden and Norway, routine national antenatal HIV screening programmes have been in place since 1987 and have had high acceptance rates of 90-95% (Lindgren, WC3278; Samdal, WC3279). After three years of testing, the seroprevalence rates in Sweden were 0.001% in 324,256 women tested and 0.008% in 276,852 women tested in Norway. There have been concerns about the
Downloaded by [Monash University Library] at 07:20 01 February 2015
HIV TESTING, COUNSELLING 81 PARTNER NOTIFICATION
acceptability of routine testing of pregnant women in the UK, and Meadows (MC3330) questioned 300 London antenatal patients about this. HIV testing was acceptable as a routine test to 54% of the patients. At the same time, 86% believed they were not at risk and only 36% finally elected to be tested. Less than a third of participants were satisfied with their counselling and the knowledge of HIV was particularly poor among persons from ethnic minorities. The authors believed that clients may have refused testing after inadequate pretest counselling, and this should be improved. In a similar study in the US (McGuinness, MC3334), 59% of 219 antenatal patients accepted the test after counselling and 81% returned later for the result. In Switzerland, Weiser (MC3333) examined the effectiveness of communication with patients during routine pretest counselling. Among 105 seronegative women questioned, only 58% recalled being informed of the test when first seen and 4.7% would have refused the test if offered it. Only 56% were given the test result afterward. Again, it was felt that staff should be trained to provide better counselling. A study from Zaire highlighted the need for specific culturally appropriate intervention programmes for prevention of HIV in women. Batter (MD4013) evaluated the impact of counselling women about their infected status on their plans for pregnancy and future family life. Among 365 seropositive women questioned, 30% did not want to tell their partners and 68% said their HIV infection and the known risks of transmission to the child would not affect their future plans for pregnancy. Counselling and partner notification It has now been ten years since the first report of AIDS but the appropriate role for partner notification and referral in prevention and control programmes is still controversial. Bayer (MD4219) discussed the significance and origins of the US debate in a
4 15
poster titled ‘The two faces of partner notification’. He concluded that ‘public health authorities have an ethical obligation to create the institutional mechanisms to assure that such notification takes place’. The epidemic has now encircled the globe and was first detected in the Eskimo population of Greenland in 1985, where it prompted an aggressive public health response (Melbye MC3276). Although the number of cases reported so far is small, the proportion that are heterosexually acquired is high (71% of cases in 1990) and seropositivity rates were comparable to those found in large cities in Europe. In response to this, a national registry of cases that identifies individuals has been established and there is active tracing of the contacts of all positive patients over the previous two years. The system has already uncovered a cluster of 8 infected persons in a chain with another 19 uninfected persons with known exposure to the infection. One report from the US detailed the success of a partner notification programme in which intensive counselling was a foundation for a combined patient/provider approach to referral. (Daniell, MC3327). Only 53% of 531 HIV positive index patients gave adequate information. for identifying contacts. Among these, 33 (88%) of 43 regular contacts of the past year were traced (11 were found to be infected) and 64 (28%) of 229 regular contacts of more than one year ago were traced, of whom one was found to be infected. Approximately a third of the partners named by the index case were notified within a year; of these, 86% required long distance notification through other agencies. It appears, however, that this programme was only moderately successful in achieving its goals. The numbers of successful notifications were relatively small; only 37% of all the potentially identifiable contacts were traced. Twelve percent of the contacts were found to be infected, but unfortunately, there was no inforrnation about the risk categories of patients and their contacts and
Downloaded by [Monash University Library] at 07:20 01 February 2015
4 16 FLORENCE SUMMARIES: R. A. KEENLYSIDE whether the latter already knew of their infection or could have been identified by other means. The overall cost of the programmes was $1 15 per index person and $75 for each reportable contact. The UK has no national guidelines for partner notification (PN) for patients with HIV infection. Keenlyside (MC3335) surveyed physicians and health advisers in STD clinics to determine their attitudes and practices regarding PN. Overall, 62% of all staff discussed PN during pretest counselling and 89% encouraged infected persons to notify their contacts; only 56%,however, would offer the services of the clinic staff for this purpose. Health advisers, especially in the London regions, were generally more opposed than physicians to informing partners of infected persons and more likely to agree that programmes for PN would deter clinic attendance, undermine patient confidentiality and make contacts unnecessarily anxious. They also questioned the importance of PN in epidemic control; the rights of contacts to know of their exposure; the value of early interventions and the ability of existing services to cope with a demand for more counselling. The difficulties in providing appropriate counselling services in areas of high seroprevalence in Thailand were described by Taywaditep (MC3329). In a survey of 168 physicians, nurses and social workers in a large medical centre, almost all staff thought that pre and post test counselling was necessary but less than half gave it routinely. Test results were frequently not given to patients and almost all seropositive patients had no follow up counselling. These failures were ascribed to lack of time and opportunities for counselling and poor coordination between professionals. The authors suggested that a single centralised counselling service may be more effective than several scattered throughout the institution. Impact of services for counselling and testing
