Counseling before HIV testing didn't reduce later infection rates

Providing counseling about risk reduction at the time of HIV testing did not reduce patients' risk of later acquiring a sexually transmitted infection, according to a recent study.

The AWARE clinical trial randomized 5,012 patients seen at 9 U.S. sexually transmitted disease clinics in 2010 to either brief evidence-based, patient-centered counseling (including negotiation of realistic and achievable risk-reduction steps) and a rapid HIV test or just a rapid HIV test with information. Results were published in the October 23/30 Journal of the American Medical Association.

Over the next 6 months, all participants were screened for Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum (syphilis), herpes simplex virus 2 and HIV, as well as Trichomonas vaginalis in women. The two groups showed no significant difference in disease incidence (adjusted risk ratio, 1.12; 95% CI, 0.94 to 1.33). The counseling group actually had slightly more incident cases of sexually transmitted infections than the information-only group (12.3% vs. 11.1%).

The researchers also surveyed the patients about their sexual behavior and did find some reductions in risky behaviors in the counseling group. The lack of an associated reduction in infection rates may mean that the magnitude of the behavior change was insufficient to affect disease rates or that the counseling group had a bias toward reporting reductions in risky behavior whether or not they actually occurred. Either way, actual biological outcomes are the most important result, the authors said. Overall incidence of sexually transmitted infections, the primary outcome of this study, was intended as a surrogate marker for HIV incidence, because an HIV-specific study would require too large a sample.

Prevention counseling significantly raises the cost of HIV testing, the authors noted. Given the lack of effect seen in this study, counseling at the time of testing is an inefficient use of health care resources, the authors concluded. Post-test counseling for patients who are HIV-positive remains essential, but clinics should consider reallocating resources from preventive risk-reduction counseling to conducting HIV tests in more patients, they said.

This study is one of the largest trials of prevention counseling and also benefits from inclusion of a broad study sample, use of rapid HIV testing, and a high follow-up rate, according to an accompanying editorial. The editorialists noted that the CDC explicitly removed its recommendation for prevention counseling as part of HIV testing in 2006. “Prevention counseling is staff-intensive, often perceived as onerous, and often not performed well,” the editorialists wrote. Given these limitations, the study's findings, and the need for cost-efficient practice, preventive counseling should not be routinely provided with HIV testing, the editorial concluded.