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Background
On June 1-2, 2009, the Centers for Disease Control and Prevention (CDC) sponsored a Consultation
on Revised Guidelines for HIV Counseling, Testing, and Referral (CTR) in Non-Health-care Settings.
The consultation explored the topics of Targeting and Recruitment; Counseling; Testing; and Linkage
and Referral in the non-health-care setting (i.e., health fairs, mobile vans, churches, etc.).
Approximately 60 federal employees and 60 external consultants attended this consultation, including
academicians, personnel from local and state health departments, community-based organizations, and
prevention training centers.
The consultation began the morning of June 1st with a plenary session to review the guideline
development and consultation process, and review the content of the previous guidelines published
in 2001[1], emerging HIV testing technologies, background and key findings on the four main guideline
topics. In the afternoon, participants could attend one of four topic-specific work group sessions
to examine the current state of the research in more depth and provide recommendations to present to
the entire group during the general session on the second day of the consultation. During the work
group sessions, participants reviewed available data from teleconferences and literature reviews and
discussed key areas that should be addressed in the revision of the guidelines, as well as gaps
requiring further research. On the morning of the second day, on behalf of the smaller work group
sessions, consultants external to CDC presented recommendations to the entire group during the general
session and all the topics were discussed.
Recommendations Presented at the Consultation:
These recommendations, which solely represented the views and experiences of the work group
participants, rather than CDC, will be considered when revising the guideline document.
Summaries of the recommendations shared during the general session are presented below:
- Work Group Session I: Targeting and Recruitment
When determining which population a program should target to identify new cases for counseling,
testing, and referral (CTR) services, multiple methods can be used, including the use of epidemiological
data. Epidemiological profiling with a community planning group should be augmented with available
incidence data, behavioral risk indicator data, and an assessment of testing patterns. When determining
the appropriate strategy to identify new cases in a place or during an event, community mapping and
Geographical Information System (GIS) can be used to identify areas where high-risk populations
congregate. An assessment of the appropriateness of the place or event should also be utilized.
Once a place or event is selected, CTR services should be offered to everyone.
Many strategies were recommended to identify new cases and link them to care such as: social
networking approaches, social marketing, community-level interventions, agency referrals, bundling
of CTR services with other health-care and non-health care related services, and the use of incentives.
Formative research can be beneficial when deciding which strategy to use.
CDC should implement a monitoring and evaluation component, including community-level and
process/operational goals with streamlined reporting system. Barriers encountered during recruitment
should be addressed, as well as their proposed solutions.
- Work Group Session II: Counseling
A variety of risk-reduction approaches are available (i.e., videos, computer counseling, and
face-to-face counseling) and should be considered in conjunction with an HIV testing program.
There are minimum components, which should be included, in any testing service: Information, Consent,
Testing, Results disclosure, and Referral. Including a risk-reduction intervention before the results
disclosure is highly recommended, but should not be a barrier to testing for the client. This supports
the recommendation that testing be a required component of all HIV prevention programs.
The information component, provided before an HIV test is administered, should include: a description
of the test, meaning of test results, benefits of testing, basic transmission and prevention information,
referrals available, seroconversion “window” period, reporting requirements, and the procedure following
a positive test result. More information needs to be provided in these guidelines regarding consent.
Recommended components to include in a brief individual/couple-level risk-reduction intervention include:
introduction; personalized risk assessment; filling in of knowledge gap; identification of teachable
moment and use of dissonance; past successes, barriers, and self-efficacy; skill-building opportunities;
client-developed risk-reduction plan; self-efficacy for current risk-reduction plan; and implications of
results. Ongoing technical assistance is needed for the training of counselors and supervisors, quality
assurance, and support supervision.
- Work Group Session III: Testing
All clients should receive their HIV test results, whether or not the test result is reactive.
The provision of test results during a face-to-face encounter is most desirable; however, alternatives
which allow for a mechanism to verify identity are permissible. Clients should have the option of
receiving a written copy of their results. The messages delivered to clients should be clear and
simple, not modified based on risk. Clients should be linked immediately following a preliminary
positive HIV test.
More research is needed regarding the use of incentives to improve HIV testing rates, including the
use of non-monetary incentives (i.e., bundling HIV tests with other STD screenings). Retesting should
be recommended following a single recent exposure, in high-prevalence populations (determined by
geographic location, community or population), for high-risk MSM, and before a new sexual relationship.
- Work Group Session IV: Linkage and Referral
A proposed definition to Linkage to HIV Care is when a client sees a medical provider within 3
months and before a maximum of 6 months following their HIV diagnosis at a CTR program. Medical
care includes a full medical evaluation, CD4 count, and viral load count. The community-based
organization (CBO) is responsible for linking clients to medical care, prevention services, and
other supportive services within the appropriate time period, as well as establishing a comprehensive
memorandum of understanding with partner agencies to make an active referral. CBOs may have to realign
their resources to support a linkage/support case manager to provide active linkage.
Primary services for newly HIV-infected clients should include medical care and a referral to a
case manager. Secondary services include prevention services and support services (i.e., psychosocial,
housing, and substance abuse), as well as other STD screenings, economic benefits, and partner services.
Services recommended for high-risk HIV-negative clients would include referral to preventive services,
education, STD screenings, and support services.
Barriers to successful linkage and referral should be addressed in the guidelines. A monitoring and
evaluation system should be developed to ensure access to services and verify completed referrals.
More research is needed regarding linkage to care among different demographic groups, cost-effectiveness,
and working with non-traditional partner organizations and communities.
Conclusion:
The consultation highlighted the need to update the 2001 Revised Guidelines for HIV Counseling, Testing,
and Referral to meet the needs of organizations conducting HIV testing in non-health-care settings.
The information obtained in this consultation will inform potential future CDC activities,
the development of prevention messages, and the creation of future funding announcements.
As follow-up to this consultation, CDC will develop a guidance document on counseling, testing,
and linkage in the non-health-care setting. The revised guidelines are scheduled to be released in
2010.
References
- Revised guidelines for HIV counseling, testing, and referral. MMWR
Recomm Rep 2001; 50(RR-19): 1-57; quiz CE1-19a1-CE6-19a1.
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