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Can Barrier Methods Help in HIV Prevention?

Why barrier methods?

Barrier methods are a relatively low-cost, accessible and important part of the pregnancy and sexually transmitted disease (STD) prevention landscape. Barrier methods can be physical or chemical substances which prevent pregnancy and/or block the spread of STDs including HIV. They do not include hormonal contraceptive methods. People have successfully used contraceptive physical barriers for centuries.¹ Since the beginning of the HIV epidemic, the latex male condom has been the exclusive prevention tool. After two decades, there is a call to create a greater selection of barrier methods to combat HIV. Because HIV rates continue to increase among women and among men who have sex with men (MSM)^2,3, it is time to strengthen both current condom use programs and develop other barrier methods that optimize usage and choice in prevention.

What methods are available?

Currently, the male and female condoms are used for the prevention of HIV, STDs and unintended pregnancy.^4,5 The female condom, made of polyurethane plastic, is also used for receptive anal sex, but it was not designed for that purpose.⁶ The diaphragm, cervical cap and sponge are often used with a spermicide and block the cervix to prevent conception. Although studies have shown that these cervical blocking methods may also prevent certain STDs⁷, research has not been conducted to show that they prevent HIV. Dental dams are latex sheets used to provide a barrier in oral/anal and oral/vaginal sex. Spermicides (gels, creams, foams, or films that can be inserted into the vagina) are available for preventing pregnancy. One of the most widely used spermicides, Nonoxynol 9 (N-9), was recently tested for its ability to prevent HIV. The study of female sex workers in Thailand, South Africa, Cote d’Ivoire and Benin, randomly assigned women to use either a gel containing 52.5 mg of N-9 or a placebo, a vaginal moisturizer known as Replens. Preliminary results showed that there were more new HIV infections among the N-9 group than in the Replens group.⁸ In August, 2000, the CDC recommended against N-9 as a sole barrier method for HIV prevention.⁹ This study documented the harmful effects of a relatively large dose of N-9 on HIV infection. N-9 is commonly used in much smaller amounts as part of a condom lubricant. The impact of small doses of N-9 is not clear.

Why do we need alternatives to male condoms?

Male condoms are an extremely effective means of HIV, STD and pregnancy prevention. What most often limits condoms’ effectiveness is user failure rather than product failure. For example, users may fail to either put on a condom before genital contact or completely unroll the condom. In addition, some people fail to use a condom with every act of sexual intercourse. Some don’t use condoms because they reduce sexual sensation. For others, using condoms is seen as a barrier to intimacy. Male condom use requires male participation or negotiation. Female-controlled and receptive-partner-controlled options (such as female condoms or future microbicides) may be used without the participation or consent of the insertive partner. These methods are still detectable by sexual partners and partners can still refuse to use them. Female- and receptive-partner-controlled options can be used in situations where it is difficult to negotiate condom use such as in an abusive relationship, where there is economic disincentive to use a condom¹⁰ or where the insertive partner refuses to use a condom.⁵ Female-controlled HIV/STD prevention methods can be empowering¹¹ and are vital in an HIV epidemic that is increasingly infecting women, especially in developing countries. Finally, there is no barrier method that allows women to protect themselves from HIV and still get pregnant. Hopefully, a barrier method can be developed that separates the control of fertility from the prevention of STDs. This is an important consideration for many women.²

What are the drawbacks?

Barrier methods can provide protection against HIV and STDs, yet they are not an option for everyone. Although some methods are low-cost, others, such as the female condom, may have limited accessibility because of their cost. Most barrier methods require application before each act of sexual intercourse, making consistent use more difficult. Barrier methods may not protect against STDs that are transmitted via skin-to-skin contact such as herpes and human papilloma virus (HPV). Products may be messy or may require adequate cleaning and storage, which may not be available to some people. Some barrier methods are inserted into the vagina which requires comfort and familiarity with one’s body. Diaphragms and cervical caps require a health care worker to fit the devices. Further, individuals may have sensitivities to products’ chemicals or materials, such as latex allergies.¹ Barrier methods under development are addressing some of these limitations.

What about microbicides?

Microbicides are topically-applied chemical barriers that prevent HIV and/or STD transmission. They are not currently available, but are under development and being tested for efficacy as an alternative to current methods. Microbicides may come in the form of gels, creams, foams or films that can be inserted into the vagina or rectum. Development is currently focused on creating products which destroy or immobilize germs or viruses through a variety of mechanisms: breaking down the outer cell membranes of pathogens, enhancing normal vaginal defenses, providing a physical coating to the vagina or the rectum, inhibiting HIV from entering cells or preventing HIV replication if HIV does enter a cell.¹² Studies show that there is large potential demand for microbicides from women in the US and internationally.¹³ People are also willing to participate in efficacy trials, as studies in women and MSM have shown.^14,15

What’s being done?

Male condoms are currently the best comprehensive prevention method. Education and prevention campaigns must be continued to optimize condom usage while also searching for alternatives. HIV prevention efforts may be more effective among certain populations if condom use and HIV are addressed together with STD and unintended pregnancy prevention. Some STD and family planning clinics are encouraging condom use for both STDs and HIV prevention with great success.¹⁶ New physical barrier methods currently being researched include the disposable diaphragm, alternative types of cervical shields, caps and sponges and alternative types of condoms, both male and female. New materials are also under development, including various plastics and silicone rubber.² It is also important to examine the potential for adapting current products and testing existing products for HIV prevention. As these products are already FDA approved, the testing process is not as lengthy.

What are the next steps?

