Brief Risk-Reduction Counseling at Time of HIV Testing Does Not Reduce Rate of STIs

November 4, 2013

Brief risk-reduction counseling at the time of a rapid HIV test was not effective at reducing new sexually transmitted infections (STIs) during the subsequent six months among persons at risk for HIV. Findings from the study are online in the October 23rd issue of JAMA.

Columbia Mailman School researcher Lisa R. Metsch, PhD, and colleagues conducted a trial to assess the effectiveness of counseling in reducing STI incidence. Participants were from nine STI clinics affiliated with the National Institute on Drug Abuse (NIDA) Drug Abuse Treatment Clinical Trials Network in Columbia, S.C.; Jacksonville, Fla.; Los Angeles; Miami; San Francisco; Pittsburgh; Portland, Ore.; Seattle, and Washington, DC.

From April to December 2010, Project AWARE randomized 5,012 patients from the nine STI clinics to receive either brief patient-centered HIV risk-reduction counseling with a rapid HIV test or the rapid HIV test with information only. Participants were assessed for multiple STIs at both the beginning of the study and six-month follow-up. The core elements of the counseling that the patients received included a focus on the patient's specific HIV/STI risk behavior and negotiation of realistic and achievable risk-reduction steps.

The pre-specified outcome was a cumulative incidence of any of the measured STIs over six months. All participants were tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum (syphilis), herpes simplex virus 2, and HIV. Women were also tested for Trichomonas vaginalis.

The researchers found no statistically significant difference in six-month composite STI incidence by study group: STI incidence was 250 of 2,039 (12.3 percent) in the counseling group and 226 of 2,032 (11.1 percent) in the information group. This pattern was consistent at all sites. Analyses by age group, race/ethnicity, and sex (for heterosexuals) also demonstrated no effect of counseling on STI rates.

In the U.S., approximately 1.1 million people are estimated to be living with HIV infection. The incidence of HIV infection is thought to have remained steady over the last decade, with about 50,000 new infections annually. About one in five people living with HIV is thought to be undiagnosed. The U.S. Preventive Services Task Force recently recommended that all persons age 15 to 65 years be screened for HIV, according to background information in the article. A major issue regarding HIV testing of such a large population is the effectiveness of HIV risk-reduction counseling at the time of testing, as counseling involves considerable time, personnel, and financial costs.

“Despite the historical emphasis on risk-reduction counseling as integral to the HIV testing process, no contemporary data exist on the effectiveness of such counseling. The results of Project AWARE help fill this gap,” said Dr. Metsch, the Stephen Smith Professor and Chair of the Department of Sociomedical Sciences at the Mailman School.

“Overall, these study findings lend support for reconsidering the role of counseling as an essential adjunct to HIV testing. This inference is further buttressed by the additional costs associated with counseling at the time of testing: Without evidence of effectiveness, counseling cannot be considered an efficient use of resources,” noted Dr. Metsch. “Post-test counseling for persons testing HIV-positive remains essential, both for addressing psychological needs and for providing and ensuring follow-through with medical care and support. A more focused approach to providing information at the time of testing 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.”

The study was funded by NIDA, of the National Institutes of Health, with a $12.3.million grant awarded through the American Recovery and Reinvestment Act.

Columbia University co-authors are Lauren Gooden, PhD, and Paco Castellon, MPH, in the Department of Sociomedical Sciences at the Mailman School of Public Health; and Susan Tross, PhD, in Columbia’s Department of Psychiatry and the New York Psychiatric Institute.

This article originally appeared on the Mailman School of Public Health website.