AIDs testing and treatments have progressed to such an extent that researchers from Miami question whether the resources devoted to pre-test counseling would be better spent linking newly diagnosed people with the treatments they need.
When it was first discovered, a diagnosis of HIV/AIDs was tantamount to a death sentence, but today's highly effective treatments have transformed this to the point that AIDs can be seen as a chronic disease.
Researchers from the University of Miami's Miller School of Medicine feel that this, coupled with the speed with which test results are returned, has rendered pre-test counseling redundant.
In a study published in JAMA, Daniel Feaster, associate professor of public health sciences, and co-authors claim that pre-test counseling "cannot be considered an efficient use of resources" as it has "no significant impact on the subsequent acquisition of sexually transmitted diseases (STDs)."
Advice about avoiding STDs
When the counseling was first introduced, people concerned about their HIV/AIDs status faced a lengthy wait of up to 2 weeks before they would know the results. Brief counseling was given to reduce the incidents of STDs and to give people realistic and achievable advice about avoiding infection.
Project RESPECT, a 1998 study into the effectiveness of counseling, showed that it reduced the number of patients with STDs. However, the study omitted the group of people most at risk from new infections - men who have sex with men. This group account for nearly 66% of new infections in the US.
With this in mind, researchers set out to assess the efficacy of brief patient-centered counseling and the acquisition of STDs at the time of a rapid HIV test.
Prof. Feaster says:
"What we have to realize is things have changed. We're not saying that counseling to reduce risk behavior doesn't work. We're saying that this quick 20-minute counseling when you get a test doesn't have a whole lot of impact.
So, if you're not spending as much time counseling people when they get an HIV test, then you can spend more time counseling those who test positive and getting them into care."
In what is known as The AWARE Randomized Trial, researchers compared the STD infection rate among people who underwent a short counseling session when they attended an STD clinic for a rapid HIV test, with those who had the test and were offered information only.
Participants from nine American cities were chosen, all of whom were visiting STD clinics. The researchers then randomly assigned the 5,012 participants into two groups - one receiving counseling and the other information only. Both groups were followed up 6 months later.
Of the 2,039 AWARE participants in the counseling group, 250 (12.3%) tested positive for an STD compared with 226 of the 2,032 participants (11.1%) in the information only group.
Prof. Feaster speculates that the normalization of AIDS, the advent of rapid testing and the evolution of the disease from a fatal to a chronic disease have played a significant role in the effectiveness of brief counseling. And with test results available within 30 minutes, people can undergo more frequent testing.
The authors warn against seeing the AWARE study as evidence that other, more in-depth counseling is ineffective. But they predict that greater emphasis will be placed on universal testing than brief patient-centered counseling at the time of rapid HIV testing.
The study also notes:
"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 engaging HIV-infected people in care."
And as Prof. Feaster points out, if all people infected with HIV were taking the appropriate anti-viral therapy from the onset of their infection, the chances they would infect someone else would be virtually non-existent, and AIDS could finally be eradicated.