HIV Testing Services as Prevention

Introduction

  1. Definition of the Prevention Area

    HIV testing services (HTS) help to prevent HIV transmission by identifying HIV positivity and informing individuals, partners and couples, and families of their HIV status and counseling them to develop appropriate measures to prevent or minimize HIV risks in sexual behavior, alcohol and drug use, and other behaviors. These measures differ according to the serostatus of the individual or 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).

    HIV testing is also an essential step in access to other HIV services, including antiretroviral therapy (ART), prevention of mother-to-child transmission, and voluntary medical male circumcision. Successful HTS programs encompass effective linkages to clinical and community-based prevention, care and support, and treatment services.

    Note that the term "HIV testing services," as currently used, encompasses the full range of accompanying services. However, studies on testing use various terms, including VCT (voluntary counseling and testing), HTC (HIV testing and counseling), and others. The summaries in this collection reflect this diversity.

  2. Epidemiological Justification for the Prevention Area

    The evidence on whether HTS directly affects HIV incidence is mixed. However, studies show that HTS 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. Also, some studies show a reduction in sexual risk behaviors for HIV-negative concordant partners who are tested together using couples HTS. Other studies suggest reductions in risk behaviors after HTS (e.g., reduction of unprotected sex or in number of sexual partners).

    Studies on HTS 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 HTS may occur when HTS is available in the context of other harm reduction services. Serosorting, in which 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.

  3. Core Programmatic Components

    HTS is available through a wide variety of delivery models, and can be accessed through providers or initiated by clients. Provider-initiated HTS 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. In client-initiated HTS, an individual wants to get tested and searches for the best HTS center for him or her. This could include a stand-alone VCT site, a provider-initiated HTS site, or a community-based HTS site, such as a mobile or workplace HTS.

    HTS should be specific to the type of epidemic, population, and level of risk. In concentrated epidemics, offering HTS at specific sites, such as outreach centers or mobile facilities, may be the most effective way to provide HTS to hard-to-reach populations. The World Health Organization (WHO) states that in settings with concentrated and low-level epidemics, provider-initiated HTS should be considered for sexually transmitted infection and tuberculosis (TB) clinics, services for key populations, and childbirth, antenatal care, and postpartum services. In generalized epidemics, WHO recommends offering provider-initiated HTS at all clinical settings, including services for sexually transmitted infections, TB, and antenatal care, as well as in- and outpatient services. In generalized epidemics, stand-alone, mobile, and home-based testing approaches have also demonstrated increased uptake of HTS among harder-to-reach populations, such as rural or higher-risk groups. For mixed epidemics, HTS programming can use a range of these options based on the epidemiological and social context of the country.

    HTS, per WHO guidelines, includes the full range of services that should be provided in addition to HIV testing: counseling (pre-test information and post-test counseling); linkage to appropriate HIV prevention, treatment and care, and other clinical and support services; and coordination with laboratory services to ensure high-quality, accurate results. All forms of HIV testing should adhere to the WHO 5Cs: Consent, Confidentiality, Counseling, Correct test results, and Connection (linkage to prevention, treatment, and care services).

  4. Current Status of Implementation Experience

    The new global 90-90-90 targets call for 90 percent of all people with HIV to be diagnosed, 90 percent of people with HIV diagnosed to receive ART and 90 percent of those on ART to have a suppressed viral load by 2020. There have been significant increases in access to HTS; however, several challenges affect the diagnosis of HIV. HIV testing rates for men area generally lower than those for women in countries with high HIV prevalence where HTS is mainly offered in reproductive health services mostly antenatal care services. Provider-initiated HIV testing services need to be expanded to reach more pregnant women, children, TB patients, and adolescents. Access for key populations should be a priority because of marginalization and stigmatization. Generally, many people diagnosed with HIV are not linked to treatment and care because of barriers including transportation costs and distance to the facility, stigma, discrimination, fear of disclosure, staff shortages, and long waiting times, and because of policies that may prevent adolescents and key populations from accessing HTS.

