Optional pre-test HIV counseling in California

Required pre-test HIV prevention counseling has been speculated to deter repeat testing among high-risk individuals. The objective of this dissertation was to characterize repeat HIV testers, assess the acceptance of counseling among recent repeat testers (RRTs), and evaluate the acceptability and feasibility of a self- administered client HIV risk assessment survey and optional HIV pre-test counseling for repeat testers from the perspective of clients and clinic staff. Surveillance data collected from all clients tested for HIV at publicly funded counseling and testing sites throughout California from 2005 to 2006 were analyzed to characterize repeat testers. A subsequent pilot study was conducted allowing RRTs, defined as those receiving HIV testing in the previous year, to opt-out of counseling. After completion of standardized questionnaires by individuals testing between September 2008 and February 2009 at three sites in Orange and Los Angeles Counties, RRTs were compared with non-RRTs to identify correlates of repeat testing. In addition, those accepting counseling were compared to those refusing, to identify correlates of counseling decisions. Finally we applied qualitative and quantitative methods; including quantitative comparison of client responses to assessment options (self- versus counselor- administered), post-visit client satisfaction surveys and qualitative in-depth interviews with clinic staff. Examination of state testing records found female and heterosexual male RRTs reported higher risk behaviors than non-RRTs, while men who have sex with men (MSM) RRTs did not report higher risk activities than non-RRTs. Of 707 clients surveyed during the pilot study, 202 (28.6%) were RRTs. Compared to non-RRTs, RRTs were more likely to report oral sex in the past 12 months, have high-risk sexual and injection behaviors (all p-values < 0.05). Among 150 RRTs who were eligible to skip counseling, 91 (60.3%) chose to forego counseling. Testing at the STI clinic, being MSM, and having no diagnosis of gonorrhea or syphilis in the past year were significantly associated (p <0.05) with accepting counseling in multivariate analysis. Risk assessment survey self-administration and optional counseling for RRTs were well received by counselors and clients. Our findings suggest that self-administration of surveillance tools and offering RRTs optional pre-test counseling are reasonable and practical additions to the HIV testing proces