HIV-1 Counseling and Testing Sites, Minnesota: Analysis of Trends in Client Charactertistics RICHARD N. DANILA, PHD, MPH, JAMES M. SHULTZ, MS, PHD, MICHAEL T. OSTERHOLM, PHD, MPH, KEITH HENRY, MD, MARGARET L. SIMPSON, MD, AND KRISTINE L. MACDONALD, MD Abstract: We report here a summary of the data obtained from two HIV-1 antibody counseling and testing sites in Minneapolis-St. Paul for the first 48 months of operation (24,911 persons tested). The HIV-1 antibody seroprevalence rate for all persons tested was 5 percent. The highest seroprevalence rates were in male homosexual/ bisexual intravenous drug users (23 percent) and homosexual/ bisexual men (13 percent). There was a significant decrease in the HIV-1 antibody seroprevalence rate among clients during the 48-
month period from 14 percent in the first six months to 3 percent in the last six months. This decrease coincided with an increase in the number of low-risk female clients and low-risk heterosexual male clients, and a decrease in the number of homosexuallbisexual males participating in the programs. These findings suggest the need for development and implementation of other strategies to identify and reach persons at highest risk for HIV-1 infection. (Am J Public Health 1990; 80:419-422.)
Introduction In July 1985, the Minnesota Department of Health (MDH) established human immunodeficiency virus (HIV-1) counseling and testing sites at the two major public health sexually transmitted disease clinics in the Twin Cities (Minneapolis, St. Paul) to allow persons at risk for HIV-1 infection to ascertain their HIV-1 antibody status. To examine the potential role of these Minnesota programs in HIV-1 infection prevention efforts, data on client demographic and risk factor characteristics and HIV-1 antibody seroprevalence were analyzed for the first 48 months of operation (July 1985 to June 1989).
considered positive by Western blot assay if the following bands are detectable: p24 or p31 and either gp4l or gpl20/ gpl60, with or without additional HIV-1 characteristic bands.3 Specimens with other HIV-1 band patterns not meeting the criteria for a positive assay are considered to be indeterminate. Data were analyzed for 24,911 clients who had HIV-1 antibody serology completed from July 1985 through June 1989. Male clients were categorized into one of five HIV-1 transmission categories: homosexual/bisexual, homosexual/ bisexual intravenous drug user, heterosexual intravenous drug user, heterosexual sex partner of a person at high risk for HIV-1 infection, or other (immigrant from a high-risk country or no identified risk). Female clients were categorized into one of three HIV-1 transmission categories: intravenous drug user, sex partner of a person at high risk for HIV-1 infection, or other (immigrant from a high-risk country, female prostitute, or no identified risk). Data were analyzed using standard univariate methods and chi-square test for trend measures.4
Methods The two programs provide free services to all persons requesting them. Prospective program clients are scheduled for appointments by telephone. All clients are interviewed by trained nurses or clinicians according to protocols established by the US Public Health Service Centers for Disease Control' and the MDH (available upon request to authors). During pre-test and post-test sessions, staff assess client risks for HIV-1 infection, interpret HIV-1 antibody test results, and provide individualized risk reduction and disease prevention counseling. Self-reported demographic and risk factor data are recorded on standardized client information sheets. Serum specimens are initially screened for HIV-1 antibody using enzyme immunoassay (EIA) test kits from Abbott Laboratories, Electronucleonics, or Genetic Systems. Specimens are considered reactive if the absorbance values are above the cutoff levels specified by the manufacturers' instructions. Initially reactive specimens are tested a second time; specimens that are repeatedly reactive are then tested using the Western blot technique.2 Western blot testing utilizes HIV-1 antigen from Bio-tech Dupont, Rockville, Maryland, or Litton Bionetics, Charleston, South Carolina. Specimens are From the Acute Disease Epidemiology Section, Minnesota Department of Health, Minneapolis (Danila, Shultz, Osterholm, MacDonald); St. PaulRamsey Medical Center, and St. Paul Division of Public Health (Henry); and Hennepin County Medical Center, Minneapolis (Simpson). Address reprint requests to Richard N. Danila, PhD, MPH, Acute Disease Epidemiology Section, Minnesota Department of Health, 717 Delaware Street, SE, Minneapolis, MN 55440. This paper, submitted to the Journal July 3, 1989, was revised and accepted for publication October 31, 1989. © 1990 American Journal of Public Health 0090-0036/90$1.50
AJPH April 1990, Vol. 80, No. 4
Results Between July 1, 1985 and June 30, 1989, 25,306 client visits were recorded; 24,911 clients (98 percent) were tested for HIV-1 antibody and 395 clients (2 percent) declined testing after the pre-test visit. An increase occurred in the number of clients tested per month over the first 36 months with a leveling over the last 12 months (Figure 1). The HIV- I antibody seroprevalence rate for all clients tested was five percent (1,299 of 24,911). First-time and Repeat-Test Clients
For tested clients, 18,288 (73 percent) were persons being tested for HIV-1 antibody for the first time (first-time clients) and 6,623 (27 percent) were clients who had been tested at least once before (repeat-test clients). The HIV-1 antibody seroprevalence rate for first-time clients (898 of 18,288; 5 percent) was lower than the rate for repeat-test clients (401 of 6,623; 6 percent). For the repeat-test clients, 2,672 (40 percent) had been tested previously at a health department site, 353 (5 percent) at a family planning clinic, 306 (5 percent) at a physician's office, 81 (1 percent) at a plasma center, 58 (1 percent) at a blood collection facility, and 3,153 (48 percent) at other unspecified sites. Of the 401 clients who were HIV-1 antibody positive on the repeat test: 175 (44 percent) had tested positive for HIV-1 antibody previously; nine (2 percent) had prior tests with indetermi419
DANILA, ET AL.