UPDATED 7/2016

What We Know

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 (August 2011), 57(5): 435441. 

This study looked at women's sexual behavior before and after seroconversion. The subjects comprised 327 women who became HIV-positive while participating in a randomized controlled trial of lubricant gel and diaphragm use for HIV prevention in southern Africa. Every three months, the women gave information about sexual practices using computer-assisted self-interviews. Findings showed that they reduced their sexual risk behaviors, such as unprotected sex, anal sex, multiple sexual partners, and inconsistent condom use after seroconversion. However, the reduction in frequency of risk behaviors was modest: typically a 10 percent change. These findings, the authors said, suggested a need for more secondary prevention. The study design had several strengths, such as frequent interviewing, which reduces the risk of recall bias, and data collection both before and after seroconversion.

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 (July 2010), 10: 412. 

This study used data collected from 600 young people aged 18 to 24 years 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; conversely, among those who had never been pregnant, HIV testing 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 concluded that although HIV testing and counseling (HTC) may not have any immediate impact on behavior, repeated HTC over the long term may increase 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 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 (May 2010), Vol. 88 No. 8, pp. 615623.

This systematic review and meta-analysis of 19 studies assessed the effectiveness of positive prevention programs in developing countries; 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 that included 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 studies involving a total 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 does indeed affect 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. 

Lost Opportunities to Identify and Treat HIV-Positive Patients: Results from a Baseline Assessment of Provider-Initiated HIV Testing and Counseling in Malawi

Ahmed, S., Schwarz, M., Flick, R.J., et al. Tropical Medicine and International Health (February 2010), 21(4): 479485. 

This study reviewed implementation of provider-initiated testing and counseling (PITC) for HIV in Malawi's public sector by examining routinely collected program data and surveying 71 providers from 12 rural  facilities. PITC implementation varied by setting. Most providers reported practicing symptom-based PITC, which can miss the opportunity for early diagnosis. Antenatal clinics and maternity wards reported that routine opt-out PITC was widespread. HIV status was identified for more than 90 percent of patients at antenatal (92.6%) and tuberculosis (94.3%) clinics, and for about half of patients at sexually transmitted infection clinics. All providers reported test kit shortages as a challenge for PITC, along with inadequate physical space (80%), not enough trained counselors (45%) and, in inpatient units, the inability to perform HIV tests on weekends. All had at least one dedicated space for testing and counseling, which seems to be insufficient. Only 57 percent of facilities surveyed used a register to track PITC use. The high proportion of clients at ANC and TB clinics with known HIV status implies that routine testing is possible. The authors and others have worked with the Ministry of Health to develop clear policies on implementation, train a new cadre of counselors, and address supply  shortfalls.

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 (February 2010), 24:2: 117136.

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 in Uganda. 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. At follow-up, both HIV-positive and HIV-negative participants were significantly more likely to know their partners’ HIV status than at baseline; even so, only one-third knew their partners’ HIV status. Married or cohabiting individuals were more likely to find out their partners’ HIV status, but women were only half as likely as men to know their partner’s status either before or after HTC. Over 85 percent of participants who were found to be positive enrolled in care. While HTC had an effect on risky and safe sexual behaviors among certain groups in this study, it was not statistically significant; half of all participants were still engaging in risky sex. The authors concluded that provider-initiated HTC has the potential to increase testing, especially among first-time testers; but since the study only followed participants for six months, findings can only be generalized to a limited degree.

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 (April 2009), 38(4): 9971007.

This article presented the long-term findings from a prospective study of the pre- and post-test sexual behavior of 801 participants, of whom 151 were HIV-positive. The authors compared self-reported behavior among these 151 women before and after the testing. The proportion reporting any unprotected sex in the previous month dropped from approximately three-quarters before diagnosis to just over half at 12 to 16 months after diagnosis. Changes among the HIV-positive women included a reduction in overall frequency of sexual intercourse and an increase in condom use. However, uninfected women did not report a change in their pre- and post-test behavior. A strength of the study, the authors said, was that its results were more generalizable to African women compared to previous research, which focused on high-risk populations. However, the self-reported nature of the data could suggest bias, they said.

