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Developed by JHPIEGO’s Training in Reproductive Health Project with funding from USAID.

Lesson 2: Understanding Who is at Risk for HIV: Risk Assessment and Identification
Instructor: Jean Anderson

Objectives

In this lesson we are going to discuss risk assessment and identification of HIV infection in individuals. The objectives for this lesson are:

• Discuss reasons to determine HIV infection status
• Review risk assessment for HIV and its strengths and weaknesses
• Describe signs and symptoms that may suggest HIV
• Discuss components of HIV counseling and testing
• Describe effectiveness of HIV counseling and testing
• Review barriers to HIV counseling and testing

In order to provide the best care to people with HIV/AIDS, it is important to know that they are infected. That is not as simple as it might sound. You cannot tell who is HIV-infected by looking at them, and many individuals who are HIV-infected have no idea that have ever been at risk for HIV. In low-resource settings, there are often limited human resources for counseling about HIV testing and limited supplies for testing. Furthermore, there is much stigma in many areas to being identified as HIV-positive. HIV-positive persons may be rejected by their family and friends or abandoned by their husbands or wives. They may lose jobs or not be allowed to attend school. In particular, women may be beaten by their partner if they disclose their HIV status. It is not surprising, therefore, that even when testing is available many people refuse to be tested.

Reasons to be Tested for HIV

Despite people’s reluctance to be tested, there are several benefits for HIV-infected people in knowing their HIV status, even in the absence of access to antiretroviral drugs. In most limited resource areas, there are basic medications available to treat or prevent some of the most common opportunistic infections, such as tuberculosis (TB). These infections are the major causes of morbidity and mortality in persons with AIDS. There are options to prevent mother-to-child transmission (MTCT) of HIV such as using abbreviated and less expensive antiretroviral regimens and changing infant feeding practices. Individuals found to be infected with HIV can also be educated about protective practices to reduce spread to others. Knowledge of HIV status can help infected individuals plan for the future, including plans for childbearing and care for their families. Finally, as antiretroviral drugs become available in these settings, diagnosis of HIV will be essential to have access to these therapies. 

For those who receive HIV prevention counseling, whether or not they are infected, studies in both industrialized and developing countries show that risky behaviors are reduced. For those who are not infected but have high risk behaviors, this can reduce their risk for acquiring HIV. Within communities affected by HIV, the widespread availability of HIV counseling and testing can help reduce fear and ignorance about HIV that lead to stigma surrounding this infection. Counseling and testing programs can also promote community support of infected persons and help mobilize communities to encourage behavior changes that will reduce risk of HIV infection.

Risk Assessment for HIV

In areas with limited resources for testing there may be a need to target these resources to individuals who are at increased risk for HIV. In some cases this includes everyone served at certain sites. These include sexually transmitted disease, postabortion care, and adolescent clinics; drug and alcohol treatment programs; TB clinics; prisons; and clinics targeting men who have sex with men. In other settings, personal risk assessment or risk screening can help determine who should receive priority for testing and for more in-depth HIV prevention services. Risk assessment involves identifying characteristics that are associated with increased risk for HIV:

• because of behaviors known to transmit HIV; 
• because of membership in a group or community where those behaviors are found more commonly; or 
• because there are coexisting conditions which increase risk for transmission and acquisition of HIV, or which are more common in people with HIV and therefore indicates increased likelihood of HIV infection. 

High-risk characteristics commonly used in risk assessment include the following:

1. Age < 25 years
2. Single
3. Sexual behavior: 
   • More than one partner in last 3 months
   • Multiple partners
   • New or casual partner
4. Mobile population (less stable sexual relationships)
   • Refugee
   • Husband in military or long distance truck driver
5. Sexually transmitted infections
   • History of STIs
   • Signs or symptoms of STIs
6. History of drug or alcohol abuse
7. History of TB
8. Prostitute
9. Signs or symptoms suggesting HIV

In individuals who are found to have high-risk characteristics, more personalized risk assessment can help identify specific behaviors and circumstances that place them at increased risk for acquiring HIV. These include 

• Sex with high-risk partners, such as prostitutes or bisexual men
• Sex in high-risk situations, such as while under the influence of alcohol or drugs 
  or with forced sexual activity
• Use of injection drugs and sharing of drug equipment.