---D-
Totid aieffla First Time CHents Repeat-too aionb
700600
-
SOO
-
TABLE 2-HIV-1 Antibody Seroprevalence Rates by Client Transmission Categories for First-Time Clients, Minnesota Counseling and Testing Sites, July 1985 through June 1989
HIV-1 Transmission Categories
No. Tested (%)
No. HIV-1 Antibody Seroprevalance Positive Rate (%)
£
z4
400
E
300 200
-
100-
1985
1986
1987
1988
1989
Date of Clinic Visit
FIGURE 1-Number of Clients Attending Counseing and Test Site Programs Tested for HIV-1
Antibody by Visit. Status by Month, Minnesota, 1985-89
nate Western blot test results; 107 (27 percent) had previously tested either EIA negative or EIA reactive and Western blot negative; 33 (8 percent) had tested EIA reactive previously but had not had confirmatory Western blot testing performed; and information on previous testing was unavailable for 77 (19 percent). Most clients (91 percent for first-time clients) were between 20 and 49 years of age. The HIV-1 antibody seroprevalence rate was higher in males than females (Table 1). The HIV-1 seroprevalence rate for Blacks was 1.6 times higher than the rate for Whites and the rate for Hispanic clients was 1.8 times as high as the rate for Whites. The highest HIV-1 seroprevalence rate was found in male homosexual/bisexual intravenous drug users (23 percent; Table 2). Rates were also analyzed by transmission category and race for first-time clients; higher rates were consistently found in Black and Hispanic males (data available upon request to authors). HIV-1 seroprevalence rates for first-time clients were 6 percent and 4 percent at each of the TABLE 1-HIV-1 Antibody Seroprevalence Rates by Gender, Age, and Race for First-Time Clients; Minnesota Counseling and Testing Sites; July 1985 through June 1989
Client Characteristics
No. Tested (%)
Total Gender Male Female Unrecorded Age Group (years) 0-12 13-19 20-29 30-39 40-49 50-59 60 and over Unrecorded Race White Black Hispanic Other* Unrecorded
18,288 (100.0)
898
4.9
12,085 (66.1) 6,128 (33.5)
876 22 0
7.2 0.4 0.0
2 9 384 377
89 22 3 12
9.1 1.5 5.1 5.5 3.9 3.7 1.3 6.2
788 79 16 11 4
4.7 7.7 8.5 3.6 2.4
75 (0.4)
22(0.1) 612 (3.3)
7,495 (41.0) 6,830 (37.3) 2,307 (12.6) 598 (3.3) 229 (1.3) 195 (1.1) 16,609 (90.8) 1,020 (5.6) 188 (1.0) 303 (1.7) 168 (0.9)
No. HIV-1 Anitbody Seroprevalence Postive Rate
*Includes Native American and Asian/Pacific Islander.
Males Homosexual/Bisexual Homosexual/Bisexual Intravenous Drug User Heterosexual/intravenous Drug User Heterosexual Sex Partner at High-Risk Other Heterosexual/ No Identified Risk Total Females Intravenous Drug User Sex Partner at High-Risk Other/No Identified Risk Total
5,866 (48.5)
761
13.0
172 (1.4)
40
23.3
803 (6.7)
50
6.2
1,403 (11.6)
5
0.4
3,841 (31.8)
20 876
0.5 8.1
6 7 9 22
1.5 0.4 0.2 0.4
12,085 (100.0) 405 (6.6) 1,881 (30.7)
3,842 (62.7) 6,128 (100.0)
two clinics, respectively; the higher seroprevalence rate was due to a larger proportion of homosexual/bisexual male clients seen at that site. Analyses of Trends Over Time
A significant downward trend in the monthly HIV-1 antibody seroprevalence rate was noted over time for all clients tested (both first-time and repeat-test clients) (p < 0.001) (Figure 2). The seroprevalence rate for all clients tested during the six months of testing in 1985 was 14.3 percent. The seroprevalence rate dropped to 8.3 percent during 1986 and declined further to 3.9 percent during 1987 and to 3.5 percent during 1988. During the first six months of 1989, the overall seroprevalence rate was only 2.5 percent. The number and proportion of repeat-test clients increased significantly over time (p < 0.001) (Figure 1). Repeattest clients accounted for 1.2 percent of all clients during the first six months of operation in 1985, but comprised 15.9 percent of all clients in 1986, 26.1 percent of all clients in 1987, 35.0 percent of all clients in 1988, and 40.2 percent ofall clients during the first six months of 1989. This increase in the proportion of repeat-test clients did not account for the observed decline in the overall HIV-1 antibody seroprevalence, since the seroprevalence rate for repeat-test clients was actually higher than for first-time clients, as noted previously. 20.0-
O _
co
15.0
X
I 0 S o
10.0-
CO521.00
0.0 1
1985
1986
1987
1988
198I
Month of Clinic Visit
FIGURE 2-IV-1 Antibody Seroprevalence Rates among Clients Attending Counseling and Test Site Programs by Month, Minnesota, 1985-89
HIV COUNSELING, TESTING SITES: CLIENT CHARACTERISTICS
Analysis of data from first-time clients only demonstrated that the HIV-1 seroprevalence declined from 14.2 percent for the first six months of operation in 1985 to 1.8 percent for the last six months of operation in 1989. The HIV-1 seroprevalence rate for repeat-test clients similarly declined from 26.3 percent in the first six months in 1985 to 3.5 percent in the last six months of operation in 1989 (data available on request to authors). Major changes were noted in client characteristics over the 48-month period. Initially, most clients were at increased risk for HIV-1 infection; however, the number and proportion of clients at low risk for HIV-1 infection increased over time. During the first six months of the program, females comprised 8 percent of all first-time clients, whereas they made up 43 percent of all first-time clients during its last six months. During the first six months, 54 percent (69 of 128) of the females were at increased risk (intravenous drug user or sex partner of a person at high risk) and 46 percent (59 of 128) were at low risk; whereas, during the last six months, 33 percent (261 of 795) were at increased risk and 67 percent (534 of 795) were at low risk. There were no seropositive females in the first six months and only one for the last six months. During the first six months, 81 percent of all first-time clients were homosexual/bisexual males and 10 percent were heterosexual males; whereas, only 14 percent were homosexual/bisexual males and 43 percent were heterosexual males during the last six months of observation (Figure 3). For homosexual/ bisexual male clients, a significant decline in HIV-1 antibody prevalence over time was noted (p < 0.05) (Figure 4). Discussion
Counseling and testing site programs were originally conceived, funded, and opened in 1985 to assure safety of the blood supply by providing alternate sites for potential volunteer blood donors to ascertain their HIV-1 antibody status.5 They have become a major cornerstone for AIDS (acquired immunodeficiency syndrome) prevention programs throughout the country and an integral part of the Minnesota statewide plan for AIDS prevention.6 In evaluating the contribution of these programs to primary prevention of HIV-1 transmission, three issues need to be considered. * First, are they currently serving clients most at risk for HIV-l infection? * Second, are they successful in HIV-1 infection prevention efforts through effecting and maintaining behavior change in clients? 500