The development of alternative barrier methods must be a priority among private and public researchers alike. With over 50 microbicides in the research pipeline, one should be on the market by the year 2005. Advocacy groups have played a large role in increasing awareness and attention to microbicides and should continue advocating for accessible barrier methods.¹⁶ Although US government funding for microbicides has increased, in the 1998 fiscal year, microbicide-related research received only 1% of the National Institutes of Health AIDS research budget.¹⁷ There is no single solution to HIV and STD prevention. Prevention requires continued work on many levels, including increasing access to products, advocating for social change to eliminate unsafe situations that many people are in, and developing stronger prevention and treatment alternatives. Barrier methods are an integral part of these prevention alternatives and must be developed to their fullest potential to enhance health and prevent disease. Says who? 1. Feldblum P, Joanis C. Modern barrier methods: effective contraception and disease prevention. Family Health International. 1994. 2. The Population Council and International Family Health. The case for microbicides: a global priority . 2000. 3. Microbicides: a new weapon against HIV. American Foundation for AIDS Research (AmFAR) Report. www.amfar.org . 4. Pinkerton SD, Abramson PR. Effectiveness of condoms in preventing HIV transmission . Social Science and Medicine. 1997;44:1303-1312. 5. Elias CJ, Coggins C. Female-controlled methods to prevent sexual transmission of HIV . AIDS. 1996;3:S43-51. 6. Gibson S, McFarland W, Wohlfeiler D, et al. Experiences of 100 men who have sex with men using the REALITY condom for anal sex . AIDS Education and Prevention. 1999;11:65-71. 7. Rosenberg MJ, Davidson AJ, Chen JH, et al. Barrier contraceptives and sexually transmitted diseases in women: a comparison of female-dependent methods and condoms . American Journal of Public Health. 1992; 82:669-674. 8. UNAIDS. Nonoxynol-9 not effective microbicide, trial shows https://pubmed.ncbi.nlm.nih.gov/12296062/  9. Gayle H. Dear Colleague. Centers for Disease Control and Prevention. August 4, 2000. 10. Abdool Karim Q, Abdool Karim SS, Soldan K, et al. Reducing the risk of HIV infection among South African sex workers: socioeconomic and gender barriers . American Journal of Public Health. 1995;85:1521-1525. 11. Gollub EL. The female condom: tool for women’s empowerment . American Journal of Public Health. 2000;90:1377-1381. 12. Heise L. Topical microbicides: new hope for STI/HIV prevention. Center for Health and Gender Equity (CHANGE). Takoma Park, MD. 13. Darroch JE, Frost JJ. Women’s interest in vaginal microbicides . Family Planning Perspectives. 1999;31:16-23 14. Hammet TR, Mason TH, Joanis CL, et al. Acceptability of formulations and application methods for vaginal microbicides among drug-involved women: results of product trials in three cities . Sexually Transmitted Diseases. 2000;27:119-126. 15. Gross M, Buchbinder SP, Celum C, et al. Rectal microbicides for U.S. gay men: are clinical trials needed? Are they feasible? Sexually Transmitted Diseases. 1998;39:55-61. 16. Kamb ML, Fishbein M, Douglas JM Jr, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Project RESPECT Study Group . Journal of the American Medical Association. 1998;280:1161-1167. 17. Harrison PF. A new model for collaboration: the alliance for microbicide development . International Journal of Gynecology and Obstetrics. 1999;67:S39-S53. PREPARED BY Beth Freedman MPH, Nancy Padian PhD, CAPS, ARI December 2000. Fact Sheet #39E Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © December 2000, University of California

What is the role of male condoms in HIV prevention?

revised 01/05

do condoms work?

Yes. The condom is one of the only widely available and highly effective HIV prevention tools in the US.¹ When used consistently and correctly, latex male condoms can reduce the risk of pregnancy and many sexually transmitted infections (STIs), including HIV by about 80-90%^1-6. Condoms, including female condoms, are the only contraceptive method that is effective at reducing the risk of both STIs and pregnancy. When placed on the penis before any sexual contact, the male condom prevents direct contact with semen, sores on the head and shaft of the penis and discharges from the penis and vagina. Condoms thus should effectively reduce the transmission of STIs that are transmitted primarily through genital secretions such as gonorrhea, trichomoniasis, chlamydia, hepatitis B and HIV.^1-6 Because condoms only cover the penis, they provide less protection from STIs primarily transmitted through skin-to-skin contact such as genital herpes, syphilis, chancroid and genital warts. Abstinence, mutual monogamy between uninfected partners, reducing the number of sexual partners and correctly and consistently using condoms during intercourse are all essential to slowing the spread of HIV/STIs.⁷ Condom effectiveness depends heavily on the skill level and experience of the user. Appropriate education, counseling and training on partner negotiation skills can greatly increase the ability of a person to use a condom correctly and consistently.²

what are the advantages?

Accessibility. Using condoms does not require medical examination, prescription or fitting. Condoms can be bought at drug stores, grocery stores, vending machines, gas stations, bars and the internet, and are distributed free at many STI and HIV clinics. Sexual enhancement. Using condoms can help delay premature ejaculation. Lubricated condoms can make intercourse easier and more pleasurable for women. And condoms do away with the “wet spot” left by semen leakage after sex. Using condoms helps reduce anxiety and fears of pregnancy and STIs so that men and women can enjoy sex more. Protect fertility. Some STIs can affect a woman’s ability to get pregnant; condoms can protect against some STIs and therefore help reduce the risk of infertility.⁸

what are the disadvantages?

Lack of cooperation. Women cannot directly control whether a condom is used and have to rely upon male cooperation. When men refuse, condom use may be impossible. Physical problems. Many men and their partners complain that condoms reduce sensitivity. Proper condom use requires an erect penis. Some men cannot consistently maintain an erection so condom use becomes difficult. Trying different kinds of condoms (such as thinner condoms) and using water-based lubricant can help increase sensation. Embarrassment. Some men and women may be embarrassed to buy condoms at a store, or take free condoms from a clinic. Others may be embarrassed to suggest or initiate using condoms because they perceive condom use implies a lack of trust or intimacy.⁹

how are they used?

The most important key messages for condom use are quite simple: 1) Use a new condom every time, with every act of intercourse, if there is a risk of pregnancy or STIs. 2) Before penetration, carefully unroll the condom onto the erect penis, all the way to the base. Put it on before the penis comes in contact with the partner’s vagina or anus. 3) After ejaculation (while the penis is still erect), hold the rim of the condom against the base of the penis during withdrawal.^2,10 Even with adequate training and access to condoms, people won’t always use condoms perfectly. In the real world, people may fall in love, or make mistakes, or get drunk or simply decide not to use condoms. Having sex under the influence of alcohol and/or drugs greatly increases the chances of condom non-use, misuse and failure.¹¹

what are concerns?