A woman who is pregnant is considered a high priority for offering HIV testing because interventions to prevent mother-to-child transmission (MTCT), such as short-course antiretroviral regimens, are increasingly available even in low resource settings. A pregnant woman who finds that she is HIV-positive may also make different decisions about her pregnancy than if she is HIV-negative. She may choose pregnancy termination if that is a legal and safe option or she may make different plans for her future and the future of her children. Because women who become pregnant or who may be trying to become pregnant generally have unprotected sex, they are also at increased risk for being or becoming HIV-infected. This is another reason to routinely offer HIV testing if possible to women in antenatal care clinics and in family planning clinics.

Risk assessment has certain limitations. In populations with high HIV prevalence, these characteristics will underestimate the number of individuals actually infected with HIV and ALL sexually active individuals should be considered at risk. Furthermore, because women around the world are often infected sexually with HIV from their husbands or only sexual partner, they may not know that they are at increased risk for HIV because it is their sexual partner who is engaging in risky behaviors.

Signs and Symptoms That May Suggest HIV

Even though HIV causes no physical signs or symptoms until there has been significant damage to the immune system (often years after initial infection) people who develop certain signs or symptoms should be evaluated for infection. These signs and symptoms include:

• fevers of unknown cause
• oral thrush
• chronic diarrhea
• significant weight loss
• generalized enlargement of lymph nodes 

There are also a number of infections or cancers that are strongly associated with HIV infection. TB is the leading HIV-associated opportunistic infection in developing countries and, active TB is more common in HIV-infected individuals than in uninfected persons. Almost 80% of cervical cancer cases occur in women living in low-resource settings. HIV-positive women have higher rates of cervical dysplasia, a precancerous condition, and without adequate screening and treatment for dysplasia, are at increased risk for invasive cervical cancer. Genital herpes simplex virus infections occur in both HIV-infected and HIV-uninfected individuals; however, in HIV-infected people with weakened immune systems these infections are often more frequent, severe, and may be chronic. Other infections and cancers linked to HIV, such as cytomegalovirus infection, toxoplasmic encephalitis, Kaposi’s sarcoma and others are seen at very advanced stages of HIV infection when the immune system is very damaged. It is obviously most beneficial to identify HIV early in the course of infection when there is an opportunity to prevent development of some of these later signs, symptoms or conditions, as well as to better prevent HIV and TB transmission to others. Nevertheless, even in the later stages of HIV/AIDS, identification of infection can provide access to care that can give relief from symptoms, allow people to make plans for their future and for their families, including reproductive health decisions, and generally to make the best use of the time they have left.

Components of HIV Counseling and Test

HIV counseling and testing should be a voluntary process and accepting or refusing testing must not have adverse consequences for the individual or for the quality of care offered to them. If a person feels coerced or forced to undergo counseling and testing, they will be less likely to benefit from the information provided and may be driven away from needed care. Because of the stigma that is associated with HIV in many areas, information about the use of HIV counseling, testing and other related services should remain absolutely confidential and results of testing should never be shared with others (friends, family, employers, etc.) without the express permission of the individual tested. Although basic information about HIV can be provided in many ways, including written material or group sessions, assessment of individual risk and individualized HIV counseling should be provided privately using an interactive approach between the person (or in some cases, the couple) and the counselor. Counseling should be nonjudgmental and supportive. Services should be appropriate to the client’s culture, age, language, literacy level, and gender, since these factors may affect how they seek, accept and understand these services. Informed consent ensures that the person receiving counseling understands the information they are given and agrees freely to undergo testing. 

The general components of HIV counseling and testing include:

• Provision of information about HIV, including dealing with false rumors, myths, and misperceptions 
• Personalized prevention counseling 
• Use of diagnostic HIV tests
• Referrals, as needed, for further care and support for both infected and uninfected individuals

Traditionally, because of the length of time needed for test results to be available, “pre-test” counseling and testing were done in one visit and a second visit was used to give test results, arrange follow-up counseling, support, and referrals as needed for both HIV-positive and HIV-negative clients. Today, however, there is increasing availability of rapid HIV tests, which allow clients to receive the test results on the same day the test is done. This has been shown to increase the number of people who actually obtain their test results, since using the two-step process, many people do not return for the second visit. However, before proceeding with testing it is important to assess the person’s coping strategies and support systems, especially if the test turns out to be positive. With the use of rapid tests the client must be prepared to receive a result in minutes to hours, rather than days or weeks.