,
400
C)
300
0
-0
E
200
z
100
Month of Clinic Visit
FIGURE 3-Number of Male Clients Attending Counseling and Test Site Programs by Month, by Sexual Orientation, Minnesota, 1985-89
AJPH April 1990, Vol. 80, No. 4
0
25
0X
20
co J ASOND
1985
FMAMJ J
1986
AS6OD
F
FMAM6J J ASO6
AMJ J OND
1987
1988
FAMJ 1989
Month of Clinic Visit
FIGURE 4-HIV-1 Antibody Seroprevalence Rate for Homosexual/Bisexual Males Attending Counseling and Test Site Programs by Month, Minnesota, 1985-89
0 Third, are current counseling-testing program activi-
ties the best use of public health resources or are additional outreach strategies needed to target persons at highest risk of infection? As these programs evolved in Minnesota over this 48-month observation period, they progressively served fewer clients at increased risk for HIV-1 infection and increasingly served clients at low risk for HIV-1 infection. A significant decrease in the number of homosexual/bisexual males seeking counseling and testing occurred over time. The HIV-1 antibody seroprevalence in homosexual/bisexual males seeking program services later in the observation period was lower than those seen early in the observation period, suggesting that men seen later were at lower risk for HIV-1 infection. In addition, 27 percent of the clients seen during this time period had been tested previously. Of these, most (97 percent) who initially tested negative were still negative for HIV-1 antibody on repeat testing. Some were clients who were instructed to return for follow-up testing to confirm their seronegative status, since they were in a potential "window-period" for HIV-1 antibody development based on their exposure history. Some of these repeat-test clients possibly were persons who continued to engage in high-risk behaviors. However, based on seroprevalence, it is likely that the majority of these repeat-test clients represent a low risk "worried well" population. Also, of the repeat-test clients who tested HIV-1 antibody positive, 175 (44 percent) had tested positive on a previous occasion, indicating that they likely were returning only to verify their infection status. Counseling and testing site program policies remained stable during this time period. HIV-l infection is a reportable condition in Minnesota and has been since shortly after the opening of these programs (October 1985), but clients are not denied services if they refuse to give a name or show proof of identity. This decrease in the number of persons at increased risk and corresponding increase in the number of persons at low risk for HIV-1 infection cannot be attributed to any change in program policy over the observation period. Also, similar trends demonstrating a decrease in HIV-1 seroprevalence at programs have been noted elsewhere in the country in states where HIV-1 infection is not reportable.7-9 Because long-term behavioral data were not collected at the sites, we have no direct measures of the effectiveness of our programs in promoting behavior change which prevents HIV-1 infection. Data on repeat-test clients can be used as an indirect measure. Of the 401 clients who were HIV-l antibody positive on repeat testing, 107 (27 percent) had tested negative 421
DANILA, ET AL.
previously; data are not available on the time of the previous test for 28 (26 percent) of the clients. Eighteen (17 percent) had tested HIV-1 antibody negative within the previous six months and thus may represent persons who were infected but had not yet seroconverted at the time ofthe prior test. However, 61 (57 percent) of the 107 clients reported testing HIV-1 antibody negative in the previous seven months or longer and thus may represent new infections due to ongoing high-risk activity, despite having received risk reduction counseling at the time of previous testing. Current data regarding knowledge of HIV-1 infection status and subsequent behavior change are unclear and suggest different effects. Knowledge of HIV-1 infection, particularly of a positive status, has been associated with a reduction of high-risk behavior in some studies10-'7; however, only one of these studies examined persons tested at counseling and testing sites. Other studies have not demonstrated behavior changes associated with knowledge of HIV-1 infection.'8-2' These studies may not necessarily be extrapolated to persons tested at counseling and testing sites nor are there data regarding long-term behavior change after a single instance of counseling and testing. In recent years, large amounts of federal and state dollars have gone into expanding and maintaining HIV-1 counseling and testing sites. Approximately $1.4 million was spent in Minnesota on this program at these two sites during this 48-month observation period. Despite expenditure of these resources, the trends identified here indicate that the program may not be reaching persons at highest risk and that providing free services to anyone requesting them may not be the best use of available public health dollars for AIDS prevention. In areas such as Minnesota where heterosexuals (other than intravenous drug users) are at low risk for HIV-1 infection, services need to be targeted to those at highest risk. In addition, counseling and testing sites might attract more persons at increased risk for HIV-1 infection by being linked to additional services such as HIV-1 disease diagnostic and treatment services. Strategies to both identify and develop outreach programs for those at highest risk are also needed. Clinic-based sites likely to provide services to persons who are engaging in high-risk behaviors, such as chemical dependency treatment programs and clinics for treatment of sexually transmitted diseases, need to have well-developed risk assessment programs and on-site availability of HIV-l antibody testing. Other outreach strategies, such as programs involving street workers, need to be expanded. Third-party partner notification programs, which actively and selectively reach those at highest risk for HIV-1 infection, need to be considered by state health departments as another outreach mechanism.22-24 The data presented here may not be applicable to all areas of the country, particularly where HIV-1 infection has become endemic in certain racial and high-risk groups. Criteria can be developed locally to determine which persons are at highest risk for HIV-1 infection and testing sites can then be tailored accordingly. ACKNOWLEDGMENTS The authors thank Mary Sheehan, MPH, Michael Moen, MPH, and Judy Beniak, MPH, for reviewing the manuscript. Robert Gillespie, MS, provided some data analyses. Counseling and testing activities were partially supported with funding from the Centers for Disease Control. Portions of this paper were presented at the V International Conference on AIDS, Montreal, June 4-9, 1989.
