Individual and Organizational Characteristics of Effective Frontline Practitioner Performance: A Study of Los Angeles County HIV Testing Organizations.

AIMS: This study examines the strategic contributions of three Frontline Practitioner (FP) attributes for effective HIV testing: risk assessment use, having specialized HIV training, and organizational test setting (nonprofit, forprofit, and public). METHODS: Data from 621staff in 159 organizations in Los Angeles County, are used to model individual and organizational correlates and use of risk assessment and measures of effective performance (volume of HIV tests, HIV seropositive tests, and referrals to treatment). RESULTS: FP with specialized training in HIV care situated in nonprofit outpatient clinics are more likely to use risk assessment. Nonprofit outpatient clinics, FP with specialized training in HIV, and risk assessment use are associated with higher HIV test volume. DISCUSSION AND IMPLICATIONS FOR POLICY AND PRACTICE: FP with specialized HIV training in nonprofit outpatient settings offer testing/counseling services qualitatively different from FP in other settings.

Staff strategies for improving HIV detection using mobile HIV rapid testing.

This paper examines the performance of 13 mobile testing units (MTUs) and rapid HIV testing technology in Los Angeles County as reflected in the relationship between the cognitive strategies used by MTU staff regarding instructions to clients about picking up their test results and returning for test results, and following up with those clients who did not return, and the spatial distribution of MTUs and AIDS rates in 2003. Maps were created using geographic information systems (GIS) data on 93 MTU testing locations and 2003 AIDS cases data. MTU staff (N = 45) were interviewed and several themes were identified. MTU testing locations were clustered near high AIDS rate areas. Staff reports were obtained on 24 clients in the past 6 months who received HIV-negative test results and 24 clients during the same time period who received HIV-positive test results. Staff strategies that were used included keeping clients with them while rapid test results were being processed and adjusting to clients' schedules when arranging for picking up test results. Some staff used tangible incentives such as vouchers for area businesses to encourage preliminary HIV-positive clients to return for confirmatory test results. Staff also sought to convince clients who preliminarily tested HIV-positive to convert from anonymous to confidential testing in order to facilitate clients' linkage to treatment. The GIS findings and client risk data support the Centers for Disease Control and Prevention policy of implementing MTUs and rapid testing in large urban communities with high AIDS rates.

Egocentric networks of Chinese men who have sex with men: network components, condom use norms, and safer sex.

Research on risk behaviors among men who have sex with men (MSM) is often based on individualistic models of health behavior, but sexual behavior is inherently social in nature and often determined by constituents of social networks. The objective of this study was to examine relationships among social networks, network norms of condom use, and safer sex. A respondent-driven sampling study recruited 350 MSM in the Shenzhen region of China between November and December 2007 and collected information on network components (relations, structures, and functions) and HIV risk behavior among egos (those interviewed) and their network alters. A total of 2385 alters were nominated by the 350 egos. Egos reported an average of 4 nonsexual relation alters and 2 sexual-partner alters. Egos perceived receiving more tangible and emotional support from nonsexual relation alters than from sexual-partner alters. Two thirds (69%) of egos consistently used condoms. Sixty-seven percent of egos reported having 1 or more alters who always encouraged egos to use condoms, 84% had 1 or more alters who consistently used condoms, and 55% had 1 or more alters who insisted on condom use. Both subjective and descriptive norms were positively associated with consistent condom use. Network components were associated with the levels of the two norms. These findings suggest that social network components may activate or strengthen condom use norms within networks, which, in turn, determine consistent condom use among MSM. HIV behavioral interventions need to target the promotion of safer sex practices through enhancing peer norms of condom use within networks.

Increasing the reach of HIV testing to young Latino MSM: results of a pilot study integrating outreach and services.