Provision of Information about HIV

Information about HIV that should be given before testing is offered includes: 

• Information about what HIV and AIDS are 
• How transmission occurs and can be prevented 
• Information about HIV testing-how the test is done 
• What different test results mean 
• Benefits of receiving test results 
• Information about how and where to obtain further information or services related to HIV or HIV prevention

In order to prevent misunderstanding and to uncover possible myths and misconceptions about HIV, it may be helpful to ask:

• Have you have heard things about HIV or AIDS that seem to be different from what I am telling you? 
• Are there specific things about HIV/AIDS that you want to ask about?

There are common but specific beliefs from place to place that may lead to an increase in risk behaviors. For example, in many areas in Africa, AIDS is often called “Slim disease” because late-stage HIV/AIDS is usually associated with significant weight loss. As a result, there is the belief that having sex with a woman who has normal weight or is even overweight is safe without the use of condoms. Another false and tragic belief is that having sex with a virgin will cure a man who has AIDS. This practice has led to an increase in sexual assault and rape of young girls, who are more vulnerable to becoming infected themselves and does nothing to cure the individual suffering from HIV/AIDS.

Personalized Prevention Counseling

HIV prevention counseling focuses on the individual’s unique circumstances to help them identify and acknowledge their personal risks for HIV, identify their personal barriers to change, and then help them set and reach a specific goal for behavior change that will prevent transmission or acquisition of HIV. HIV prevention counseling is usually done in the context of HIV testing. but this intervention can be effective even without testing. In rural Uganda, a community-based counseling service was established to offer HIV counseling about safer sex and condoms were distributed, but testing was not available. Attendance rose by 500% in two years and uptake of condoms increased considerably (1). 

Use of Diagnostic Tests

The most common HIV tests detect antibodies to the virus in blood serum or plasma. Standard tests use a two-step process with a screening enzyme immunoassay (EIA). Reactive or positive results are generally confirmed with a Western Blot assay that detects specific antibodies to the virus. This testing sequence has a sensitivity and specificity greater than 99.9%. More recently rapid HIV tests have been developed which generally provide results in 10-15 minutes. They are also simple and relatively inexpensive and increase the likelihood that people actually receive their test results. There is also now the ability to test for HIV using specimens other than blood, such as urine or saliva, which may increase the acceptability of HIV testing. Although rapid tests and HIV tests performed on other types of specimens are very sensitive, positive results with these tests require confirmation, since they are less specific than standard assays. Confirmation strategies for reactive EIAs and positive rapid or alternative specimen tests may vary depending upon the HIV prevalence in the population tested, the presence or absence of symptoms of HIV, and the local availability of specific types of tests. For example, a symptomatic person living in a high-prevalence area who has a reactive screening test may be considered HIV-positive, particularly if resources for additional testing are limited. In all other situations reactive screening tests should be confirmed with standard serology or with a second and different screening test. 

A positive test result indicates that a person is HIV-infected, except in very rare circumstances. A negative test indicates the absence of HIV infection unless the individual has been recently infected and has not yet developed detectable antibodies, often called the “window period”. Antibodies generally take 8-12 weeks to develop. Therefore, retesting should be encouraged in those who have negative test results and have had recent high-risk behaviors. An indeterminate test is defined as a reactive screening EIA and an indeterminate Western Blot. This most often represents detection of nonspecific reactions in serum from an uninfected person, but may also indicate an evolving HIV antibody response in a newly infected individual or infection with HIV-2 or with a different HIV-1 strain. In the absence of recent and ongoing risk behavior, repeated indeterminate test results at least one month apart do not represent HIV infection. 