Serosorting and the Evaluation of HIV Testing and Counseling for HIV Prevention in Generalized Epidemics

Reniers, G., and Helleringer, S. AIDS and Behavior (January 2010), 15(1): 18.

This paper argued 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 an 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 said. First, it creates a bias by omitting a significant variable, since 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 were included in the evaluation process, the authors concluded, the impact of HTC interventions on behavioral change could be measured more accurately. 

Global Health Diplomacy, Monitoring and Evaluation, and the Importance of Quality Assurance and Control: Findings from NIMH Project Accept (HPTN 043): A Phase III Randomized Controlled Trial of Community Mobilization, Mobile Testing, Same-Day Results, and

Kevany, S., Khumalo-Sakutukwa, G., Singh, B. et al. PLOS ONE (February 2016), 11(2): e0149335.

This paper reported on quality assurance (QAC) procedures to measure the quality of service delivery within a cluster-randomized trial that assessed the effectiveness of a community-based voluntary counseling and testing (CBVCT) strategy. The QAC component, administered by supervisors, measured staff competence and adherence to the intervention protocol. Communities were randomly assigned to receive either the CBVCT plus standard clinic-based voluntary counseling and testing (SVCT) or SVCT alone. The CBVCT included three elements: mobile voluntary counseling and testing, community mobilization, and post-test support services (PTSS). Of the three elements, staff had most difficulty in implementing the PTSS, a new process that was also influenced by changes in staff and staff responsibilities. With feedback and training, performance in the PTSS area improved to the same standard as the other components by the intervention's second year. The authors said that providing a complex, multifaceted intervention is possible, and that QAC is feasible and acceptable to staff and study participants. They underscored the importance of efficient and effective QAC procedures to ensure that such interventions are delivered consistently and with high quality within HIV prevention trials and in programs. 

Seeking Wider Access to HIV Testing for Adolescents in Sub-Saharan Africa

Sam-Agudu, N.A., Folayan, M.O., and Ezeanolue, E.E. Pediatric Research (February 2016), doi: 10.1038/pr.2016.28, e-publication ahead of print.

This article reviewed access to HIV testing among adolescents in African countries with a high burden of adolescent HIV that are included in the "All In to #EndAdolescentAIDS" initiative. AIDS is now the leading cause of death in adolescents aged 10–19 in Africa. Difficulty accessing HIV testing services can lead to late or limited access to HIV treatment and care. Current data showed varied rates of testing between countries, but even the highest (44% among girls in Malawi) falls far short of the All In and UNAIDS target of 90 percent. Special attention is needed to make testing available for adolescents who acquired HIV perinatally and do not know their HIV status, began sex early, have multiple and/or older partners, are pregnant, or are female. Testing rates among adolescents are lower in West and Central Africa than in East and Southern Africa, with more restrictive age at consent requirements among the factors. Other major barriers include fear of the impact of an HIV diagnosis, including stigma and family response; provider attitudes; and parental consent requirements. A rights-based approach should guide access to testing for adolescents, the authors argued. They recommended several strategies to improve access: testing outside of health centers; training to sensitize health care providers; educating and involving parents; and legal and policy reform regarding consent. 

Implementation and Operational Research: Strengthening HIV Test Access and Treatment Uptake Study (Project STATUS): A Randomized Trial of HIV Testing and Counseling Interventions.

McNaghten, A.D., Schilsky Mneimneh, A., Farirai, T., et al Journal of Acquired Immune Deficiency Syndromes (December 2015), 70(4) e140146. 

