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ASP's New Prevention Department

November/December 2004

Greg Smith
Recently, AIDS Survival Project was awarded a grant from the Centers for Disease Control and Prevention (CDC) under the CDC's Prevention for Positives Initiative. We were funded to implement an HIV Counseling and Testing Center here at our agency and develop a Healthy Relationships program (see Mary Lynn Hemphill's article in this issue). There has been a lot of discussion around the new prevention efforts. What is the rapid test? Can you really get your results in one day? Why is an agency that services people who are already positive offering testing services? I would like to share with you what the new prevention initiative is and how ASP is incorporating this new directive from the CDC.

First, you should know that the agency is also completing a renovation of our offices to accommodate the new programs. We have added additional counseling rooms, support group space and bathrooms. We are very excited but also very cautious. Many have asked us how this new initiative will affect what we do. I've included below some useful information from the CDC about the initiative, along with some notes about ASP's response to the program's goals and objectives. Following that are frequently asked questions about the OraQuick Rapid Test we will be using in the clinic.

Why a new initiative for HIV prevention?

An estimated 40,000 new HIV infections still occur in the United States each year. An estimated one quarter of the 850,000 to 950,000 people living with HIV in the United States do not yet know they are infected. In addition, data from several studies have shown increases in syphilis diagnoses among men who know that they are infected with HIV, suggesting increases in risk behaviors among people living with HIV and their partners.

ASP Response: Our mission here at ASP is to address the needs of persons living with AIDS. This is where we begin to assist our community by offering free confidential and anonymous HIV testing services and counseling.

How does the Advancing HIV Prevention Initiative address this problem?

This initiative consists of the following four strategies aimed at reducing barriers to diagnosis of HIV infection and access to and use of quality medical care, treatment and ongoing prevention services for persons with HIV.

  1. Make HIV testing a routine part of medical care whenever and wherever patients go for care

  2. Use new models for diagnosing HIV infection outside of traditional medical settings

  3. Prevent new infections by working with people diagnosed with HIV and their partners

  4. Continue to decrease mother-to-child HIV transmission

ASP Response: ASP has a long history of providing peer support for reducing barriers, guiding the recently diagnosed and assisting people living with AIDS (PLWA) with accessing medical care and other support services. Our ongoing peer counseling program has been meeting such client needs for many years and will continue to be vital in enhancing these aims. In addition, we will be developing outreach strategies to high-risk groups, encouraging them to get friends and partners to access our HIV counseling, testing and Healthy Relationships programs.

How will increasing HIV testing help reduce HIV infections?

There are many benefits to early knowledge of HIV infection, including early entry into treatment to prevent illnesses that arise from a weakened immune system, treatment of other conditions like substance abuse and sexually transmitted diseases, and access to social services and medical treatments, when appropriate. HIV-infected persons in care are now living longer than before thanks to new, highly effective treatments.

Knowledge of one's HIV infection can help prevent spread of the infection to others. When people know that they are infected with HIV, they are significantly more likely to protect their partners from infection than when they were unaware of their infection.

About 40% of HIV-infected persons first find out that they have HIV less than one year before AIDS diagnosis. On average, it takes ten years after HIV infection for symptoms of AIDS to appear. People who have their first HIV test close to getting an AIDS diagnosis have been infected and not known it possibly for many years, potentially passing the infection to their partners. Early diagnosis of HIV enables infected persons and those close to them to take steps to prevent transmission.

If a person with HIV is tested, learns of his or her status and has access to appropriate treatments, the amount of virus in the body can be reduced, which may decrease the risk of transmission to partners. This reduction of HIV transmission is most clearly seen in reducing transmission of HIV from mother to child by treating pregnant women who are HIV positive.

ASP Response: Our primary focus is on PLWA. Our clients include those who have family members, friends and coworkers who are living with AIDS or who may need to talk with someone about HIV/AIDS. We are in direct line with the needs of the community to create a comfortable environment by providing counseling, testing and our Healthy Relationships program. Our goal is to be a conduit for persons who have partners (past and present), friends and family members who need access to counseling and testing services.

Why these four strategies?

  1. Make HIV testing a routine part of medical care

  2. Routine voluntary screening for disease is a basic and effective public health tool used to identify unrecognized medical conditions so that treatment and other services can be offered. HIV screening meets the three generally accepted principles that apply to screening efforts:

    • It is a serious disease that can be detected before symptoms occur using a reliable and inexpensive test.

    • Treatment given before symptoms develop is more effective than waiting until after symptoms develop.

    • Cost of screening is reasonable compared with anticipated benefits.

    Screening all persons in high-prevalence medical settings -- regardless of what, if any, HIV risks are reported -- makes sense because testing based on reported or perceived risk alone fails to identify many HIV-infected persons. Acceptance of HIV testing, as demonstrated among pregnant women, is greater when it is offered routinely than when it is based on risk assessments.

    ASP Response: We know all too well the importance of early intervention. Our goal is provide a professional and culturally sensitive setting for the community to access HIV counseling and testing services in a safe environment that meets all the government-required standards to insure quality testing services.

  3. Use new models for diagnosing HIV infection outside of traditional medical settings

  4. HIV testing programs outside of traditional medical settings are more likely to reach some racial/ethnic minorities and persons who report increased risk for HIV but do not have access to medical care. In addition, the rate of positive test results in nontraditional settings is generally higher compared with conventional testing sites. For example, it has been estimated that nearly 25% of persons living with HIV pass through the corrections system, yet fewer than half of these systems routinely test inmates at entry. This means that many HIV-infected persons miss out on the opportunity to be routinely screened.