A total of 2.3 million HIV tests were re-
ported from publicly supported STD and HIV C T clinics in the US during 1989-90. Investigators from the Centers for Disease Control analysed the data from these sites to estimate the extent of CT nationwide, the characteristics of the clients using these services and those who failed to return for a test result. (West, MC3339; Moore, MC3342; Anderson, MC3337; Campbell, MC3341; Kirby, WC38). Using data from the National Health Interview Surveys and publicly funded C T sites, they estimated that 24% of the US adult population had been tested for HIV by 1990, two thirds of whom were tested in relation to blood donation/transfusion. Those in high risk categories were more likely to use public clinics and were tested at higher rates. Even so, 66% of these persons in high risk categories had not been tested and services in STD clinics in cities with high rates of syphilis and HIV infection were seen to be failing to reach these groups. Females, AfroAmericans and residents of the Mid-West region had lower rates of voluntary testing. Overall, 36% of those tested failed to return for the test result. The failure to return rate (FTRR) was lowest in anonymous test sites and highest in STD clinics. Those least likely to return were young black women, those who were seronegative, heterosexuals, prostitutes and those who had received no pretest counselling. The FTRR was lowest among persons who had symptoms, an HIV positive partner or who were anxious about being infected. The quality of services for women has received more attention recently. Women appear to present with more advanced disease with a worse prognosis, and this has been attributed to poor access to medical care and underdiagnosed HIV infections. In 1989-90, over 1 million women were counselled and tested in public C T sites in the US, representing 48% of all consultations (Cahil, MC3336). Schoenbaum (WC3093) reported that among patients seeking care in an emergency room in New York City, HIV infection, when present, was 33% less likely
Downloaded by [Monash University Library] at 07:20 01 February 2015
HIV TESTING, COUNSELLING 8 PARTNER NOTIFICATION
4 17
to be diagnosed in women than in men. Conclusions and future needs Their infection was most commonly identiThis year’s presentations of C T programmes fied only when they developed AIDS. Called have provided valuable information on the for are improved services for women and a characteristics and attitudes of clients and greater awareness among health professiontheir use of different services and have docals that women are likely to be infected. umented some success in achieving shortIn a report from France, Serafy term changes in high risk behaviour. They (WD4289) described the establishment of have also raised concerns about the quality free and anonymous C T sites in 119 departand coverage of counselling services and the ments since 1988. Since then, 600,000 HIV impact of health education. Notably, these tests have been done in France, 60,000 of concerns were that clients in high risk categwhich were performed in these centres. The ories are not receiving counselling; that serprevalence of HIV carriers in France is apvices for women are inadequate; that imporproximately 100-200,000, but those who are tant facts about HIV are misunderstood by tested are not those at the highest risk. T o certain groups; counselling before and after investigate this, Dab (MD4148) studied the HIV testing is often overlooked, and that knowledge and practices of persons over 18 counsellors communicate poorly with clients years old in the Paris region in 1987 and and need more training. More detailed studagain in 1990. The percentage of persons ies of the performance of programmes are who had been tested for HIV in the previous needed to confirm these impressions and to 12 months increased from 11.2% in 1987 to develop interventions to correct these prob21.7% in 1990; 36% were self initiated, 28% lems. In particular, more studies are refollowed medical advice and others were quired of the efficacy and cost benefit of associated with blood donation. Factors asalternative counselling techniques and the sociated with being tested were knowledge resources needed to monitor and sustain about transmission, disagreement with coerlong term behaviour change need to be cive attitudes, self perception of being at identified. Health care providers should be high risk, use of condoms, having more than encouraged to study and report on the one sexual partner and a positive opinion effectiveness and cost benefit of different about education campaigns. The authors approaches to partner notification and refersuggested that voluntary testing may be effiral in order to inform discussion about the cient if confidentiality and absence of disrole of this in prevention programmes. crimination could be guaranteed.
