HIV testing in non-health care settings is an effective strategy for increasing the proportion of persons aware of their infection. We conducted 21 focus groups with 186 past and potential clients in five U.S. cities to explore attitudes and experiences related to HIV counseling and testing in non-health care settings. Qualitative analysis yielded several key themes. HIV-related stigma and fear emerged as a main theme throughout the discussions. Knowing one's HIV status quickly and accurately was of primary importance; HIV prevention counseling was secondary. Participants prioritized a supportive, nonjudgmental environment with adequate privacy and confidentiality. Provision of immediate emotional support, medical information, and linkage services to HIV-infected clients were considered essential. Staff with HIV-specific skills to address clients' emotional and informational needs was considered a strength of non-health care testing programs. Frequently, however, participants compared non-health care settings unfavorably to health care settings regarding privacy, competency, confidentiality, and test accuracy. Recommendations for enhancing counseling and testing services in non-health care settings are discussed.

BACKGROUND: Over a three-year period, CDC invested $102.3 million in a large-scale HIV testing program, the Expanded HIV Testing Initiative, for populations disproportionally affected by HIV. Policy makers, who must optimize public health given a set budget, are interested in the financial return on investment (ROI) of large-scale HIV testing. METHODS: We conducted an ROI analysis using expenditure and outcome data from the program. A health system perspective was used that included all program expenditures including medical costs of treating newly diagnosed patients. We incorporated benefits of HIV transmissions averted from persons diagnosed of their infection through the Initiative compared to when, on average, those persons would have been diagnosed without the Initiative (3 years later in the base case). HIV transmissions were derived from a published mathematical model of HIV transmission. In sensitivity analysis, we tested the effect of 1 -5 year alternate testing intervals and differences in the prevalence of undiagnosed HIV infection. RESULTS: Under the Initiative, 2.7 million persons were tested for HIV, there was a newly diagnosed HIV positivity rate of 0.7%, and an estimated 3,381 HIV infections were averted. It achieved a return of $1.95 for every dollar invested. ROI ranged from $1.46 - $2.01 for alternative testing intervals of one to five years and remained above $1 (positive return on investment) with a prevalence of undiagnosed HIV infection as low as 0.12%. CONCLUSION: The Expanded Testing Initiative yielded ROI values of >$1 under a broad range of sensitivity analyses and provides further support for large-scale HIV testing programs.

BACKGROUND: The reliability of CDC HIV partner notification (PN) disposition codes has not been evaluated. METHODS: Disease Intervention Specialists (DIS) working for health departments in high HIV/STD-morbidity metropolitan areas completed a questionnaire that presented vignettes describing PN interviews. Questionnaires asked DIS to indicate whether they would record a disposition and what codes they would assign to each partner. RESULTS: A total of 136 DIS from 28 of 29 eligible states participated. Partner 1: The index case says he will inform his partner of his HIV diagnosis and, at follow-up, reports that the partner has tested negative. Seventeen percent of DIS indicated they would record a partner disposition. DIS used 7 different codes to define the PN outcomes. Partner 2: The index case says she will inform her partner, who attends the clinic, indicates no history of testing, and tests HIV-negative. 93% of DIS reported they would record a disposition, 90% of whom used code 6, "Not Previously Tested, New Negative." Partner 3: The index case with partner 2 (above) agrees to have DIS notify her second partner. When contacted, the partner tells DIS that he had previously tested negative and will arrange to be tested himself. He subsequently reports testing HIV-negative, but DIS do not confirm this. Seventy-three percent of DIS recorded a disposition for the partner, of whom 84% used code J, "Located, Refused Counseling and Testing." CONCLUSIONS: CDC HIV PN disposition codes are reliable for simple scenarios with verified outcomes, but less reliable when DIS elicit partner-reported outcomes.