Condom education/distribution in schools. Although schools can be an important source of information on HIV/STIs, only 2% of public schools have school-based health centers, and only 28% of those make condoms available to students.¹³ In 2000, persons aged 15-24 had 9.1 million new cases of STIs and made up almost half of all new STI cases in the US. 47% of US high school students have had sexual intercourse.¹⁵ Condom breakage and slippage (condom failure). Condom quality has been improving¹⁶ and for most users condom failure is relatively rare. About 4% of condoms break or slip off.² However some persons report much higher rates. In one study, gay men who were unemployed and reported amphetamine and/or heavy alcohol use were more likely to report condom failure. Men who were frequent users of condoms and used lubricant reported less failure¹¹. Counseling and education on condom use can greatly reduce condom failure.² Effectiveness of N-9. Condoms lubricated with the spermicide nonoxynol-9 (N-9) often cost more, have no proven protective advantage over condoms without N-9, have a shorter shelf life and might be harmful if used excessively. Many manufacturers have discontinued N-9 condoms.^2,16

what works?

The following programs have been documented as effective by the Centers for Disease Control and Prevention, and are currently being replicated nationwide.¹⁷ Training on condom use and negotiation. The SISTA Project is a social skills training intervention for African American women designed to increase their comfort with and use of condoms. In small group sessions, women learn sexual assertion skills and proper condom use and discuss cultural and gender triggers that affect condom negotiation. Homework activities involve their male partners. Participants reported more condom use.¹⁸ Changing community norms. The Mpowerment Project is a community-level program developed by and for young gay men that increases peer support and acceptance for safer sex. Peer-led M-groups use a gay-positive and sex-positive approach to teach men negotiation and condom use and train and motivate them to conduct informal outreach with their friends. Participants reported decreased rates of unprotected anal intercourse.¹⁹ Combining HIV prevention with STI and unintended pregnancy prevention.The VOICES/VOCES program was implemented in an STI clinic and uses culturally-specific videos and skills building to increase condom use and negotiation among African American and Latino/a heterosexuals. The program is bilingual and includes education about different types of condoms and condom distribution. Participants reported more condom use and fewer repeat STIs.²⁰

what needs to be done?

Better marketing and increased accessibility to condoms is needed in the US. Although condom use has increased in the past decade, there are still unacceptably high rates of STIs among sexually active adolescents and young adults and among gay men, two populations that are also at increased risk for HIV. New approaches to condom promotion are needed, ideally before the onset of sexual activity. For adolescents to use them, condoms must be easily and anonymously accessible, widely available and low cost. Distributing free condoms can also help increase condom use.²¹ To effectively address HIV prevention, all persons should have accurate and complete information about different prevention options. But the emphasis needs to be different for different groups. For example, while young people who have not started sexual activity need information and access to condoms, the first priority should be to encourage abstinence and delay of sexual intercourse. When targeting those at highest risk for HIV, the first priority should be to encourage correct and consistent condom use along with avoiding high-risk behaviors and partners.⁷ Are condoms foolproof? No. Neither are seat belts, helmets, abstinence pledges or vaccines. But in the real world we drive to work, vaccinate our children, and hope to get through the day unscathed. No public health strategy can guarantee perfect protection. The real question is not are condoms 100% effective, but how can we more effectively use condoms and other approaches to help reduce the risk of disease.

Says who?

1. Scientific evidence on condom effectiveness for STD prevention. Report from the NIAID. July 2001. 2. Warner L, Hatcher RA, Steiner MJ. Male Condoms. In: Hatcher RA, Trussel J, Stewart F, et al, editors. Contraceptive Technology. New York: Ardent Media Inc. 2004:331-353. 3. Holmes KK, Levine R, Weaver M. Effectiveness of condoms in preventing sexually transmitted infections. Bulletin of the World Health Organization. 2004;82:454-461. 4. Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Systematic Review. 2002;(1):CD003255. 5. Hearst N, Chen S. Condom promotion for AIDS prevention in the developing world: is it working? Studies in Family Planning. 2004;35:39-47. 6. CDC. Male latex condoms and STDs. 7. Halperin DT, Steiner MJ, Cassell MM, et al. The time has come for common ground on preventing sexual transmission of HIV. Lancet. 2004;364:1913-1915. 8. Ness RB, Randall H, Richter HE, et al. Condom use and the risk of recurrent pelvic inflammatory disease, chronic pelvic pain, or infertility following an episode of pelvic inflammatory disease. American Journal of Public Health. 2004;94:1327-1329. 9. Miller LC, Murphy ST, Clark LF, et al. Hierarchical messages for introducing multiple HIV prevention options: promise and pitfalls. AIDS Education and Prevention. 2004;16:509-25. 10. ASHA. The right way to use a male condom. 1/30/05. 11. Stone E, Heagerty P, Vittinghoff E, et al. Correlates of condom failure in a sexually active cohort of men who have sex with men. Journal of AIDS. 1999;20:495-501. 12. McElderry DH, Omar HA. Sex education in the schools: what role does it play? International Journal of Adolescent Medical Health. 2003;15:3-9. 13. Santelli JS, Nystrom RJ, Brindis C, et al. Reproductive health in school-based health centers: findings from the 1998-99 census of school-based health centers. Journal of Adolescent Health. 2003;32:443-451. 14. Weinstock H, Berman S, Cates W. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives in Sexual and Reproductive Health. 2004;36:6-10. 15. Youth risk behavior surveillance–US, 2003. Morbidity and Mortality Weekly Report. 2004;53:1-98. 16. Condoms: extra protection. Consumer Reports. Feb 2005. 17. https://www.cdc.gov/hiv/effective-interventions/index.html 18. DiClemente RJ, Wingood GM. A randomized controlled trial of an HIV sexual risk reduction intervention for young African-American women. Journal of the American Medical Association. 1995;274:271-276. 19. Kegeles SM, Hays RB, Pollack LM, et al. Mobilizing young gay and bisexual men for HIV prevention: a two-community study. AIDS. 1999;13: 1753–1762. 20. O’Donnell CR, O’Donnell L, San Doval A, et al. Reductions in STD infections subsequent to an STD clinic visit: using video-based patient education to supplement provider interactions. Sexually Transmitted Diseases. 1998;25:161–168. 21. Cohen DA, Farley TA. Social marketing of condoms is great, but we need more free condoms. Lancet. 2004;364:13. Prepared by Markus Steiner PhD* and Pamela DeCarlo** *Family Health International, **CAPS January 2005. Fact Sheet #2ER Special thanks to the following reviewers of this Fact Sheet: Barb Adler, Daniel Bao, Willard Cates, Bill Cayley Jr, Rick Crosby, Scott Dougherty, Ralph DiClemente, Paul Feldblum, Steve Gibson, Daniel Halperin, Norman Hearst, Mary Hoban, John James, Doug Kirby, Andrzej Kulczycki, Kay Stone, Koray Tanfer, Lee Warner, Dan Wohlfeiler.

Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © January 2005, University of California

How does disclosure affect HIV prevention?

why is disclosure important in HIV?

Disclosure of HIV+ status is a complex, difficult and very personal matter. Disclosing one’s HIV+ status entails communication about a potentially life threatening, stigmatized and transmissible illness. Choices people make about this are not only personal but vary across different age groups, in different situations and contexts, and with different partners, and may change with time, depending on one’s experiences. Disclosure may have lifelong implications since more people are living longer, and often asymptomatically, with HIV. Public health messages have traditionally urged disclosure to all sexual and drug using partners. In reality, some HIV+ persons may choose not to disclose due to fears of rejection or harm, feelings of shame, desires to maintain secrecy, feelings that with safer sex there is no need for disclosure, fatalism, perceived community norms against disclosure, and beliefs that individuals are responsible for protecting themselves.¹ This Fact Sheet primarily focuses on disclosure in the context of sex. Discussing and disclosing HIV status is a two-way street. Be it right or wrong, most people feel that when a person knows that he/she is HIV+ then he/she has an obligation to tell the other person, and counselors are encouraged to help people with this process. Also, laws in some areas require disclosure of HIV+ status prior to sex.² However, both partners should be responsible for knowing their own status, disclosing their own status when it seems important, and asking their partner about their status if they want to know. Most HIV+ persons disclose their status to some, but not all, of their partners, friends and family. Disclosure generally becomes easier the longer someone has been living with HIV, as he/she becomes more comfortable with an HIV+ status. Disclosure to sex partners is more likely in longer-term, romantic relationships than in casual relationships (one-night stands, anonymous partners, group scenes, etc.).³ Disclosure also varies depending on perceived HIV status of partners, level of HIV risk of sex activities, sense of responsibility to protect partners (personal vs. shared responsibility) and alcohol or drug use.

does disclosure affect sexual relationships?

The relationship between disclosure, sexual risk behaviors and potential transmission of HIV varies. Research findings have presented a mixed picture.⁴ Some studies have found that increased disclosure is associated with reduced sexual risk behavior.⁵ Other studies show that disclosure doesn’t always alter risk taking behaviors.⁶ Even with disclosure, unsafe sex sometimes occurs. Some people engage in safer sex behaviors without any discussion of HIV status.⁷ Disclosure can provide psychological benefits. In one study, HIV+ injection drug users who disclosed their status experienced increased intimacy with partners and reaffirmation of their sense of self.⁸ Many HIV+ persons who disclose their status find that it reduces anxiety about transmission, so sex can be much more comfortable and relaxed. A challenging issue for many people is the timing of disclosure. If it’s not done relatively early, it can become more difficult as time goes on, and can cause significant disruption to an ongoing relationship if the disclosed-to partner feels betrayed due to the lack of an earlier disclosure. HIV+ persons who have thought through a disclosure plan and have a consistent strategy for managing disclosure are less likely to engage in risky sexual behaviors than those who do not disclose or have inconsistent disclosure strategies.⁵

does disclosure affect social relationships?

Yes. Disclosure to significant others can help increase support for HIV+ persons. A study of Latino gay men found that disclosure was related to greater quality of social support, greater self-esteem, and lower levels of depression.⁹ Disclosure also can lead to support that facilitates initiation of, and adherence to, HIV treatment and medications.^10,11 Disclosing HIV+ status can and sometimes does result in rejection, discrimination or violence. Disclosing to certain persons also can be more of a burden than a benefit. One study found that friends were disclosed to most often and perceived as more supportive than family members, and mothers and sisters were disclosed to more often than fathers and brothers and perceived as more supportive than other family members.¹²

what are the controversies?

There is debate around whether partners have a right to know if their partner is HIV+, in order to be able to make a fully informed decision about what sexual behavior to engage in. Some HIV+ persons believe that if they only have protected sex, there is no need for disclosure, especially with casual partners, and that encouraging disclosure only serves to further stigmatize HIV+ persons. These issues can be complicated by complex gender role norms and local laws—23 states have laws that make it a crime for a person to engage in certain risk behaviors without disclosing their HIV status.² People may use disclosure as a way to limit their partners to only persons of the same status, be it HIV+ or HIV- (sometimes known as serosorting). The success of serosorting as a prevention strategy depends upon honest and accurate disclosure on the part of any two sexual partners.¹³ Even when persons do choose to disclose, their awareness of their own HIV status may not be accurate.¹⁴ For example, some people who think that they are HIV- may be, in fact, in the acute stage of HIV infection. If an individual is in the acute stage of HIV infection, which are the initial weeks to months after acquiring HIV when the body has not yet produced a detectable antibody response, then he or she will have a negative result on a standard HIV test. This is especially concerning because when people are in this stage of infection, they more readily transmit the virus during unprotected sex than at other times.¹⁵

what’s being done?

Because many experts believe that HIV+ status disclosure helps prevent HIV transmission and increases social support for HIV+ individuals, there are efforts to develop programs to encourage disclosure and make it a constructive experience. Most programs to support HIV status disclosure have been part of overall prevention and well-being programs for HIV+ persons. Programs may include discussions of the benefits of disclosure, when to disclose and to whom. Programs should include practicing skills to discuss HIV status in the context of sexual negotiation and dating. The Healthy Living Project is a 15-session, individually delivered, cognitive behavioral intervention to help HIV+ persons cope with the challenges of living with HIV. The project addressed issues of stress, coping and adjustment, safer behavior, including disclosure to partners, and health-related behaviors. Participants reported fewer unprotected sexual risk acts with persons of HIV- or unknown status.¹⁶ Healthy Relationships is a 5-session, small-group skills-building program for HIV+ persons, and is one of the CDC’s Diffusion of Effective Interventions (DEBI). It is designed to reduce participants’ stress related to safer sexual behaviors and disclosure of their HIV status to family, friends and sex partners. Participants reported significantly less unprotected intercourse and greater condom use at follow-up.¹⁷ Other disclosure approaches have aimed at encouraging both HIV+ and HIV- persons to not make assumptions about their partner’s HIV status, to get tested, to disclose their own status and practice safer sex with all partners. The Department of Public Health in San Francisco, CA, created the Disclosure Initiative social marketing campaign which aims to normalize the disclosure of HIV status for both HIV+ and HIV- men.¹⁸

what needs to be done?

