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Fitzgerald, Maxi, Marcelin, Johnson, and Pape (2004) studied 1,168 Haitians in Port au Prince who tested HIV-positive and returned for posttest counseling. They found that refusal to notify a sexual partner of one's positive HIV status was associated with being poor and female and holding the belief that HIV transmission can occur by magic. Interestingly, acceptance of medical referral was also associated with holding the belief that HIV transmission can occur by magic. In addition, it was associated with expressing denial at the time HIV test results were received and having clinical symptoms associated with HIV disease at the time testing was voluntarily sought. Fitzgerald and colleagues conclude that "information collected during counseling can predict patient's future adherence with [risk reduction] counseling and medical referral. Counselors can use information such as signs of severe depression, gender, fear, economic status, magical beliefs, and denial to identify patients who are at risk for nonadherence and to adapt their counseling to respond to patient needs" (p. 662).
In another study focused on returning for HIV testing results, Desai and Rosenheck (2004) interviewed 5,890 homeless adults with severe mental illness (SMI) who were enrolled in a community-based, intensive case management program at baseline and again 3 months following enrollment.
Overall, 38.0% of clients were tested for HIV in the 3 months after program entry; of these, 88.8% returned to receive their test results. Likelihood of being tested was independently associated with having been tested before, more severe psychiatric symptoms and drug problems, level of worry about getting AIDS, younger age, less education, minority status, longer-term homelessness, being sexually assaulted, being arrested, and health services utilization. Among those tested, likelihood of receiving the test results was higher among those with a history of prior testing and return for results, a higher frequency of testing, and more years of education and lower among those with drug abuse problems, outpatient medical service utilization, disability, and [an STD other than HIV]. ... [F]or men, greater social support increased the likelihood of both HIV testing and receipt of results, while sexual victimization during follow-up decreased the likelihood that men would return for their HIV results. (p. 2287)
Desai and Rosenheck indicate that
[k]nowing whether clients have been tested previously and, if so, whether they received those earlier results will help clinicians to identify individuals who may benefit from additional and more careful follow-up. In addition, repeated HIV testing during follow-up increased the likelihood of actually getting the results and thus may prove to be a useful strategy in helping to increase HIV serostatus awareness among mentally ill homeless persons, who often live chaotic lives and for whom returning for test results may be a challenge. (p. 2293)
Drawing on earlier research studies and recent epidemiological information, Holtgrave and Anderson (2004) set out to differentiate and prioritize HIV prevention service needs for the diversity of Americans living with HIV. These investigators estimated transmission rates for a variety of populations: those unaware of their HIV status; those aware (through HIV testing) but not yet receiving counseling; those receiving counseling and no longer engaging in behavior that puts others at risk for infection; and those receiving counseling and continuing to engage in behavior that puts others at risk for infection. They write:
The overall, annual HIV transmission rate in the US has been about 4% since the early 1990s. ... [W]e find that the transmission rate for persons unaware of their HIV serostatus is approximately 10.79%, and for persons aware of their HIV seropositivity is about 1.73% overall. However, the latter statistic can be further disaggregated. For persons who receive HIV counselling and testing, and for whom these services are effective, the transmission rate is near 0%. For persons who do not receive counselling services as well as testing, or for whom counselling and testing [are] insufficient to induce behavioural change, the HIV transmission rate is between approximately 2% and 4%. (p. 789)
On the basis of these estimated transmission rates, along with the actual number of transmissions and the particular populations examined, Holtgrave and Anderson offer the following recommendations for prioritizing HIV prevention services for those who are living with HIV.
First and foremost, it seems that promoting knowledge of HIV serostatus for persons living with HIV but unaware of their serostatus is critical. Second, given the effectiveness level of HIV counselling and testing for modifying HIV transmission risk behaviours, it is imperative that testing be accompanied by appropriate counselling services. Third, even though counselling and testing [have] a high effectiveness level, [they do] not work to modify transmission risk behaviours for everyone. Therefore, during the course of ongoing clinical care, it is important to monitor for incident risk behaviours and [STDs]; the occurrence of either might suggest the need for an intensification of counselling, support and other prevention services. It is clear that different persons living with HIV will have different needs for various levels and types of HIV-prevention counselling services; the intensity of the services should be matched to the real needs of the client. (p. 791)
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Spring 2005 Newsletter
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