Referrals

HIV counseling and testing should be an entry point for prevention and care of HIV-infected persons and those at high risk for HIV. Therefore, it is important to develop linkages and a referral system with antenatal care clinics, other reproductive health care settings, and clinics providing medical care for persons with HIV. An individual newly found to be HIV-positive will need emotional support and help in coming to terms with their diagnosis. They may have a range of emotions, from denial and anger to despair; they may even think about killing themselves. These reactions are normal but counseling can help HIV-positive persons deal with their feelings, accept the reality of having HIV, and plan for the future. It is also important to discuss when and to whom to disclose their HIV status. Disclosure of one’s HIV status increases practical and emotional support for those who test HIV seropositive, but it is essential to assess the risk for abandonment or abuse in sharing their HIV status with others. In many areas peer support groups and post-test clubs have been developed in association with HIV testing and counseling to help people cope by sharing experiences and providing mutual support. Individuals with ongoing risk behaviors should have access to further prevention counseling and assistance whether they are HIV-positive or HIV-negative. This counseling is critical for those who test HIV-negative, since they may assume that their behaviors are safe or that they are somehow protected against HIV, and therefore may not only continue but may in some cases actually increase risky sex or drug-using practices. Special emphasis should be given to drug and alcohol use associated with sexual activity, since this has a disinhibiting effect and decreases the likelihood of condom use. It should clearly be stated that a negative test does not mean there is no risk for HIV or that the person cannot become HIV-infected. 

Effectiveness of HIV Counseling and Test

A number of studies in low-resource settings have now demonstrated that HIV counseling and testing are effective in reducing HIV risk behaviors and also can reduce actual rates of HIV or other STIs. A prospective cohort study of HIV education, counseling and testing of over 1400 childbearing women in Rwanda resulted in an increase in condom use from 7% before the intervention to 22% one year later. Gonorrhea prevalence decreased from 13% to 6% among HIV-positive women and HIV seroconversion rates declined from 4.1 to 1.8 per 100 person years in women whose male partners also received counseling and testing. Unfortunately, there was a lack of risk reduction seen in HIV-negative women whose partners’ status was unknown (2). In the former Zaire (now the Democratic Republic of the Congo) HIV counseling and testing in 149 serodiscordant couples (one partner HIV-positive and the other HIV-negative) resulted in increased condom use from less than 5% to greater than 75% at 18 months of follow-up (3).

In India HIV counseling and testing of heterosexual men attending STI clinics resulted in a reduction of sexual risk behavior and an HIV seroconversion rate of 6.1 per 100 person-years, significantly lower than the 18% per year estimated from a previous study in the same population (4). In Thailand HIV-positive individuals reported fewer sex partners and more consistent condom use after counseling and testing when compared to HIV-positive persons who were questioned before counseling and testing and did not know their status (5). A recent randomized clinical trial of voluntary HIV counseling and testing versus basic health information was conducted in Kenya, Tanzania and Trinidad involving over 3100 individuals and 586 couples. In both couples and individuals HIV counseling and testing was associated with a greater reduction in unprotected sex than basic health information alone (6). A recent comprehensive meta-analysis of voluntary HIV counseling and testing concluded that HIV testing resulted in risk reduction in persons who were HIV-positive and in serodiscordant couples (7)(8).

Barriers to HIV Counseling and Testing

The barriers to HIV counseling and testing should be recognized, considered, and confronted. Concerns about confidentiality not only deal with stigma attached to a diagnosis of HIV/AIDS, but also related to fears of rejection, abandonment or abuse, or discrimination in the workplace, in school, and in other areas of society. In one study in Rwanda HIV-positive women were more likely to suffer physical beatings and the break-up of relationships, especially when the spouse was HIV-negative (9). In studies from low-resource areas many HIV-positive individuals do not disclose their status to their partners, and commonly the reason is fear of their partner’s reaction. This is a problem because many studies have shown that a significant proportion of couples in steady relationships have serodiscordant HIV test results and, the risk of the uninfected partner becoming infected is high unless safer sexual practices are used. Inability to discuss HIV test results with a sexual partner makes it more difficult to adopt safer sexual practices. Safety issues should be addressed both during initial counseling and when positive results are given, ensuring that HIV-positive individuals, especially women, have the protection and the resources needed to deal with their diagnosis. 