This article described a randomized controlled trial testing the effect of three HIV testing and counseling (HTC) approaches on uptake of HIV testing and entry into care in outpatient departments (OPDs). Rates of HIV testing in OPDs are lower than in other clinical venues, and OPDs may offer opportunities to expand testing and channel HIV-positive patients into care. Thirty-six OPDs in South Africa, Tanzania, and Uganda were randomly assigned to offer patients HTC either a) after, b) during. or c) before the clinical consultation that prompted the visit. Eligible patients were age 1849, had not had an HIV test in the past year, and were not known to be HIV-positive. Forty-five percent of eligible patients were tested for HIV (N=16,099), and 10 percent tested positive. Model C, in which a nurse or lay counselor offered and provided HTC before clinical consultation, showed the highest proportion of testing (54.1%), followed by model A (after consultation) (41.7%) and model B (during the consultation) (33.9%). No significant differences were seen by model in the proportion referred for care (94% overall) or who entered care (58%). The authors concluded that routine HTC in OPDs is effective for identifying new HIV-positive patients, but called for more interventions to facilitate entry into care. 

Stage of HIV Presentation at Initial Clinic Visit Following a Community-Based HIV Testing Campaign in Rural Kenya

Haskew, J., Turner, K., Rø, G. et al. BMC Public Health (January 2015) 15(16), doi: 10.1186/s12889-015-1367.

This study analyzed whether a community-based integrated prevention campaign (IPC) in Western Kenya identified HIV-positive individuals earlier in the clinical course of HIV infection than HIV voluntary counseling and testing(VCT). The IPC comprised HTS, water filters, insecticide-treated bed nets, condoms, cotrimoxazole, and referral to care for those who tested positive. Data were derived from 1,752 adults (> 15 years) who tested positive through VCT or the IPC (n=108) and the regional hospital's clinic from 2008 to 2010. Regression models assessed the association of CD4 count and World Health Organization (WHO) clinical stage at the first appointment with age group, gender, marital status, and testing mode (VCT or IPC). Being male, divorced, widowed, or over 50 were independently associated with later-stage HIV presentation. The community-based IPC identified HIV-positive people earlier than VCT, measured both by mean CD4 count and WHO clinical stage. Patients who tested HIV positive during the IPC were more than twice as likely to present at the clinic for the first time with a CD4 count greater than 350 and with WHO clinical stage 1 or 2. The authors concluded that such community-based campaigns may be effective in implementing earlier testing and initiation of treatment, but underscored the need to improve referral to care and linkages between testing and treatment. 

Association of Sexual Risk Behavior with Previous HIV Testing Among VCT Clients in Kigali, Rwanda

Stalter, R., Chen, M., Uwizeye, G. et al. International Journal of Sexually Transmitted Diseases and AIDS (November 2015), pii: 0956462415617590, e-publication ahead of print.

The authors conducted secondary analysis to determine whether activities to encourage repeat testing in public-sector voluntary counseling and testing (VCT) facilities attract clients at high risk of HIV; and if repeat testing reduces risk behaviors. The study was conducted at all public-sector VCT sites in Kigali, Rwanda in June and July 2011. The analysis (N=1,852) included both people testing for the first time and those who had previously tested HIV-negative. The authors analyzed data from a cross-sectional survey to assess the association between repeat testing and recent sexual risk behaviors. The majority (86.4%) of participants reported having had at least one previous HIV test; 41.6 percent reported having one-two previous tests and 45 percent had had three or more HIV tests.  Repeat testing was associated with being female, older (age 2534) and occupation (drivers, uniformed service, informal merchants, or manual laborers). Individuals who had tested previously were more likely to report recent unprotected sex, and those with three or more previous HIV tests were more likely to have had multiple sexual partners. The authors concluded that the VCT program is reaching some of its goals, in that individuals who report high-risk behaviors are returning for repeat tests, but that it may not be as successful in addressing sexual risk behaviors.

Recruiting Male Partners for Couple HIV Testing and Counseling in Malawi's Option B+ Program: An Unblinded Randomized Controlled Trial

Rosenberg, N.E., Mtande, T.K., Saide, F. et al. Lancet HIV (November 2015). 2(11): e483491. 