We need to normalize and facilitate comfortable discussions about HIV, so that disclosure of HIV+ status isn’t such a difficult thing to do. The more HIV is talked about, and the more people come out about being HIV+, the less stigma there will be. Disclosure is a two-way street. That means it is up to both people who are having sex with each other to address the issue. People living with HIV often are much happier in their relationships (long and short-term) when their HIV status is known by their partner. There’s no simple answer or policy for disclosure of HIV. Clinicians, counselors and programs need to be sensitive to the complexity of disclosure, and understand that disclosure is not for all people in all contexts. However, disclosing one’s HIV status can facilitate support for HIV+ persons and may lead to better communication, including discussion of risk reduction practices between sexual partners.

Says who?

1. Wolitski RJ, Parsons JT, Gómez CA, et al. Prevention with HIV-seropositive men who have sex with men: lessons from the Seropositive Urban Men’s Study and the Seropositive Urban Men’s Intervention Trial. Journal of AIDS. 2004;37:S101-109. 2. Galletly CL, Pinkerton SD. Conflicting messages: how criminal HIV disclosure laws undermine public health efforts to control the spread of HIV. AIDS and Behavior. 2006;10:451-461. 3. Duru OK, Collins RL, Ciccarone DH, et al. Correlates of sex without serostatus disclosure among a national probability sample of HIV patients. AIDS and Behavior. 2006;10:495-507. 4. Simoni JM, Pantalone D. Secrets and safety in the age of AIDS: does HIV disclosure lead to safer sex? Topics in HIV Medicine. 2004;12:109-118. 5. Parsons JT, Schrimshaw EW, Bimbi DS, et al. Consistent, inconsistent, and non-disclosure to casual sex partners among HIV-seropositive gay and bisexual men. AIDS. 2005;19:S87-S97. 6. Crepaz N, Marks G. Serostatus disclosure, sexual communication and safer sex in HIV-positive men. AIDS Care. 2003;15:379-387. 7. Klitzman R, Exner T, Correale J, et al. It’s not just what you say: Relationships of HIV dislosure and risk reduction among MSM in the post-HAART era. AIDS Care. 2007;19:749-756. 8. Parsons JT, VanOra J, Missildine W, et al. Positive and negative consequences of HIV disclosure among seropositive injection drug users. AIDS Education and Prevention. 2004;16:459-475. 9. Zea MC, Reisen CA, Poppen PJ, et al. Disclosure of HIV status and psychological well-being among Latino gay and bisexual men. AIDS and Behavior. 2005;9:15-26. 10. Stirratt MJ, Remien RH, Smith A, et al. The role of HIV serostatus disclosure in antiretroviral medication adherence. AIDS and Behavior. 2006;10:483-493. 11. Klitzman RL, Kirshenbaum SB, Dodge B, et al. Intricacies and inter-relationships between HIV disclosure and HAART: a qualitative study. AIDS Care. 2004;16:628-640. 12. Kalichman SC, DiMarco M, Austin J, et al. Stress, social support, and HIV-status disclosure to family and friends among HIV-positive men and women. Journal of Behavioral Medicine. 2003;26:315-332. 13. Cairns G. New directions in HIV prevention: serosorting and universal testing. IAPAC Monthly. February 2006:42-45. 14. MacKellar DA, Valleroy LA, Behel S, et al. Unintentional HIV exposures from young men who have sex with men who disclose being HIV-negative. AIDS. 2006;20:1637-1644. 15. Pilcher CD, Eron JJ, Galvin S, et al. Acute HIV revisited: new opportunities for treatment and prevention. Journal of Clinical Investigation. 2004;113:937-945. 16. The Healthy Living Project Team. Effects of a behavioral intervention to reduce risk of transmission among people living with HIV: the Healthy Living Project randomized controlled study. Journal of AIDS. 2006; 44:213-221. 17. Kalichman SC, Rompa D, Cage M, et al. Effectiveness of an intervention to reduce HIV transmission risks in HIV-positive people. American Journal of Preventive Medicine. 2001;21: 84-92. Program information 18. hivdisclosure.com All websites accessed July 2007.

Prepared by Robert H. Remien and Mark Bradley HIV Center for Clinical & Behavioral Studies, NY State Psychiatric Institute and Columbia University July 2007. Fact Sheet #64E Special thanks to the following reviewers of this fact sheet: Mark Cichocki, Joe Imbriani, Phebe Lam, Jennifer Lewis, Bradford McIntyre, Bob Munk, Michael Paquette, Tom Patterson, Steve Pinkerton, Jane Simoni, Jef St De Lore, David Vance, John K. Williams. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©July 2007, University of CA.

What is the role of disclosure assistance services in HIV prevention?

why assistance for disclosure?

After more than 20 years of the HIV epidemic, with advances in treatment and increases in understanding and acceptance of HIV, getting an HIV+ diagnosis still can be a traumatic experience. HIV+ persons must come to terms with their own infection and be concerned with possible infection in past and future partners. Talking to partners about HIV is especially hard because even though it is a manageable disease, HIV still is not curable. Disclosure assistance services (also known as partner counseling and referral services or PCRS) are an array of voluntary and confidential services available to persons living with HIV and their exposed sex and/or needle-sharing partner(s). Disclosure assistance is cost effective and can play a critical role in identifying those individuals most at risk for HIV infection, and linking those who are infected to early medical care and treatment.^1,2,3 Most HIV+ persons make the decision to disclose or not disclose to their partners on their own. But HIV+ persons may want support for telling their partners about HIV, whether by encouragement for self-disclosure or by having someone who is well-trained carefully and confidentially notify a partner for them. In one study, persons who received disclosure assistance were over three times more likely to have informed a partner of their risk.⁴ In the past few years, HIV counseling and testing programs across the US have shifted their emphasis from testing anyone, to finding and testing persons at greatest risk for HIV infection.⁵ At general HIV testing sites, around 1% of clients tested are found to be HIV+, whereas 8-39% of clients tested through disclosure assistance are found to be HIV+.²

what is disclosure assistance?