REFERENCES 1. Centers for Disease Control: Public Health Service guidelines for counseling and antibody testing to prevent HIV infection and AIDS. MMWR
422
1987; 36:509-515. 2. Tsang VCW, Peralta JM, Simons AR: Enzyme-linked immunoelectrotransfer blot techniques (EITB) for studying the specifications of antigens and antibodies separated by gel electrophoresis. Methods Enzymol 1983; 92:377-391. 3. Lundberg GD: Serological diagnosis of human immunodeficiency virus infection by Western blot testing. JAMA 1988; 260:674-679. 4. Fleiss JL: Statistical Methods for Rates and Proportions. New York: John Wiley and Sons, 1981; 19,139. 5. Centers for Disease Control: Human T-lymphotropic virus type III/ lymphadenopathy-associated virus antibody testing at alternate sites. MMWR 1986; 35:284-287. 6. MacDonald KL, Commissioner's Task Force on AIDS: Human immunodeficiency virus in Minnesota. 1988 statewide HIV risk-reduction and disease-prevention plan. Minn Med 1988; 71:300-301. 7. Grabau JC, Morse DL: Seropositivity for HIV at alternate sites. (letter) JAMA 1988; 260:3128. 8. Fehrs LJ, Fleming D, Foster LR, et al: Trial of anonymous versus confidential human immunodeficiency virus testing. Lancet 1988; 2:379-382. 9. Evans PE, Barnhart JL, Rutherford GW, et al: Trends in HIV testing and counseling programs in San Francisco. (Abstract #6025) In: Final Program and abstracts of the IV International Conference on AIDS. Book 1. Stockholm, Sweden: Swedish Ministry of Health and Social Affairs, National Bacteriological Laboratory, Karolinska Institute, World Health Organization, 1988; 360. 10. Coates TJ, Morin SF, McKusick L: Behavioral consequences of AIDS antibody testing among gay men. (letter) JAMA 1987; 258:1889. 11. Van Griensven GJP, de Vroome EMM, Tielman RAP, et al: Impact of HIV antibody testing on changes in sexual behavior among homosexual men in the Netherlands. Am J Public Health 1988; 78:1575-1577. 12. Schecter MT, Craib KJP, Willoughby B, et al: Patterns of sexual behavior and condom use in a cohort of homosexual men. Am J Public Health 1988; 78:1535-1538. 13. McCusker J, Stoddard AM, Mayer KH, et al: Effects of HIV antibody test knowledge on subsequent sexual behavior in a cohort of homosexually active men. Am J Public Health 1988; 78:462-467. 14. Coates TJ, Morin SF, McKusick L, et al: Long-term consequences of AIDS antibody testing on gay and bisexual men. (Abstract #8101) In: Final Program and abstracts of the IV International Conference on AIDS. Book 1. Stockholm, Sweden: Swedish Ministry of Health and Social Affairs, National Bacteriological Laboratory, Karolinska Institute, World Health Organization, 1988; 474. 15. Fox R, Odaka NJ, Brookmeyer R, Polk BF: Effect of HIV antibody disclosure on subsequent sexual activity in homosexual men. AIDS 1987; 1:241-246. 16. McCusker J, Stoddard AM, Zapka JG, Zorn M, Mayer KH: Predictors of AIDS-preventive behavior among homosexually active men: a longitudinal study. AIDS 1989; 3:443-448. 17. Cates W Jr, Handsfield HH: HIV counseling and testing: Does it work? (editorial) Am J Public Health 1988; 78:1533-1534. 18. Doll LS, O'Malley P, Pershing A, et al: High-risk behavior and knowledge of HIV-antibody status in the San Francisco city clinic cohort. (Abstract #8102) In: Final Program and abstracts of the IV International Conference on AIDS. Book 1. Stockholm, Sweden: Swedish Ministry of Health and Social Affairs, National Bacteriological Laboratory, Karolinska Institute, World Health Organization, 1988; 474. 19. Ostrow DG, Joseph J, Soucey J, et al: Mental health and behavioral correlates of HIV antibody testing in a cohort of gay men. (Abstract #4082). In: Final Program and abstracts of the IV International Conference on AIDS. Book 1. Stockholm, Sweden: Swedish Ministry of Health and Social Affairs, National Bacteriological Laboratory, Karolinska Institute, World Health Organization, 1988; 280. 20. Wiktor S, Biggar R, Melbye M, Ebbesen P, Goedert J: Effect of knowledge of HIV status upon sexual activity among homosexual men. (Abstract #4073) In: Final Program and abstracts of the IV International Conference on AIDS. Book 1. Stockholm, Sweden: Swedish Ministry of Health and Social Affairs, National Bacteriological Laboratory, Karolinska Institute, World Health Organization, 1988; 278. 21. Frazer IH, McCamish M, Hay I, North P: Influence of human immunodeficiency virus antibody testing on sexual behavior in a "high-risk" population from a "low-risk" city. Med J Aust 1988;149:
365-368. 22. Wykoff RF, Heath CW, Hollis SL, et al: Contact tracing to identify human immunodeficiency virus infection in a rural community. JAMA 1988; 259:3563-3566. 23. Centers for Disease Control: Partner notification for preventing human immunodeficiency virus (HIV) infection-Colorado, Idaho, South Carolina, Virginia. MMWR 1988; 37:393-396, 401-402. 24. Potterat JJ, Spencer NE, Woodhouse DE, Muth JB: Partner notification in the control of human immunodeficiency virus infection. Am J Public Health 1989; 79:874-876.
