GS-9620 br Discussion HIV testing and
Discussion HIV testing and linkage to care are essential for fighting the HIV epidemic, and evidence-based methods for increasing coverage of testing and accelerating linkage to care are needed. We report that abbreviated counselling was as effective as full length counselling in reducing sexual risk behaviour in both HIV-infected and uninfected individuals, and was roughly 30 min shorter in duration (panel). This finding has important implications for policy and practice in terms of scale-up of HIV counselling and testing services. Provider GS-9620 increases uptake of HIV counselling and testing, and evidence suggests that it is no worse than other approaches to HIV testing in terms of ensuring informed consent, confidentiality, and counselling. Our findings extend these results by showing that an abbreviated counselling protocol can be used without fear of compromising the reductions in HIV risk behaviours afforded by detailed counselling. Adoption of abbreviated counselling could alleviate many of the burdens on medical professionals, while retaining value for patients. Time saved in counselling will probably reduce counsellor and provider effort and, eventually, the cost of provider-initiated HIV counselling and testing. Our study was not designed to assess the cost-effectiveness of provider-initiated HIV counselling and testing and additional assessment is needed. In addition, traditional counselling was associated with improved retention in the study among HIV-positive people, which may warrant further investigation. Enhanced linkage significantly decreased time to start of antiretroviral treatment in men and entry into HIV care in women. Early entry into care and treatment can increase survival and decrease secondary HIV transmission. The difference by sex was surprising, but could be because, for women, enhanced linkage was helpful for initial clinic attendance, whereas for men, enhanced linkage did not increase the rate of getting to the clinic but instead served to retain them in clinic long enough to start treatment. Men access health care (for HIV or otherwise) less frequently and later than do women and have poorer retention in care than women. Thus, introducing men to the clinic could have an important effect on early treatment initiation. Enhanced linkage had no effect on receipt of prophylaxis for opportunistic infections; this finding is not surprising, since co-trimoxazole prophylaxis is cheap and nearly universal in HIV clinics in Uganda. The absence of an effect on survival might be because follow-up was only for 1 year; longer-term effects are plausible. Our study had several limitations. The main outcomes—other than mortality—were self-assessed. Risky sexual behaviour at follow-up might have been under-reported, and those who received traditional, lengthier counselling might have been more likely to under-report risky behaviour because of social desirability. However, under-reporting in the traditional group would still support our conclusion that abbreviated counselling was no worse than traditional counselling in terms of sexual risk. To verify self-reported antiretroviral treatment, we reviewed patients\' charts when treatment regimens were not specified in the study survey. For patients who received HIV care at Mulago Hospital, we verified that most (79%) agreed with the chart review to within 3 months. We might have underestimated the rate of receiving HIV care, because we asked about attending HIV care only at the participant\'s most recent medical visit. This misclassification could have resulted in a bias to the null. Another limitation was the different loss to follow-up in each counselling group. If greater loss to follow-up in the abbreviated counselling group was also associated with greater risky sexual behaviour, we could have incorrectly rejected inferiority. However, our results did not differ substantially when we used multiple imputation to account for missed visits. Another limitation is the use of a single site. However, many features of this setting—high HIV prevalence, widespread risky sexual behaviour, and persistently limited access to counselling, testing, care, and treatment services—are common to other health-care settings. The findings cannot be extended to home-based and community-based testing.