Often, disclosure assistance or PCRS mistakenly has been seen as only provider disclosure, but there are three forms of assistance: Self disclosure–The client chooses to notify a partner him/herself. The disclosure assistance provider guides and prepares the client before disclosure. Currently, most HIV+ persons choose this method. Dual disclosure–The client chooses to notify a partner in the presence of a provider. The provider supports the client during disclosure and acts as a resource for the partner. This method is rarely chosen and requires highly skilled providers. Provider disclosure (anonymous third party)–The client prefers a professional to notify a partner, and gives his/her provider identifying and locating information for partner(s). Most often, providers give this info to Disease Intervention Specialists (DIS) who then locate and notify the named partners, keeping client identity strictly confidential. This method is chosen less often, yet it is the only one with client anonymity. For the partners of an HIV+ client, disclosure assistance services can include: being notified of exposure to HIV, HIV prevention counseling, HIV testing options, referrals for HIV medical evaluation if positive and referrals for other social or medical services.⁶

how does it work?

Disclosure assistance services are first offered when a person receives a positive HIV test result. It is not a one-time only service, but should be offered as clients’ risk circumstances and needs change. The main element is helping HIV+ persons tell their sexual and/or needle-sharing partners about possible HIV exposure. The quality and use of disclosure assistance services can vary widely. Services differ from state to state: some have legal mandates to provide it, some offer it through HIV, STD or combined HIV/STD programs, and states can receive referrals from clinicians, health departments or testing sites.⁷ Services can be provided by HIV service agencies, health departments and most clinics and hospitals. Most service agencies can provide coaching and support for self or dual disclosure and gather partner identifying and locating information which is forwarded to DIS staff. Most notification of partners has been done by DIS at local health departments because they have the capacity, expertise, trained staff and protection from liability. Good provider disclosure depends on DIS staff who are properly trained and have enough experience and knowledge of the populations they serve. DIS staff should be evaluated regularly to assure quality and be provided with support and ongoing training.⁶

what are the concerns?

Public health messages have traditionally urged disclosure to all sexual and drug using partners. In reality, disclosure is complex and difficult. Some HIV+ persons may fear that disclosure will bring partner or familial rejection, limit sexual opportunities, reduce access to drugs of addiction or increase risk for physical and sexual violence. Because of this, some HIV+ persons choose not to disclose. Programs need to accept that not disclosing is a valid option. Many HIV service agencies and testing and counseling sites routinely offer self disclosure and dual disclosure, working with HIV+ clients by preparing and supporting them to disclose to partners on their own. Although provider disclosure services have been used for many years with other STDs, there is a wide variety in rates of acceptance of provider disclosure in HIV: in North Carolina, 87% of newly diagnosed HIV+ persons accepted provider disclosure,⁸ in Florida 63.1%,⁹ Los Angeles, CA 60%,¹⁰ New York State 32.9%,¹² Seattle, WA 32% and among anonymous testers in San Francisco, CA 3.1%.¹³ In Los Angeles, the most common reasons for refusal were: already notified partner (23.4%), not being ready to disclose (15.3%), being abstinent (15%) and having an anonymous partner (11%).¹⁰ Disclosing HIV status to partners can be scary, but also can be empowering. In one study, HIV+ injection drug users who disclosed their status found increased social support and intimacy with partners, reaffirmation of their sense of self and the chance to share experiences and feelings with sexual partners. Another study of HIV+ persons and their partners who received disclosure assistance found that emotional abuse and physical violence decreased significantly after notification.¹⁵

what’s being done?

Florida utilizes trained DISs to deliver disclosure assistance for all reported new HIV infections. In 2004, 63.1% of all newly infected HIV+ persons accepted provider disclosure, identifying 4,460 sex or needle-sharing partners. Among those, 21.8% had previously tested HIV+. Of the 2,518 persons notified, 84.2% agreed to counseling and testing and 11.5% were HIV+.⁹ The Massachusetts Department of Public Health piloted a client-centered model of disclosure assistance that is integrated into the client’s routine prevention, care and support services. The program required significant changes to the standard model of DIS provider disclosure, building close relationships between service providers and DIS to better support clients’ disclosure needs while protecting confidentiality.¹⁶ California instituted a voluntary disclosure assistance program that includes counseling and preparing HIV+ persons for self disclosure; anonymous third party provider notification; counseling, testing and referrals for notified partners; and training and technical assistance to providers in public and private medical sites. About one-third of patients opted for provider disclosure and 85% referred partners. Of the partners located, 56% tested for HIV and half had never tested before. Overall, 18% of partners tested HIV+.⁴

what needs to be done?

New HIV testing technologies can be useful with disclosure assistance services. Improved rapid testing is a potential invaluable tool for offering HIV tests in the field to notified partners. Nucleic acid amplification testing (NAAT) can determine acute infections, that is, new HIV infections that do not show up during the window period of other HIV tests. Combining these testing strategies with disclosure assistance can help identify newly infected persons and provide immediate counseling, support and referrals to medical or social services as needed.¹⁷ Disclosure assistance services, and particularly provider disclosure, may need extensive changes from the traditional DIS model in order to work well and be accepted within HIV services. Health departments could forge closer ties between their STD and HIV programs and with outside service agencies. HIV staff also can be trained to be DIS providers to broaden access to and comfort with disclosure services. Disclosure assistance services should be made available not only upon HIV diagnosis, but on an ongoing basis as HIV+ persons’ circumstances and needs change. It is not the role of providers to decide if a client will need or want disclosure assistance, but to offer clients support and choices, whether or not a client chooses to disclose. Prepared by Fern Orenstein MEd, CA STD Control Branch, Prevention Training Center

Says who?