This randomized controlled trial compared two approaches for recruiting male partners for couples HIV testing and counseling (CHTC) in Malawi’s option B+ prevention of mother-to-child transmission program. Two hundred HIV-positive pregnant women were enrolled in the study with 100 randomly assigned to each of two groups. In the first, women who met the eligibility criteria were given an invitation for their male partners to accompany them to the antenatal clinic (invitation-only). In the second group women were given the same invitation and, if the partner did not come to the clinic, he was traced by a community health worker through information provided by his partner (invitation plus tracing). The invitation plus tracing strategy was more effective; 74 couples reported to the clinic for CHTC, compared with 52 couples in the invitation-only group. These visits consisted of information on topics related to pregnancy, the importance of CHTC, and opt-out CHTC. Few social harms were found during women’s follow-up visits; 181 of the 200 women in the study provided follow-up data with no women reporting intimate partner violence, 2 reporting their relationships dissolved, and 1 reporting emotional distress. The authors concluded that the invitation plus tracing approach is very effective at increasing the uptake of CHTC.

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 (December 2004),37(5): 16201626.

This study assessed whether involving partners in antenatal HIV testing and counseling (HTC) 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 clinical 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 versus 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. Although male uptake of HTC was poor in this study population (with fewer than one in seven partners coming in for testing), the authors concluded that antenatal couple counseling could be a useful strategy for preventing HIV. 

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 2010), (9), Article Number CD001224, doi: 10.1002/14651858.CD001224.pub4.

This systematic review examined the efficacy of VCT in changing HIV-related risk behaviors among various populations in low- and middle-income countries. It included studies involving client-initiated VCT in low- or middle-income countries published in peer-reviewed journals between 1990 and 2010. The authors defined VCT as comprising pre-test counseling, HIV testing, and post-test counseling and test results, and included different modalities (clinic-, mobile-, and home-based VCT). The search of client-initiated testing (provider-initiated testing was analyzed separately) yielded 17 studies used in the qualitative synthesis, with 8 included in the meta-analysis. Most studies offered clinic-based VCT (12); the others offered employment-based (3), mobile (1), and home-based (1) VCT. Assessing differences in effects by modality was not possible. Decreased numbers of sexual partners and increased condom use were significant; when stratified by HIV status they remained significant for people found to be HIV-positive. VCT is an effective strategy for reducing some HIV-related risk behaviors, including decreasing the number of sexual partners and increasing condom use and protected sex among those who test positive, the authors said. They noted that HIV testing is critical for implementing new prevention approaches; and called for research about VCT implementation modalities and counseling strategies, and how to implement VCT to maximize its effectiveness on risk behavior and increase uptake of HIV-related care and treatment. 

Sexual Behavior of HIV Discordant Couples after HIV Counseling and Testing

Allen, S., Meinzen-Derr, J., Kautzman, M., et al. AIDS (March 2003), 17(5): 733740.

This study of 963 HIV-discordant heterosexual couples in Lusaka, Zambia looked at the effect of HIV counseling and testing (C&T) on sexual behavior. The participants self-reported condom use and underwent clinical tests for biological markers (sperm detected on vaginal smears, pregnancy, and four sexually transmitted infections—HIV, gonorrhea, syphilis, and Trichomonas vaginalis). Before HIV counseling and testing, fewer than 3 percent of couples reported using condoms; after C&T, the proportion exceeded 80 percent. 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 showed that joint counseling can improve condom use, and that biological markers can help identify under-reporting, the authors concluded. They also urged more work on strategies to encourage participants in future studies to report their behavior truthfully.

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 (July 2000), 356(9224): 103112.

This study examined 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, both couples and individuals in the HTC arm were significantly less likely to have unprotected sex with non-primary partners, and unprotected sex with the partners who enrolled with them. Among HIV-negative participants, the proportion having unprotected sex fell by roughly a third for women and by a fifth for men; 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 the first follow-up and were diagnosed as HIV-positive showed similarly reduced rates of unprotected sex at the second follow-up. The authors concluded that HTC does help 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 (April 2007), 44(5): 569577.