BACKGROUND: In the U.S., HIV infections are increasing among men who have sex with men (MSM), particularly young, racial/ethnic minority MSM. OBJECTIVE: To examine the feasibility of increasing HIV testing among young Latino MSM by integrating tailored outreach strategies with testing, counseling, and HIV medical services. DESIGN: Descriptive study comparing demographic characteristics, behaviors, and HIV test results of clients from the intervention period with clients who tested during other time periods. RESULTS: Clients in the intervention period were younger and more likely to be Latino than those in other time periods. In addition, clients who received outreach were more likely than those who did not receive outreach to report methamphetamine use, sex with an HIV-positive person, and sex with a sex worker. CONCLUSION: Venue-based and selective media outreach, in combination with linking rapid testing to HIV care, may help overcome some of the barriers to testing among high-risk young Latino MSM.

HIV partner notification: predictors of discussion and agreements from provider reports.

This study examines organizational, provider, client, and test-event level predictors of HIV partner notification (PN) discussion and agreements based on providers' most recent HIV-positive post-test counseling session. Staff (n = 621) were sampled from for-profit, nonprofit, and county government HIV testing organizations (N = 159) in Los Angeles County from 2003 to 2007. Among providers who conducted an HIV-positive post-test counseling session (n = 204), 65% discussed PN but only 10% had confirmed agreement to provider-involved PN (PIPN). In multi-level regression analyses PN discussion was predicted by provider HIV-test training and knowledge, and patients requesting a test while presenting HIV/AIDS symptoms. The strongest predictor of PIPN agreement was public health HIV testing settings followed by counseling by program managers or infectious disease specialists across settings. None of the injecting drug users or patients presenting with AIDS, but not requesting a test, agreed to PIPN. Organizational and provider-level interventions on PN will be needed to realize cost-effective benefits of expanded HIV testing and counseling.

Client encounters in alternative HIV testing sites: counselors' perceptions and experiences.

In this study, the authors explored HIV test counselors' perceptions of and experiences working with "difficult" and "good" clients in alternative HIV testing sites. Trained interviewers made field observations and conducted sixteen 60-minute, semistructured interviews with counselors. Counselors reported 7 main characteristics of difficult clients: (1) uncooperative, (2) mean, (3) inebriated, (4) threatening, (5) "crazy," (6) sexually inappropriate, and (7) aesthetically unappealing/overly appealing. They also identified 3 main characteristics of good clients: (1) communicative, (2) responsive, and (3) vulnerable. In addition, HIV test counselors used 4 strategies to deal with difficult clients: (1) received help from other counselors, (2) refused to test or threatened to refuse to test, (3) verbally confronted clients, and (4) "followed the forms" (ie, asked the necessary questions on the standard risk assessment forms). Results highlight the combined importance of patient characteristics, HIV test counselor characteristics, and the testing environment in contributing to difficult and good encounters in alternative HIV testing sites and point to the need for better training and support services in this area.

Outcomes of blood and oral fluid rapid HIV testing: a literature review, 2000-2006.

Rapid HIV antibody testing is a new technology whose implementation promises to facilitate the early detection of persons with HIV/AIDS. The goal of this study was to review and summarize the literature from 2000-2006 regarding four outcomes of rapid (including both blood and oral fluid) HIV testing: rates of client acceptance; rates of clients' receiving their test results; rates of entry into medical care for those found to be HIV positive; and the efficacy of prevention counseling after testing. A total of 116 studies in peer-reviewed journals were screened. Twenty-six met the screening criteria (published in peer-reviewed journals and focused on at least one of the outcomes of interest) and were selected for review. Considerable variation was found in client acceptance rates with the highest rates among pregnant women in labor and delivery units and the lowest rates in needle exchange and bath-house settings. The evidence shows that most persons tested with a rapid test receive their test result. Three studies on entry into medical care among those who were newly identified HIV positive found rates of 47%, 82%, and 97% of clients adhering to their first medical appointment. No long-term medical follow-up studies were found. Only one study examined the efficacy of prevention counseling after rapid testing and found no statistically significant differences in the number of sexually transmitted diseases (STDs) conventional versus rapid HIV testers contracted following testing.

Failure to return for HIV test results: a pilot study of three community testing sites.