1. Landis SE, Schoenbach VJ, Weber DJ, et al. Results of a randomized trial of partner notification in cases of HIV infection in North Carolina. New England Journal of Medicine. 1992;326: 101-106. 2. Golden MR. Editorial: HIV partner notification, a neglected prevention intervention. Sexually Transmitted Diseases. 2002;29:472-475. 3. Varghese B, Peterman TA, Holtgrave DR. Cost-effectiveness of counseling and testing and partner notification: a decision analysis. AIDS. 1999;13:1745-1751. 4. Eckert V. Utilization of voluntary HIV partner counseling and referral services. California Office of AIDS & STD Control Branch. Presented at the Statewide PCRS Conference, May 2004. 5. Centers for Disease Control and Prevention. Advancing HIV Prevention: New Strategies for a Changing Epidemic – US, 2003. Morbidity and Mortality Weekly Report. 2003:52;329-332.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5215a1.htm (accessed April 2006). 6. HIV partner counseling and referral services guidance. Centers for Disease Control and Prevention. 1998. https://www.cdc.gov/hiv/guidelines/partners.html 7. Aldridge C, Randall L. Implementing partner counseling and referral services programs. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #TO-057. 8. Centers for Disease Control and Prevention. Partner counseling and referral services to identify persons with undiagnosed HIV–North Carolina, 2001. Morbidity and Mortality Weekly Report. 2003;52:1181-1184.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5248a4.htm (accessed April 2006). 9. George D. Partner counseling and referral services (PCRS): the Florida experience. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #M3-B1605. 10. Aynalem G, Hawkins K, Smith LV, et al. Who and why? Partner counseling and referral service refusal: implication for HIV infection prevention in Los Angeles. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #MP-036. 11. Birkhead G. HIV partner counseling and referral services in New York state. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #M3-B1603. 12. Golden MR. Partner notification: where do we stand and outstanding barriers. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #T3-D1302. 13. Schwarcz S, McFarland W, Delgado V, et al. Partner notification for persons recently infected with HIV: experience in San Francisco. Journal of Acquired Immune Deficiency Syndrome. 2001;28:403-404. 14. Parsons JT, Vanora J, Missildine W, et al. Positive and negative consequences of HIV disclosure among seropositive injection drug users. AIDS Education and Prevention. 2004;16:459-475. 15. Kissinger PJ, Niccolai LM, Magnus M, et al. Partner notification for HIV and syphilis: effects on sexual behaviors and relationship stability. Sexually Transmitted Diseases. 2003;30:75-82. 16. Cranston K. Planning for HIV partner counseling and referral services in the third decade. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #T3-D1301. 17. Pilcher CD, Fiscus SA, Nguyen TQ, et al. Detection of acute infections during HIV testing in North Carolina. New England Journal of Medicine. 2005;352:1873-1883.

September 2005. Fact Sheet #53ER Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. ©Sepetmber 2005, University of California

What Is the Role of Counseling and Testing in HIV Prevention?

why is C&T important?

HIV counseling and testing (C&T) is an important part of a continuum of HIV prevention and treatment services. C&T is one of the main times when a comprehensive individual risk assessment is taken, making it the best opportunity for accurate referrals to more intensive services. C&T is also one of the primary entry points into prevention and other services. C&T uses short, client-centered counseling that can be effective in increasing condom use and preventing sexually transmitted diseases (STDs).¹ Knowing one’s HIV status, whether HIV- or HIV+, is key to preventing the spread of HIV and accessing counseling and medical care. It is estimated that one-fourth of all HIV+ persons in the US do not know they’re infected.² A survey of young men who have sex with men (MSM), found that 14% of young Black MSM were HIV+. Among those, 93% were unaware of their infection, and 71% reported it was unlikely they were HIV+.³ Recently, the Centers for Disease Control and Prevention (CDC) announced an initiative aimed at expanding C&T in the US.⁴ Their Strategic Plan for 2005 strives to decrease by 50% the number of people who don’t know their HIV status.⁵ If this goal is met by 2010, an estimated 130,000 new HIV infections may be prevented, saving over $18 billion.⁶

how is C&T done?

C&T has three distinct components: risk assessment and counseling before the blood or oral sample is taken, testing of the sample, and counseling and referral with the test results.⁷ C&T can be confidential-a person’s name is recorded with the test results-or anonymous-no name is recorded with the test. Publicly funded HIV C&T takes place in testing centers, community health clinics, community-based organizations, outreach programs, mobile vans, STD and family planning clinics and local health departments, among other venues. Although public health workers are trained in C&T procedures, most HIV testing in the US occurs in private doctors’ offices. Many people prefer being tested as part of a routine check-up, instead of public health sites. However, testing in private venues does not offer anonymity, and patients who get tested as part of routine medical care may not receive adequate counseling or referrals.⁸ Other venues also test for HIV, such as emergency rooms, jails/prisons, military recruitment sites and Job Corps. HIV testing in the US is mandatory to get some insurance and medical benefits, apply for some jobs, join the military, give blood or enter the US as an immigrant. HIV testing is compulsory for federal prison inmates and sex offenders in some states.

what about rapid testing?

The standard testing method for the past 20 years has been a needle blood draw. In the past 10 years, a mouth swab (OraSure) that tests cells from inside the cheek has also been available. Results are sent to a lab for the ELISA test and a Western Blot to confirm an initially positive result, with an average wait of 1-2 weeks between sample collection and the provision of results. With this method, many persons don’t return for their test results, and nationally 31% of persons who test HIV+ don’t return to find out their results.⁴ Rapid testing is now available with a finger stick (OraQuick). With this method, results are known in 20 minutes, eliminating the need for a return visit for results. However, if a client’s tests is reactive, he receives a preliminary positive result. A second blood test (needle draw or OraSure) is required to confirm the result with a standard Western Blot. Final confirmation still takes 1-2 weeks. National data indicate that with rapid testing, 95% of clients who received a preliminary positive result returned for their confirmatory results.⁹ Rapid testing will change the way C&T is conducted, although clients can still opt to get their results later. Because the client needs to wait for 20 minutes for the results, the counselor takes the blood early in the session and has a “captive audience” for risk assessment and counseling. Test counselors can conduct the blood test themselves, or a separate staff person can do the finger stick and read results. Counseling with rapid testing can be more intense and client-focused due to the immediacy of getting results. It is hoped that rapid testing will dramatically increase the number of persons who know their results.

what makes good C&T?