AJPH April 1990, Vol. 80, No. 4
month period from 14 percent in the first six months to 3 percent in the last six months. This decrease coincided with an increase in the number of low-risk female clients and low-risk heterosexual male clients, and a decrease in the number of homosexuallbisexual males participating in the programs. These findings suggest the need for development and implementation of other strategies to identify and reach persons at highest risk for HIV-1 infection. (Am J Public Health 1990; 80:419-422.)
Introduction In July 1985, the Minnesota Department of Health (MDH) established human immunodeficiency virus (HIV-1) counseling and testing sites at the two major public health sexually transmitted disease clinics in the Twin Cities (Minneapolis, St. Paul) to allow persons at risk for HIV-1 infection to ascertain their HIV-1 antibody status. To examine the potential role of these Minnesota programs in HIV-1 infection prevention efforts, data on client demographic and risk factor characteristics and HIV-1 antibody seroprevalence were analyzed for the first 48 months of operation (July 1985 to June 1989).
considered positive by Western blot assay if the following bands are detectable: p24 or p31 and either gp4l or gpl20/ gpl60, with or without additional HIV-1 characteristic bands.3 Specimens with other HIV-1 band patterns not meeting the criteria for a positive assay are considered to be indeterminate. Data were analyzed for 24,911 clients who had HIV-1 antibody serology completed from July 1985 through June 1989. Male clients were categorized into one of five HIV-1 transmission categories: homosexual/bisexual, homosexual/ bisexual intravenous drug user, heterosexual intravenous drug user, heterosexual sex partner of a person at high risk for HIV-1 infection, or other (immigrant from a high-risk country or no identified risk). Female clients were categorized into one of three HIV-1 transmission categories: intravenous drug user, sex partner of a person at high risk for HIV-1 infection, or other (immigrant from a high-risk country, female prostitute, or no identified risk). Data were analyzed using standard univariate methods and chi-square test for trend measures.4
Methods The two programs provide free services to all persons requesting them. Prospective program clients are scheduled for appointments by telephone. All clients are interviewed by trained nurses or clinicians according to protocols established by the US Public Health Service Centers for Disease Control' and the MDH (available upon request to authors). During pre-test and post-test sessions, staff assess client risks for HIV-1 infection, interpret HIV-1 antibody test results, and provide individualized risk reduction and disease prevention counseling. Self-reported demographic and risk factor data are recorded on standardized client information sheets. Serum specimens are initially screened for HIV-1 antibody using enzyme immunoassay (EIA) test kits from Abbott Laboratories, Electronucleonics, or Genetic Systems. Specimens are considered reactive if the absorbance values are above the cutoff levels specified by the manufacturers' instructions. Initially reactive specimens are tested a second time; specimens that are repeatedly reactive are then tested using the Western blot technique.2 Western blot testing utilizes HIV-1 antigen from Bio-tech Dupont, Rockville, Maryland, or Litton Bionetics, Charleston, South Carolina. Specimens are From the Acute Disease Epidemiology Section, Minnesota Department of Health, Minneapolis (Danila, Shultz, Osterholm, MacDonald); St. PaulRamsey Medical Center, and St. Paul Division of Public Health (Henry); and Hennepin County Medical Center, Minneapolis (Simpson). Address reprint requests to Richard N. Danila, PhD, MPH, Acute Disease Epidemiology Section, Minnesota Department of Health, 717 Delaware Street, SE, Minneapolis, MN 55440. This paper, submitted to the Journal July 3, 1989, was revised and accepted for publication October 31, 1989. © 1990 American Journal of Public Health 0090-0036/90$1.50
AJPH April 1990, Vol. 80, No. 4
Results Between July 1, 1985 and June 30, 1989, 25,306 client visits were recorded; 24,911 clients (98 percent) were tested for HIV-1 antibody and 395 clients (2 percent) declined testing after the pre-test visit. An increase occurred in the number of clients tested per month over the first 36 months with a leveling over the last 12 months (Figure 1). The HIV- I antibody seroprevalence rate for all clients tested was five percent (1,299 of 24,911). First-time and Repeat-Test Clients
For tested clients, 18,288 (73 percent) were persons being tested for HIV-1 antibody for the first time (first-time clients) and 6,623 (27 percent) were clients who had been tested at least once before (repeat-test clients). The HIV-1 antibody seroprevalence rate for first-time clients (898 of 18,288; 5 percent) was lower than the rate for repeat-test clients (401 of 6,623; 6 percent). For the repeat-test clients, 2,672 (40 percent) had been tested previously at a health department site, 353 (5 percent) at a family planning clinic, 306 (5 percent) at a physician's office, 81 (1 percent) at a plasma center, 58 (1 percent) at a blood collection facility, and 3,153 (48 percent) at other unspecified sites. Of the 401 clients who were HIV-1 antibody positive on the repeat test: 175 (44 percent) had tested positive for HIV-1 antibody previously; nine (2 percent) had prior tests with indetermi419
DANILA, ET AL.