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 non-primary male partners. Men in the PCC arm reported significantly 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 posited that perhaps the emphasis on 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 decisionmaking, prompting them to take action.

Changes in Sexual Risk Behavior Among MSM Participating in a Research Cohort in Coastal Kenya

Möller, L.M., Stolte, I.G., Geskus, R.B. et al. AIDS (December 2015), 29:3: S211–2119.

This longitudinal study used data from two cohorts of HIV-negative and HIV-positive men who have sex with men (MSM) in Kenya to describe changes in sexual risk behavior ensuing from regular risk reduction counseling (RRC). The study included 561 men (16% HIV-positive and 84% HIV-negative). The analysis included time since enrollment to determine if any changes were sustained over time. At enrollment and monthly or quarterly follow-up visits, participants provided behavioral data; all received RRC, and seronegative men were tested for HIV. Results showed that both HIV-positive and HIV-negative participants reported fewer regular and casual sex partners, and fewer instances of unprotected anal intercourse. The time trend was only significant in HIV-negative men, possibly because of the sample size. HIV-positive men reported decreased insertive anal intercourse, and HIV-negative men reported decreases in receptive anal intercourse. The authors concluded that regular RRC can contribute to some reduction in sexual risk behavior, although it is not clear that it continues over time. This study also showed that it is possible to follow a cohort of MSM in a very unsupportive environment. HIV incidence is very high in Kenyan MSM; the authors urged combining RRC with comprehensive biomedical prevention.

Interventions with Injection Drug Users in Ukraine

Booth, R.E., Lehman, W.E., Dvoryak, S., et al. Addiction (November 2009), 104(11): 18641873.

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. However, younger people who inject drugs and those with a shorter history of injection drug use were more likely to engage in risky practices. These findings were discouraging in one sense, because they point to further escalation of the HIV epidemic among people who inject drugs in Ukraine. However, they also offered encouragement, because they had proved that it is possible to implement community-based interventions in this setting.

Putting it Into Practice

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 (July 2011),  16(5):121726. doi: 10.1007/s10461-011-0009-9.

This multi-site randomized controlled trial by Project Accept tested the hypothesis that voluntary HIV counseling and testing, offered along with community mobilization, would shift community norms and reduce HIV incidence. This paper offered a qualitative examination of the seven community mobilization strategies used in the trial: securing stakeholder commitment, forming community coalitions, engaging communities, conducting awareness-raising, involving leaders, and building partnerships. Using semi-structured interviews, the study found that no single strategy  was used alone. The study identified three elements that are crucial to the success of community mobilization. First, strategies evolved over time and were adapted during the process of community involvement. Second, it took time for acceptance to develop in communities. Third, each intervention site had unique characteristics that required tailored community mobilization activities. 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 (July 2011), 11(7):525532.

This paper presented an interim analysis of a 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, and the intervention ran 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 concluded.

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 (July 2008), 49(4):422431. 

This paper reported 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 compared  people living where community-based HTC is offered to people living in communities with standard HTC to determine whether those living where community-based HTC is offered would 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 suggested that this community-level intervention could create changes in social norms about HIV, and because of its low cost, could be replicated in resource-poor settings.

Home-based HIV Voluntary Counselling and Testing in Developing Countries

Bateganya, M.H., Abdulwadud, O.A., and Kiene, S. M. Cochrane Database of Systematic Reviews (October 2007),(4):, CD006493.

This review focused on 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 testing (in which HTC was offered at several locations, including the home) 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 concluded 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 in other sites, including the home. The review offered 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 (n.d.).

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 in Lusaka and the Copperbelt Region, Zambia. The group planned three 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; 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, and 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 key 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, and 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. Because of the limited 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 and Joint United Nations Programme on HIV/AIDS (2007).