Good C&T depends on counselors who are properly trained and have enough experience. Counselors must protect the confidentiality of client information, obtain informed consent before testing and provide effective counseling services and appropriate referrals. Counselors should establish relationships with key service agencies to make sure the referrals they give clients reflect their needs, priorities, culture, age, sexual orientation and language. C&T counselors should be evaluated regularly to assure quality and be provided with support and ongoing training.⁷ With rapid testing, counselors need different training as they can be both the counselor and the lab. Rapid testing requires stable temperatures, adequate lighting, and careful attention to detail. Also, rapid testing is not rapid counseling. Counselors need to work closely with clients to develop a reasonable risk reduction step and to make sure their clients are actually ready to receive the test results. It is also important to obtain a second blood sample for confirmation if a client tests positive.¹⁰

what’s being done?

The Department of Public Health (DPH) in Florida made a deliberate effort to improve their C&T services and increase the number of people who know they are HIV+. State funded testing sites targeted venues with high-risk persons, including CBOs, prisons/jails and outreach settings. They also began using OraSure for testing in the field. In 2002, the DPH reported a 2% seropositive rate for blood draws and 3.2% for OraSure. In jails they found a 3.6% seropositive rate. They also used partner counseling and referral services (PCRS) and in 2002, 80% of HIV+ people gave names of partners, 64% of partners were located and counseled, and 13% of partners who tested were HIV+.¹¹ In Minneapolis, MN, rapid testing was offered at a variety of agencies serving primarily African American clients. Venues included drug treatment programs, homeless shelters, teen clinics, sex offender groups and halfway houses. Almost all (99.7%) of clients received their test results and counseling, and 95% reported they would rather have a finger stick than a blood draw.¹² Wisconsin’s AIDS/HIV Program wanted to increase the number of high-risk persons accessing testing. In the early 90s, tests jumped from 6000 per year to between 20,000-30,000. The number of high-risk persons tested, however, remained the same while seroprevalence rates dropped from 3.5% to 0.5%. In the late 90s, the program shifted its philosophy from one of public education to case finding. Publicly funded sites were reduced from 126 to 55 serving the greatest percentage of high-risk persons and persons of color. In one year, the seroprevalence rate improved to .75%, the number of low-risk persons tested decreased 42%, high-risk persons tested increased 6%, and testing among persons of color improved 18%.¹³

what is the future of C&T?

As rapid testing becomes more widely used, it is hoped that the number of people not returning for their test results will decrease. Rapid testing can allow for more targeted outreach to communities and persons at risk, as C&T occurs in venues that are more accessible and acceptable. Rapid testing should be implemented carefully to allow time for agencies to gain experience and clients to understand the new testing process. Greater efforts may be necessary to refer clients to effective services. Behavior change is a slow and difficult process, and many persons make changes incrementally. Linkages to other services and follow-up with clients may substantially increase the impact of the initial counseling. While training and quality assurance has traditionally centered on counseling in C&T, referrals may be the weakest part and need most improvement. Simply increasing the number of persons who know they are HIV+ will not slow the HIV epidemic sufficiently. As more persons in the US discover their HIV status, it is crucial to ensure that more prevention, social and treatment services are available both to HIV+ and HIV- persons. In addition to primary HIV prevention interventions, these should include access to quality drug and alcohol treatment, housing and employment services, STD testing and treatment, syringe exchange programs, quality medical care and adherence support to insure effective use of AIDS medications. Prepared by Steven R. Truax, PhD*, Pamela DeCarlo** *California State Office of AIDS, **CAPS

Says who?

1. Kamb ML, Fishbein M, Douglas JM,et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases. Journal of the American Medical Association. 1998;280:1161-1167. 2. Fleming P, Byers RH, Sweeney PA, et al. HIV prevalence in the United States, 2000. Presented at the 9th Conference on Retroviruses and Opportunistic Infections, Seattle, WA; February 24-28, 2002. 3. Centers for Disease Control and Prevention. Unrecognized HIV infection, risk behaviors and perceptions of risk among young black men who have sex with men – six US cities, 1994-1998. Morbidity and Mortality Weekly Reports. 2002;33:733-736. 4. Centers for Disease Control and Prevention. Advancing HIV Prevention: New Strategies for a Changing Epidemic – US, 2003. Morbidity and Mortality Weekly reports. 2003:52;329-332. https://pubmed.ncbi.nlm.nih.gov/12733863/  5. Centers for Disease Control and Prevention. HIV Prevention Strategic Plan Through 2005. www.cdc.gov/hiv/partners/ psp.htm 6. Holtgrave DR, Pinkerton SD. Economic implications of failure to reduce incident HIV infections by 50% by 2005 in the United States. Journal of Acquired Immune Deficiency Syndromes. 2003;33:171-174. 7. Centers for Disease Control and Prevention. Revised Guidelines for HIV Counseling, Testing, and Referral. Morbidity and Mortality Weekly Reports. 2001;50. 8. Haidet P, Stone DA, Taylor WC, et al. When risk is low: primary care physicians’ counseling about HIV prevention. Patient Education and Counseling. 2002;46:21-29. 9. Kassler WJ, Dillon BA, Haley C, et al. On-site, rapid HIV testing with same-day results and counseling. AIDS. 1997;11:1045-1051. 10. Fournier J, Morris P. Speed bumps and roadblocks on the road to rapid testing: a look at the integration of HIV rapid testing in an agency and community. Presented at the US Conference on AIDS, New Orleans, LA, 2003. 11. Liberti T. Florida’s HIV counseling, testing and referral program. Presented at the US Conference on AIDS, New Orleans, LA, 2003. 12. Keenan PA. HIV outreach in the African American community using OraQuick rapid testing. Presented at the National HIV Prevention Conference, Atlanta, GA. 2003. 13. Stodola J. Restructuring Wisconsin’s HIV CTR program: targeting CTR services. Presented at the US Conference on AIDS, New Orleans, LA, 2003.

January 2004. Fact Sheet #3ER Special thanks to the following reviewers of this Fact Sheet: Jena Adams, Barbara Adler, Chris Aldridge, Teri Dowling, Barbara Gerbert, Paul Haidet, Sydney Harvey, Willi McFarland, Patrick Keenan, Kathryn Phillips, Jim Stodola, Brenda Storey, Ed Wolf.

Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © January 2004, University of California