---D-
Totid aieffla First Time CHents Repeat-too aionb
700600
-
SOO
-
TABLE 2-HIV-1 Antibody Seroprevalence Rates by Client Transmission Categories for First-Time Clients, Minnesota Counseling and Testing Sites, July 1985 through June 1989
HIV-1 Transmission Categories
No. Tested (%)
No. HIV-1 Antibody Seroprevalance Positive Rate (%)
£
z4
400
E
300 200
-
100-
1985
1986
1987
1988
1989
Date of Clinic Visit
FIGURE 1-Number of Clients Attending Counseing and Test Site Programs Tested for HIV-1
Antibody by Visit. Status by Month, Minnesota, 1985-89
nate Western blot test results; 107 (27 percent) had previously tested either EIA negative or EIA reactive and Western blot negative; 33 (8 percent) had tested EIA reactive previously but had not had confirmatory Western blot testing performed; and information on previous testing was unavailable for 77 (19 percent). Most clients (91 percent for first-time clients) were between 20 and 49 years of age. The HIV-1 antibody seroprevalence rate was higher in males than females (Table 1). The HIV-1 seroprevalence rate for Blacks was 1.6 times higher than the rate for Whites and the rate for Hispanic clients was 1.8 times as high as the rate for Whites. The highest HIV-1 seroprevalence rate was found in male homosexual/bisexual intravenous drug users (23 percent; Table 2). Rates were also analyzed by transmission category and race for first-time clients; higher rates were consistently found in Black and Hispanic males (data available upon request to authors). HIV-1 seroprevalence rates for first-time clients were 6 percent and 4 percent at each of the TABLE 1-HIV-1 Antibody Seroprevalence Rates by Gender, Age, and Race for First-Time Clients; Minnesota Counseling and Testing Sites; July 1985 through June 1989
Client Characteristics
No. Tested (%)
Total Gender Male Female Unrecorded Age Group (years) 0-12 13-19 20-29 30-39 40-49 50-59 60 and over Unrecorded Race White Black Hispanic Other* Unrecorded
18,288 (100.0)
898
4.9
12,085 (66.1) 6,128 (33.5)
876 22 0
7.2 0.4 0.0
2 9 384 377
89 22 3 12
9.1 1.5 5.1 5.5 3.9 3.7 1.3 6.2
788 79 16 11 4
4.7 7.7 8.5 3.6 2.4
75 (0.4)
22(0.1) 612 (3.3)
7,495 (41.0) 6,830 (37.3) 2,307 (12.6) 598 (3.3) 229 (1.3) 195 (1.1) 16,609 (90.8) 1,020 (5.6) 188 (1.0) 303 (1.7) 168 (0.9)
No. HIV-1 Anitbody Seroprevalence Postive Rate
*Includes Native American and Asian/Pacific Islander.
Males Homosexual/Bisexual Homosexual/Bisexual Intravenous Drug User Heterosexual/intravenous Drug User Heterosexual Sex Partner at High-Risk Other Heterosexual/ No Identified Risk Total Females Intravenous Drug User Sex Partner at High-Risk Other/No Identified Risk Total
5,866 (48.5)
761
13.0
172 (1.4)
40
23.3
803 (6.7)
50
6.2
1,403 (11.6)
5
0.4
3,841 (31.8)
20 876
0.5 8.1
6 7 9 22
1.5 0.4 0.2 0.4
12,085 (100.0) 405 (6.6) 1,881 (30.7)
3,842 (62.7) 6,128 (100.0)
two clinics, respectively; the higher seroprevalence rate was due to a larger proportion of homosexual/bisexual male clients seen at that site. Analyses of Trends Over Time
A significant downward trend in the monthly HIV-1 antibody seroprevalence rate was noted over time for all clients tested (both first-time and repeat-test clients) (p < 0.001) (Figure 2). The seroprevalence rate for all clients tested during the six months of testing in 1985 was 14.3 percent. The seroprevalence rate dropped to 8.3 percent during 1986 and declined further to 3.9 percent during 1987 and to 3.5 percent during 1988. During the first six months of 1989, the overall seroprevalence rate was only 2.5 percent. The number and proportion of repeat-test clients increased significantly over time (p < 0.001) (Figure 1). Repeattest clients accounted for 1.2 percent of all clients during the first six months of operation in 1985, but comprised 15.9 percent of all clients in 1986, 26.1 percent of all clients in 1987, 35.0 percent of all clients in 1988, and 40.2 percent ofall clients during the first six months of 1989. This increase in the proportion of repeat-test clients did not account for the observed decline in the overall HIV-1 antibody seroprevalence, since the seroprevalence rate for repeat-test clients was actually higher than for first-time clients, as noted previously. 20.0-
O _
co
15.0
X
I 0 S o
10.0-
CO521.00
0.0 1
1985
1986
1987
1988
198I
Month of Clinic Visit
FIGURE 2-IV-1 Antibody Seroprevalence Rates among Clients Attending Counseling and Test Site Programs by Month, Minnesota, 1985-89
HIV COUNSELING, TESTING SITES: CLIENT CHARACTERISTICS
Analysis of data from first-time clients only demonstrated that the HIV-1 seroprevalence declined from 14.2 percent for the first six months of operation in 1985 to 1.8 percent for the last six months of operation in 1989. The HIV-1 seroprevalence rate for repeat-test clients similarly declined from 26.3 percent in the first six months in 1985 to 3.5 percent in the last six months of operation in 1989 (data available on request to authors). Major changes were noted in client characteristics over the 48-month period. Initially, most clients were at increased risk for HIV-1 infection; however, the number and proportion of clients at low risk for HIV-1 infection increased over time. During the first six months of the program, females comprised 8 percent of all first-time clients, whereas they made up 43 percent of all first-time clients during its last six months. During the first six months, 54 percent (69 of 128) of the females were at increased risk (intravenous drug user or sex partner of a person at high risk) and 46 percent (59 of 128) were at low risk; whereas, during the last six months, 33 percent (261 of 795) were at increased risk and 67 percent (534 of 795) were at low risk. There were no seropositive females in the first six months and only one for the last six months. During the first six months, 81 percent of all first-time clients were homosexual/bisexual males and 10 percent were heterosexual males; whereas, only 14 percent were homosexual/bisexual males and 43 percent were heterosexual males during the last six months of observation (Figure 3). For homosexual/ bisexual male clients, a significant decline in HIV-1 antibody prevalence over time was noted (p < 0.05) (Figure 4). Discussion
Counseling and testing site programs were originally conceived, funded, and opened in 1985 to assure safety of the blood supply by providing alternate sites for potential volunteer blood donors to ascertain their HIV-1 antibody status.5 They have become a major cornerstone for AIDS (acquired immunodeficiency syndrome) prevention programs throughout the country and an integral part of the Minnesota statewide plan for AIDS prevention.6 In evaluating the contribution of these programs to primary prevention of HIV-1 transmission, three issues need to be considered. * First, are they currently serving clients most at risk for HIV-l infection? * Second, are they successful in HIV-1 infection prevention efforts through effecting and maintaining behavior change in clients? 500