Another common barrier to HIV counseling and testing is simply the fear of being found to be HIV-positive, particularly in low-resource areas where HIV may be viewed as a disease without hope or help. Many people in high prevalence areas or in higher risk groups may assume they are already infected and may see no reason to be tested. It is important to discuss and emphasize what can be done when HIV is diagnosed, with emphasis on local resources. Even in less developed areas of the world the following are possible: 

• Prophylaxis of opportunistic infections with simple inexpensive generic drugs
• Nutritional interventions to maintain and enhance health
• Management of common symptoms associated with HIV
• Prevention of MTCT with short antiretroviral regimens 
• Alternatives to or modifications of breastfeeding practices 

Many people resist HIV counseling and testing because they do not believe they are at risk for HIV. This underscores the importance of individual risk assessment. HIV statistics have demonstrated that many individuals, particularly women, are at risk not because of their own behaviors but because of their partner’s practices, of which they may be unaware. 

Finally, a major barrier to HIV counseling and testing is the inability many individuals, in particular women, experience in being able to change sexual behavior. It is often difficult for a man and a woman, even if they are married, to talk openly about sex. And, women commonly have little or no power in sexual decision-making. Women or their husbands may wish to have children and therefore have unprotected sex, putting an uninfected partner at risk. For some women sex represents the only way they have to support themselves or their families. 

Summary

In summary, there are benefits to knowing one’s HIV status, even in areas with few resources. In relation to reproductive health these include the ability to make informed decisions about childbearing, helping to prevent MTCT, prevention of sexual transmission to partners, and the ability of healthcare providers to better prevent or manage certain reproductive health problems. Risk assessment can help target HIV counseling and testing resources to higher risk groups, especially when resources for these services are limited. However, negative risk assessment in an area of high HIV prevalence can give a false sense of security and has more limited value. HIV counseling and testing should be voluntary and confidential and should include information about HIV and personalized prevention counseling, whether or not testing is performed. HIV counseling is effective in reducing risk behaviors in both HIV-positive and HIV-negative individuals and in serodiscordant couples. However, the barriers to identification of HIV must be acknowledged and confronted to make this safer and more accepted.

Next Week's Lesson: 
Prevention of Sexual Transmission of HIV

References

1. Mugula F et al. (1995) A community-based counselling service as a potential outlet for condom distribution. Presented at the 9th International Conference on AIDS and STD in Africa, Kampala, (paper WeD 834).
2. Allen S, Serufilira A, Bogaerts J, et al. Confidential HIV testing and condom promotion in Africa. Impact on HIV and gonorrhea rates. JAMA (United States). Dec 16 1992, 268(23) p3338-43.
3. Kamenga M, Ryder RW, Jingu M, et al. Evidence of marked sexual behavior change associated with low HIV-1 seroconversion in 149 married couples with discordant HIV-1 serostatus: experience at an HIV counseling center in Zaire. AIDS (United States), Jan 1991, 5(1) p61-7 
4. Bentley ME, Spratt K, Shepherd ME, et al. HIV testing and counseling among men attending sexually transmitted disease clinics in Pune, India: changes in condom use and sexual behavior over time. AIDS (United States), Oct 1 1998, 12(14) p1869-77 
5. Muller O, Sarangbin S, Ruxrungtham K, et al. Sexual risk behaviour reduction associated with voluntary HIV counselling and testing in HIV infected patients in Thailand. AIDS Care (England), 1995, 7(5) p567-72
6. The Voluntary HIV-1 Counseling and Testing Efficacy Study Group. Efficacy of voluntary HIV-1 counselling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomized trial. Lancet 2000;356:103-12. 
7. Merson MH, Dayton JM, O'Reilly K. Related Articles, Links Effectiveness of HIV prevention interventions in developing countries. AIDS. 2000 Sep;14 Suppl 2:S68-84. PMID: 11061644 [PubMed - indexed for MEDLINE]
8. Weinhardt LS, Carey MP, Johnson BT, Bickman NL. Effects of HIV counseling and testing on sexual risk behavior: a meta-analytic review of published research, 1985-1987. Am J Public Health 1999; 89:1397-405. 
9. Straten A, King R, Grinstead O, Serufilira A, Allen S. Related Articles, Links Couple communication, sexual coercion and HIV risk reduction in Kigali, Rwanda. AIDS. 1995 Aug;9(8):935-44. PMID: 7576330 [PubMed - indexed for MEDLINE]