BACKGROUND: Individuals at elevated risk of contracting HIV frequently fail to return for their test result. Because rapid HIV antibody testing is still not widely implemented, failure to return for test results under conditions of standard testing remains a problem. METHODS: Direct field observation and semistructured interviews with clients (N = 16) and test counselors (N = 16) of 3 community HIV testing sites were conducted. RESULTS: Clients faced 5 barriers to receiving their result: (1) fear, (2) busyness, (3) apathy,(4) inebriation at the time of testing, and (5) testing "on a whim." Motivators that encouraged clients to receive their results were (1) positive counselor/client interactions, (2) client-friendly policies regarding picking up the test result, (3) clients' psychological "need to know," (4) incentives for picking up the result, and (5) established protocols for contacting clients who fail to return. CONCLUSION: Findings highlight the need for interventions to improve the return rate for HIV results.

Communicating indeterminate HIV Western blot test results to clients: an observational study of three community testing sites.

This study examined HIV test counselors' beliefs and practices regarding communicating indeterminate HIV test results to clients. There are many reasons for an indeterminate HIV antibody/ Western blot assay including early HIV infection, infection with other contagious diseases, autoimmune diseases, and second or subsequent pregnancies in women. Field observations of three community HIV testing sites and semistructured interviews with 16 HIV test counselors were conducted from August 2002 through June 2003. Counselors defined an indeterminate test result in different ways. They also presented several different theories of causation, yet failed to mention two potential causes of an indeterminate result, association with large animals and infection with other (non-HIV-1) HIV strains. Counselors' understanding of the meaning of an indeterminate HIV test result varied a great deal. Some counselors believed that an indeterminate result truly was ambiguous while others believed it was indicative of being either HIV-positive or HIV-negative. Counselors' primary advice to clients who received an indeterminate result was to retest immediately without a waiting period. Counselors reported that communicating indeterminate test results to clients was a challenging task because clients who received such a result were confused, angry, and/or mistrustful. Results highlight the need for further research to provide reliable estimates of the extensiveness of indeterminate HIV test results and to further assess the nature of counselor and client responses to indeterminate test results.

ZIP code correlates of HIV-testing: a multi-level analysis in Los Angeles.

In this study we examine how individuals' residential areas relate to their HIV-testing, regardless of individuals' characteristics. Data from a 1999 random probability sample of Los Angeles (LA) County adults (n = 5475) was used to conduct a multi-level analysis of HIV-testing among respondents in (1) all 233 ZIP codes and (2) the subset of regions with higher rates of higher-risk sex. Results showed that HIV-testing rates varied across individuals' residential ZIP codes. Throughout LA and in higher-risk regions, residents of areas containing concentrations of African Americans were more likely to test for HIV than residents of White or Latino areas, regardless of individuals' own race/ethnicity or the number of AIDS cases or testing sites in ZIP codes. However, residents of Latino areas were no more likely to test than residents of White areas. This is a concern because of increasing rates of HIV-infection among Latinos. We conclude that opportunities exist to increase testing in Latino higher-risk areas.

Do drug users in China who frequently receive detoxification treatment change their risky drug use practices and sexual behavior?

BACKGROUND: Relapse rates among treated drug users in China are high. We examined the associations between frequency of drug detoxification treatment and HIV-related risky drug practices and sexual behavior. METHODS: A cross-sectional study was conducted among drug users in two Anhui province detoxification centers in 2003. RESULTS: A total of 312 drug users were recruited. Seventy-seven percent of the subjects had ever received two or more detoxification treatments. The median number of detoxification treatments received was three, with an interquartile range of two to five treatments. More than 7 in 10 (72%) ever injected drugs; 19% shared needles and syringes in the past 30 days; 40% of drug users reported having both regular and commercial sex partners in the past year and 48% reported having only regular sex partners. Multiple Poisson regression analysis documented that the frequency of detoxification treatment was not associated with a decrease in drug practice (injection or sharing needles) and in unprotected sex. CONCLUSION: Drug users who frequently received detoxification treatment did not change their risky drug use practices and sexual behavior. Effective behavioral interventions and substitution maintenance treatment should become an integral part of detoxification programs in China.

Drug users: a potentially important bridge population in the transmission of sexually transmitted diseases, including AIDS, in China.