,
400
C)
300
0
-0
E
200
z
100
Month of Clinic Visit
FIGURE 3-Number of Male Clients Attending Counseling and Test Site Programs by Month, by Sexual Orientation, Minnesota, 1985-89
AJPH April 1990, Vol. 80, No. 4
0
25
0X
20
co J ASOND
1985
FMAMJ J
1986
AS6OD
F
FMAM6J J ASO6
AMJ J OND
1987
1988
FAMJ 1989
Month of Clinic Visit
FIGURE 4-HIV-1 Antibody Seroprevalence Rate for Homosexual/Bisexual Males Attending Counseling and Test Site Programs by Month, Minnesota, 1985-89
0 Third, are current counseling-testing program activi-
ties the best use of public health resources or are additional outreach strategies needed to target persons at highest risk of infection? As these programs evolved in Minnesota over this 48-month observation period, they progressively served fewer clients at increased risk for HIV-1 infection and increasingly served clients at low risk for HIV-1 infection. A significant decrease in the number of homosexual/bisexual males seeking counseling and testing occurred over time. The HIV-1 antibody seroprevalence in homosexual/bisexual males seeking program services later in the observation period was lower than those seen early in the observation period, suggesting that men seen later were at lower risk for HIV-1 infection. In addition, 27 percent of the clients seen during this time period had been tested previously. Of these, most (97 percent) who initially tested negative were still negative for HIV-1 antibody on repeat testing. Some were clients who were instructed to return for follow-up testing to confirm their seronegative status, since they were in a potential "window-period" for HIV-1 antibody development based on their exposure history. Some of these repeat-test clients possibly were persons who continued to engage in high-risk behaviors. However, based on seroprevalence, it is likely that the majority of these repeat-test clients represent a low risk "worried well" population. Also, of the repeat-test clients who tested HIV-1 antibody positive, 175 (44 percent) had tested positive on a previous occasion, indicating that they likely were returning only to verify their infection status. Counseling and testing site program policies remained stable during this time period. HIV-l infection is a reportable condition in Minnesota and has been since shortly after the opening of these programs (October 1985), but clients are not denied services if they refuse to give a name or show proof of identity. This decrease in the number of persons at increased risk and corresponding increase in the number of persons at low risk for HIV-1 infection cannot be attributed to any change in program policy over the observation period. Also, similar trends demonstrating a decrease in HIV-1 seroprevalence at programs have been noted elsewhere in the country in states where HIV-1 infection is not reportable.7-9 Because long-term behavioral data were not collected at the sites, we have no direct measures of the effectiveness of our programs in promoting behavior change which prevents HIV-1 infection. Data on repeat-test clients can be used as an indirect measure. Of the 401 clients who were HIV-l antibody positive on repeat testing, 107 (27 percent) had tested negative 421
DANILA, ET AL.
previously; data are not available on the time of the previous test for 28 (26 percent) of the clients. Eighteen (17 percent) had tested HIV-1 antibody negative within the previous six months and thus may represent persons who were infected but had not yet seroconverted at the time ofthe prior test. However, 61 (57 percent) of the 107 clients reported testing HIV-1 antibody negative in the previous seven months or longer and thus may represent new infections due to ongoing high-risk activity, despite having received risk reduction counseling at the time of previous testing. Current data regarding knowledge of HIV-1 infection status and subsequent behavior change are unclear and suggest different effects. Knowledge of HIV-1 infection, particularly of a positive status, has been associated with a reduction of high-risk behavior in some studies10-'7; however, only one of these studies examined persons tested at counseling and testing sites. Other studies have not demonstrated behavior changes associated with knowledge of HIV-1 infection.'8-2' These studies may not necessarily be extrapolated to persons tested at counseling and testing sites nor are there data regarding long-term behavior change after a single instance of counseling and testing. In recent years, large amounts of federal and state dollars have gone into expanding and maintaining HIV-1 counseling and testing sites. Approximately $1.4 million was spent in Minnesota on this program at these two sites during this 48-month observation period. Despite expenditure of these resources, the trends identified here indicate that the program may not be reaching persons at highest risk and that providing free services to anyone requesting them may not be the best use of available public health dollars for AIDS prevention. In areas such as Minnesota where heterosexuals (other than intravenous drug users) are at low risk for HIV-1 infection, services need to be targeted to those at highest risk. In addition, counseling and testing sites might attract more persons at increased risk for HIV-1 infection by being linked to additional services such as HIV-1 disease diagnostic and treatment services. Strategies to both identify and develop outreach programs for those at highest risk are also needed. Clinic-based sites likely to provide services to persons who are engaging in high-risk behaviors, such as chemical dependency treatment programs and clinics for treatment of sexually transmitted diseases, need to have well-developed risk assessment programs and on-site availability of HIV-l antibody testing. Other outreach strategies, such as programs involving street workers, need to be expanded. Third-party partner notification programs, which actively and selectively reach those at highest risk for HIV-1 infection, need to be considered by state health departments as another outreach mechanism.22-24 The data presented here may not be applicable to all areas of the country, particularly where HIV-1 infection has become endemic in certain racial and high-risk groups. Criteria can be developed locally to determine which persons are at highest risk for HIV-1 infection and testing sites can then be tailored accordingly. ACKNOWLEDGMENTS The authors thank Mary Sheehan, MPH, Michael Moen, MPH, and Judy Beniak, MPH, for reviewing the manuscript. Robert Gillespie, MS, provided some data analyses. Counseling and testing activities were partially supported with funding from the Centers for Disease Control. Portions of this paper were presented at the V International Conference on AIDS, Montreal, June 4-9, 1989.