    Recently approved rapid HIV tests can be done outside a traditional laboratory setting and can reduce the time it takes to process tests from two weeks to 20 minutes. The availability of these tests means testing can be implemented in diverse settings, and essential health information can be provided quickly in settings where people may be unlikely to return to receive test results. These tests provide opportunities to dramatically increase the number of people who know their HIV status.

    ASP Response: We understand the cultural challenges of accessing traditional testing locations. We understand the stigma that continues to be attached to the disease. We are committed to creating a testing center that represents "friendship, community, family." We will be utilizing the OraQuick and OraSure HIV test systems, which will allow us to give same-day results in most cases.

  5. Prevent new infections by working with people diagnosed with HIV and their partners

  6. Each person living with HIV who adopts safer behavior can prevent many transmissions of HIV infection. There is much evidence that, upon learning one is HIV positive, infected persons reduce their risk behaviors and the likelihood of transmitting HIV to partners. Among persons testing positive for HIV, there was a 70% reduction in reported risk behavior at one year after diagnosis. Among persons testing negative for HIV, those receiving enhanced risk reduction counseling had only 18% fewer sexually transmitted infections at one year after testing compared with persons receiving standard counseling. These studies suggest that working with HIV-infected persons will result in greater reductions in risk behaviors and HIV transmission than working with HIV-negative persons.

    In studies of partner counseling and referral services, researchers found that 8% to 39% of partners of persons with HIV infection who were tested were found to have previously undiagnosed HIV infection. Because of this finding, the CDC will increase emphasis on assisting HIV-infected persons in notifying partners of their recent exposure and ensure voluntary testing of partners.

    Prevention interventions (including ongoing case management, focused risk-reduction counseling, medical interventions and support for other psychosocial stressors) are recommended under this initiative to help HIV-positive persons maintain protective behaviors.

    ASP Response: Working with PLWA and their partners is what ASP has always done. Now we will be providing on-site testing, prevention case management, focused risk reduction, medical referrals and various support services.

  7. Implementation of initiative activities

  8. Implementation of the new initiative requires strong and extensive partnerships with cooperation and coordination among the CDC, the public health community and the medical care community. With the support of the Department of Health and Human Services, CDC and its partners, including other federal agencies, state and local health departments, community-based organizations and professional organizations will implement these activities and reenergize our efforts to meet the challenges of this changing epidemic.

    ASP Response: We are committed to meeting the needs of PLWA, and Prevention for Positives is another step for us in the right direction.

What is the OraQuick Rapid HIV-1 Antibody Test, and how is it performed?

The OraQuick Rapid HIV-1 Antibody Test checks for HIV-1, the virus that causes AIDS, in a person's blood. The test detects antibodies to HIV-1 found in blood specimens obtained by fingerstick or venipuncture. As is true of all HIV screening tests, a reactive test result needs to be confirmed by an additional, more specific test.

When testing a fingerstick specimen, the fingertip is cleaned with alcohol and pricked with a lancet (needle) to get a small drop of blood. The blood is collected with a specimen loop and transferred to a small plastic vial containing a premeasured volume of developing solution into which the sample is mixed. The testing process is the same for a whole blood specimen obtained by venipuncture. The specimen loop is inserted into the tube of blood after the tube has been inverted to ensure the blood is well-mixed. The loop is then inserted into the test vial. Results of the test can be read in as little as 20 minutes.

How well does the test work?

In the clinical studies by the manufacturer (OraSure Technologies, Inc.), the OraQuick test correctly identified 99.6% of people who were infected with HIV-1 (sensitivity) and 100% of people who were not infected with HIV-1 (specificity). The Food and Drug Administration expects clinical laboratories to obtain similar results.

What are the limitations of the test? Does this test always give a correct result?

The limitations of this test are similar to the limitations of other HIV antibody tests, including:

  • False-positive results: Although no false-positive results were found in the clinical trial, statistical analysis of the data show that a very small number of people who are not infected with HIV-1 will have reactive test results (that is, tests that show HIV infection). As the test becomes widely used in outreach settings, false-positive results may occur. Reactive results should not be considered definitive until confirmatory testing has been done.

  • False-negative results: A small number of people who are infected with HIV-1 will have negative test results.

  • Delayed detection of exposure: OraQuick may not detect HIV-1 infection in people who were exposed within three months before being tested (it can take that long for antibodies to HIV-1 to be detectable in the blood).

  • Follow-up testing: A reactive result is interpreted as preliminarily positive for HIV-1 infection. Another method should be used to confirm the initial test result.

Because of these limitations, all persons taking this test must receive counseling before being tested and after receiving their test results.

What type of counseling is provided to persons getting a rapid HIV test?

Counseling for rapid HIV tests includes:

  • Information about the importance of HIV testing

  • Ways to reduce the risk of becoming infected with HIV

  • Next steps for persons who have a reactive test result

  • Need for additional testing of persons whose rapid test result is negative but who have had a recent exposure to HIV

Does the test detect antibodies to HIV-2?

The test is approved to detect antibodies to HIV-1. Data on the test's sensitivity to detect antibodies to HIV-2 have not been reviewed, and the Food and Drug Administration has not approved the test for this purpose. Because HIV-2 is very rare in the United States, CDC does not recommend routine screening for HIV-2 at this time.

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This article was provided by AIDS Survival Project. It is a part of the publication Survival News.
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