OBJECTIVE: The objective of this study was to examine risk characteristics among bridge and nonbridge drug users. STUDY DESIGN: A cross-sectional study was conducted among drug users. Drug users who shared needles and engaged in sex with both high-risk partners and low-risk partners were defined as bridgers. RESULTS: A total of 312 drug users were recruited, among whom 49.4% (154) were bridgers. Among bridgers, 83.1% injected drugs and 35% shared needles in the past month. Eighty-seven percent (134) of bridgers had one or more commercial sex partners in the past year. Only 3.9% of the bridgers and 4.6% of nonbridgers consistently used condoms with regular sex partners. Fifty-eight percent of bridgers and 46.8% of nonbridgers tested positive for hepatitis C virus, whereas 15.6% of bridgers and 7% of nonbridgers tested positive for syphilis. CONCLUSIONS: The pervasiveness of bridgers among drug users and their risky sexual behavior underscore their role in the spread of sexually transmitted diseases.

Anonymous versus confidential HIV testing: client and provider decision making under uncertainty.

Six intensive observational studies of HIV testing sites were undertaken in order to improve understanding of confidential and anonymous testing. Three sites offered only confidential testing (a large health maintenance organization's Urgent Care clinic, the same organization's HIV clinic, and a private medical practitioner's office), one offered only anonymous testing (a free clinic), and two offered a choice of confidential or anonymous testing (a thrift shop alternate testing site and a mobile testing unit). Multiple data collection strategies were used including direct field observation, semistructured interviews with clients and providers, and document and policy analysis. Using an organizational/interactional uncertainty framework, this study found that the choice between anonymous and confidential testing is a central aspect of the HIV testing process, that some clients are unclear about the differences between anonymous and confidential testing, that alternate testing sites' providers play a significant role in encouraging confidential rather than anonymous testing in order to further their organization's resource needs and public health goals, and that testing counselors' may consider that some clients prefer anonymous testing because of fear of stigma, discrimination, or loss of privacy.

HIV testing in an urgent-care clinic.

BACKGROUND: Early detection of HIV is increasingly important in light of advances in HIV research and treatment. Although treatment advances offer the potential to curtail HIV incidence and seroprevalence, the full benefits remain unrealised because many infected individuals remain unaware of their serostatus. An intensive observational study of HIV testing and counselling was undertaken in a large health maintenance organisation's urgent-care clinic (UCC) for non-threatening illnesses and non-traumatic injuries in order to better understand the HIV testing process in a medical setting. METHODS: Multiple data collection strategies, including observation, semi-structured interviews and document and policy analyses, were used in order to identify key factors influencing HIV testing. The study examined physicians', nurses' and physician's assistants' relationships with patients in the UCC. RESULTS: It was found that HIV testing in the UCC is highly variable because some patients are asked about their sexual risk histories and given HIV prevention education materials and others are not. Moreover, for those patients who do receive these components of testing, the content of both the risk assessments and HIV prevention counselling varies from patient to patient. Findings also highlight the problematic nature of providing HIV test results in an UCC. CONCLUSIONS: A number of implementation issues were found to be relevant to the new US Centers for Disease Control and Prevention (CDC) policy of making HIV testing a routine feature of medical care. The study results suggest the need for organisationally fine-tuned interventions designed to improve the process of testing patients for HIV in medical settings.

Evaluating the accessibility of HIV testing organizations.

Consumer-based indicators were developed to evaluate the accessibility of private and public nonhospital HIV testing organizations. A comprehensive roster of 148 nonhospital HIV testing organizations in Los Angeles County was constructed from publicly available listings. A telephone survey protocol was used to contact sites and assess consumer relevant accessibility measures. Only 50% of the sites could be contacted and indicated that HIV testing was available. Hence, a consumer who tried to reach one site had only a 50-50 chance of success. HIV testing sites differed with regard to how frequently they offered testing; whether they offered anonymous and/or confidential testing; what types of counseling they provided; how quickly test results were available; and how friendly, helpful, attentive, and knowledgeable about testing procedures their attendants were. HIV testing sites must make their services accessible and be perceived by consumers as responsive if they are to be effective service providers.