US Study finds HIV Test Plus Counseling Doesn't Cut Infection Rates

New research finds that prevention counseling with HIV testing didn't cut sexually transmitted infection rates any more than testing with information only.

By Janet Kim, MPH, Everyday Health Staff Writer
TUESDAY, October 22, 2013 – HIV prevention counseling has long been a standard part of the HIV testing process, but a new study finds that it may not be all that useful in keeping certain groups of people from contracting sexually transmitted infections (STIs).

The results of Project AWARE, a study published today in theJAMA, showed no added benefit from risk-reduction counseling offered in conjunction with a rapid HIV test. "I think that right now, to my knowledge, this is probably the best evidence that can really inform the question if there is still a role for risk-reduction counseling," said Lisa R. Metsch, PhD, lead investigator of Project AWARE and chair of the Department of Sociomedical Sciences at Columbia University's Mailman School of Public Health in New York City.
Recommendations to Streamline HIV Screening

When the U.S. Centers for Disease Control and Prevention (CDC) last revised their recommendations for HIV testing, in 2006, one major change was not requiring prevention counseling as part of HIV screening. The idea was that if there were no counseling requirement, more people would get HIV screening, and it would become a routine part of medical practice.

At the time, the American Medical Association supported this change and expected physicians to support the updated recommendations. News of this change in guidance, however, was a cause for concern among HIV/AIDS advocacy groups. They feared that without prevention counseling, people would not be adequately or accurately informed about how to protect themselves and others from HIV.

 

"If we do away with prevention counseling, if we do away with additional intervention based on prevention, we're not going to have an AIDS-free generation," cautioned Lynnette Ford, MSW, managing director of program services and evaluation at the New York City nonprofit GMHC, who strongly believes in the value of prevention counseling.
HIV-Positive, But Unaware

Not knowing one's HIV status remains a significant concern in the United States, where about 20 percent of people with HIV are unaware that they're positive. Because they unknowingly put others at risk for the disease, they are responsible for many new HIV infections. And the later an HIV-positive person is diagnosed, the more advanced their disease and the more challenging it is to improve their health outcomes. One of the main goals of the federal government's National HIV/AIDS Strategy is to reduce the pool of undiagnosed HIV infections.

Earlier this year, in April, the U.S. Preventive Services Task Force (USPSTF) recommended HIV screening for everyone ages 15 to 65 regardless of their HIV risk status. The task force reasoned that HIV screening efforts on such a widespread scale would help to better control the HIV epidemic by identifying more people who are at risk or are already HIV positive. In contrast with the CDC recommendations, USPSTF recommends prevention counseling for all sexually active adolescents and for adults at increased risk for infection.

Even with the CDC and USPSTF HIV screening recommendations in place, prevention counseling continues to be a mainstay of HIV testing efforts. There's some speculation that the long-held perception of prevention counseling's effectiveness likely overshadows research about it. Probably because existing data are not clear, said Dr. Metsch. "The studies done to date did not clearly speak to the issue of whether to provide counseling at the time of HIV testing," she noted.

But, added Metsch, "There was one particular study called Project RESPECT that was published in 1998, and this was the solid scientific base supporting risk-reduction counseling at the time of testing. But it was done before antiretroviral therapy, before the era of rapid testing, when HIV was basically a fatal disease."

As Metsch and her colleagues stated in the JAMA report on the new study, Project AWARE was designed to fill this gap.
No Added Benefit From Risk-Reduction Counseling

The Project AWARE randomized clinical trial ran from April 2010 to December 2010, to evaluate the effectiveness of a rapid HIV test with either risk-reduction counseling or information only in reducing the rates of sexually transmitted infections. Counseling involved a single brief discussion with individuals about their sexual risk behaviors and how to reduce their risks for HIV and other STIs. The information-only session was limited to the basics about HIV and the test itself.

The investigators enrolled 5,012 men and women who sought services at nine STI clinics in the United States. Study participants were categorized in three groups:
Men who have sex with men (MSM), which included men who have sex with men and women
Men who have sex with women (MSW)
Women who have sex with men and/or women

All participants had a rapid HIV test and received either counseling or information only at the time of the test. They were screened for various STIs at both the start of the study and six months later. Medical records were reviewed to assess any diagnoses of STIs between these points in time. All of the participants were tested for gonorrhea, chlamydia, syphilis, herpes simplex virus 2, and HIV; women were tested for trichomoniasis as well. Participants were also asked about their sexual risk behaviors -- including total number of sex acts, number of unprotected sex acts, total number of sexual partners, and number of unprotected sexual partners -- in the six months before the study and the six months after the start of the study.

At the six-month follow-up, overall STI rates did not differ significantly between the counseling (12.3 percent) and the information-only (11.1 percent) groups. The rates of STIs by gender (for the MSW and women-only groups), age group, and race/ethnicity also did not differ significantly between the counseling and information-only groups.

Results were different in the MSM group: 18.7 percent of those who had prevention counseling were found to have had STIs compared to 12.5 percent in the information-only group.

Interestingly, investigators found the overall number of risky sexual behaviors was somewhat lower in the counseling group than in the information-only group. One possible explanation, they surmised, is that "the magnitude or nature of the behavior change was insufficient to reduce STI incidence."
Should the Role of Prevention Counseling Be Reconsidered?

Results of the Project AWARE trial will be welcome or discouraging news, depending on which side you favor in the ongoing debate over the role of prevention counseling at the time of HIV testing.

On one side, as the study authors concluded, "[W]ithout evidence of effectiveness, [risk-reduction] counseling cannot be considered an efficient use of resources."

Nicholas Hellmann, MD, executive vice president of medical and scientific affairs with the Elizabeth Glaser Pediatric AIDS Foundation in Washington, D.C., agrees. "HIV prevention counseling is viewed by many health facilities to be too costly and labor intensive, and by tested individuals to be inconvenient," said Dr. Hellmann, who was not involved with the new research.

"This study shows little or no health benefit from routine HIV prevention counseling for individuals before testing," added Hellman, noting that it "provides a rationale for removal of this key barrier to more routine and widespread HIV testing."

"Prevention counseling is a mainstay in GMHC's toolbox to combat HIV and AIDS," said GMHC's Ford, who was also not involved with the research. "I think the role of prevention counseling should not be reconsidered…there is a need for prevention counseling. Not having prevention counseling, we really miss an opportunity to potentially use teachable moments with clients."

"Prevention counseling is most often successful when utilizing other approaches, such as motivational interviewing or longer-term interventions," Ford said, "Because let's face it, behavior change does not occur overnight."

In lieu of risk-reduction counseling, the authors of the new study proposed "a more focused approach to providing information at the time of testing [that] may allow clinics to use resources more efficiently to conduct universal testing, potentially detecting more HIV cases earlier and linking and engaging HIV-infected people in care."

"I feel that there are lots of other new and exciting developments in the HIV prevention arena that we could be doing," Metsch noted. "I also think…there still could be a place for other types of counseling."