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1987; 36:509-515. 2. Tsang VCW, Peralta JM, Simons AR: Enzyme-linked immunoelectrotransfer blot techniques (EITB) for studying the specifications of antigens and antibodies separated by gel electrophoresis. Methods Enzymol 1983; 92:377-391. 3. Lundberg GD: Serological diagnosis of human immunodeficiency virus infection by Western blot testing. JAMA 1988; 260:674-679. 4. Fleiss JL: Statistical Methods for Rates and Proportions. New York: John Wiley and Sons, 1981; 19,139. 5. Centers for Disease Control: Human T-lymphotropic virus type III/ lymphadenopathy-associated virus antibody testing at alternate sites. MMWR 1986; 35:284-287. 6. MacDonald KL, Commissioner's Task Force on AIDS: Human immunodeficiency virus in Minnesota. 1988 statewide HIV risk-reduction and disease-prevention plan. Minn Med 1988; 71:300-301. 7. Grabau JC, Morse DL: Seropositivity for HIV at alternate sites. (letter) JAMA 1988; 260:3128. 8. Fehrs LJ, Fleming D, Foster LR, et al: Trial of anonymous versus confidential human immunodeficiency virus testing. Lancet 1988; 2:379-382. 9. Evans PE, Barnhart JL, Rutherford GW, et al: Trends in HIV testing and counseling programs in San Francisco. (Abstract #6025) In: Final Program and abstracts of the IV International Conference on AIDS. Book 1. Stockholm, Sweden: Swedish Ministry of Health and Social Affairs, National Bacteriological Laboratory, Karolinska Institute, World Health Organization, 1988; 360. 10. Coates TJ, Morin SF, McKusick L: Behavioral consequences of AIDS antibody testing among gay men. (letter) JAMA 1987; 258:1889. 11. Van Griensven GJP, de Vroome EMM, Tielman RAP, et al: Impact of HIV antibody testing on changes in sexual behavior among homosexual men in the Netherlands. Am J Public Health 1988; 78:1575-1577. 12. Schecter MT, Craib KJP, Willoughby B, et al: Patterns of sexual behavior and condom use in a cohort of homosexual men. Am J Public Health 1988; 78:1535-1538. 13. McCusker J, Stoddard AM, Mayer KH, et al: Effects of HIV antibody test knowledge on subsequent sexual behavior in a cohort of homosexually active men. Am J Public Health 1988; 78:462-467. 14. Coates TJ, Morin SF, McKusick L, et al: Long-term consequences of AIDS antibody testing on gay and bisexual men. (Abstract #8101) In: Final Program and abstracts of the IV International Conference on AIDS. Book 1. Stockholm, Sweden: Swedish Ministry of Health and Social Affairs, National Bacteriological Laboratory, Karolinska Institute, World Health Organization, 1988; 474. 15. Fox R, Odaka NJ, Brookmeyer R, Polk BF: Effect of HIV antibody disclosure on subsequent sexual activity in homosexual men. AIDS 1987; 1:241-246. 16. McCusker J, Stoddard AM, Zapka JG, Zorn M, Mayer KH: Predictors of AIDS-preventive behavior among homosexually active men: a longitudinal study. AIDS 1989; 3:443-448. 17. Cates W Jr, Handsfield HH: HIV counseling and testing: Does it work? (editorial) Am J Public Health 1988; 78:1533-1534. 18. Doll LS, O'Malley P, Pershing A, et al: High-risk behavior and knowledge of HIV-antibody status in the San Francisco city clinic cohort. (Abstract #8102) In: Final Program and abstracts of the IV International Conference on AIDS. Book 1. Stockholm, Sweden: Swedish Ministry of Health and Social Affairs, National Bacteriological Laboratory, Karolinska Institute, World Health Organization, 1988; 474. 19. Ostrow DG, Joseph J, Soucey J, et al: Mental health and behavioral correlates of HIV antibody testing in a cohort of gay men. (Abstract #4082). In: Final Program and abstracts of the IV International Conference on AIDS. Book 1. Stockholm, Sweden: Swedish Ministry of Health and Social Affairs, National Bacteriological Laboratory, Karolinska Institute, World Health Organization, 1988; 280. 20. Wiktor S, Biggar R, Melbye M, Ebbesen P, Goedert J: Effect of knowledge of HIV status upon sexual activity among homosexual men. (Abstract #4073) In: Final Program and abstracts of the IV International Conference on AIDS. Book 1. Stockholm, Sweden: Swedish Ministry of Health and Social Affairs, National Bacteriological Laboratory, Karolinska Institute, World Health Organization, 1988; 278. 21. Frazer IH, McCamish M, Hay I, North P: Influence of human immunodeficiency virus antibody testing on sexual behavior in a "high-risk" population from a "low-risk" city. Med J Aust 1988;149:
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