In a study, brief risk-reduction counseling at the time of a rapid HIV test was not effective for reducing new sexually transmitted infections during the subsequent six months among people at risk for HIV.
In the U.S., approximately 1.1 million people are estimated to be living with HIV infection, according to background information in the study, which was published in the Oct. 23/30 issue of the Journal of the American Medical Association. About one in five people living with HIV is thought to be undiagnosed.
The U.S. Preventive Services Task Force recently recommended that all people ages 15 to 65 be screened for HIV. A major issue regarding HIV testing of such a large population is the effectiveness of HIV risk-reduction counseling at the time of testing, the researchers noted, because counseling involves considerable time, personnel and financial costs.
Lisa R. Metsch, PhD, of Columbia Universitys Mailman School of Public Health in New York City, and colleagues conducted a trial to assess the effectiveness of counseling in reducing STI incidence among STI clinic patients. From April to December 2010, Project AWARE randomized 5,012 patients from nine STI clinics in the U.S. to receive either brief patient-centered HIV risk-reduction counseling with a rapid HIV test or the rapid HIV test with information only. Participants were assessed for multiple STIs at both the beginning of the study and six-month follow-up.
The core elements of the counseling included a focus on the patients specific HIV/STI risk behavior and negotiation of realistic and achievable risk-reduction steps. The prespecified outcome was a cumulative incidence of any of the measured STIs over six months. All participants were tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, herpes simplex virus 2 and HIV. Women also were tested for Trichomonas vaginalis.
The researchers found no statistically significant difference in six-month composite STI incidence by study group: STI incidence was 250 of 2,039 (12.3%) in the counseling group and 226 of 2,032 (11.1%) in the information group. This pattern was consistent at all sites. Analyses by age group, race/ethnicity and sex (for heterosexuals) also demonstrated no effect of counseling on STI rates.
Despite the historical emphasis on risk-reduction counseling as integral to the HIV testing process, no contemporary data exist on the effectiveness of such counseling, the authors wrote. The results of Project AWARE help fill this gap.
Overall, these study findings lend support for reconsidering the role of counseling as an essential adjunct to HIV testing. This inference is further buttressed by the additional costs associated with counseling at the time of testing: Without evidence of effectiveness, counseling cannot be considered an efficient use of resources. Post-test counseling for persons testing HIV-positive remains essential, both for addressing psychological needs and for providing and ensuring follow-through with medical care and support.
A more focused approach to providing information at the time of testing may allow clinics to use resources more efficiently to conduct universal testing, potentially detecting more HIV cases earlier and linking and engaging HIV-infected people in care.
In an accompanying editorial, Jason S. Haukoos, MD, MSc, of the Denver Health Medical Center, and Mark W. Thrun, MD, of Denver Public Health, wrote: In an era of shrinking resources, clinicians and policymakers cannot ignore data that inform efficient clinical practice.
Maximizing identification of individuals with undiagnosed HIV infection and reducing viral transmission will require consistent and extensive HIV testing with emphasis, for those identified with HIV infection, on linkage to care, treatment and adherence. Although utilization of prevention counseling in the context of these post-HIV testing efforts remains to be characterized, results of the AWARE trial support the notion that prevention counseling in conjunction with HIV testing is not effective and should not be included as a routine part of practice.
Study abstract: http://jama.jamanetwork.com/article.aspx?articleid=1758751