To support multiple approaches to help people find out about their HIV status, the World Health Organization 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. The document also 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. Audiences at any level, from policymaker to health care provider, can find useful information in this document.

Consolidated Guidelines on HIV Testing Services 5Cs: Consent, Confidentiality, Counseling, Correct Results and Connection

World Health Organization (WHO) (July 2015).

Responding to requests from practitioners, WHO consolidated its guidance on HIV testing in this document. It uses the term HIV testing services (HTS) to expand on the concept of testing and counseling and encompass the range of services to be provided along with HIV testing: counseling, linkage to appropriate care and support, assurance of laboratory quality, and delivery of correct results. The document adds new recommendations on HIV testing by trained lay providers and on HIV testing in the context of surveillance; and otherwise draws together existing WHO guidance. Chapters address pre-test and post-test services including linkage to prevention, treatment, and care; service delivery recommendations; HIV testing for specific and priority populations (infants and children, adolescents, pregnant women, couples and partners including serodiscordant partners, men, key populations, and other populations); HTS approaches in different epidemic and population contexts; how to conduct testing and quality assurance; testing and diagnosis in the context of surveillance; and monitoring and evaluation. The document also reinforces the important role of HTC in the global HIV response.

Tools and Curricula

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 delivering HIV services, the document 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 the service delivery level. A bibliography of recommended core and additional resources, as well as an extensive glossary, completes the document.

Couples HIV Counseling and Testing Intervention and Training Curriculum

U.S. Centers for Disease Control and Prevention (2011).

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, and Centers for Disease Control and Prevention (2010).

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 so that they can integrate family planning and reproductive health needs and involve 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 and a Manual for Trainers

Fischer, S., Reynolds, H., Yacobson, I., et al. (2007).

The skills and knowledge need to counsel youth about HIV are different from those needed when counseling adults. This website offers two resources for providing, or learning about providing, HIV counseling for young people. The provider's manual offers best practices for offering HIV testing services (HTS) to youth for service providers at all levels. There are chapters on the differences in counseling youth compared to adults and specifically on HTS. Sexually transmitted infections, pregnancy prevention, life skills, and creating a referral network are also covered. The companion training guide  can be used to train experienced HIV counselors on offering HTS to youth. Among other tools, the training guide includes slides, interactive exercises, and practice sessions. 

Testing and Counselling for Prevention of Mother-to-Child Transmission of HIV (TC for PMTCT): Support Tools [2011 Edition]

U.S. Centers for Disease Control and Prevention (CDC) (20011).

This set of tools was developed in 2005 to guide the delivery of essential prevention of mother-to-child transmission (PMTCT) messages and were subsequently updated to reflect guidelines from the CDC and the World Health Organization. To meet 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.

Additional Resources

Can Couples Testing Contribute to Achieving the AIDS Transition?

Over, M. (2010).

This blog entry examined couples counseling within the context of the economic theory of asymmetric information, also referring to epidemiologic findings on its efficacy. Using observational data from several different countries, the author suggested 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 of the HIV epidemic, the author argued. 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 said. He added 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., and Caceres C. The Lancet (August 2008), 372(9639): 669684.

This article argued that the radical behavioral change needed to reduce HIV transmission requires radical commitment. Reviewing 25 years of HIV prevention efforts, the authors identified successful HIV prevention interventions and ways to improve behavioral strategies to reduce HIV transmission. They stressed the need to combine behavioral, biomedical, and structural approaches to fight HIV transmission effectively. To date, behavioral changes have reduced HIV in certain countries, regions, or subpopulations because of 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, the authors noted. They concluded that behavioral strategies must take place in combination with different approaches and at multiple levels of influence. 

Publications on HIV Testing Services

World Health Organization (n.d.).

This webpage of the World Health Organization’s Department of HIV/AIDS lists all publications on testing and counseling/HIV testing services starting from 2000. Readers can link back from here to the department’s main HIV testing services page, which includes policy and guidance, advocacy, training materials, data on HIV counseling and testing, and more.