# Presentation: 782826

## Client Preferences Regarding HIV Testing and Counseling in STD Clinic Settings: RESPECT-2

- Carol Metcalf, Beth Dillon, Kevin Malotte, John Douglas, Helene Cross, and the RESPECT-2 Study Group

**Notes:**
I’m going to talk about client preferences regarding HIV testing in the RESPECT-2 study population.  This talk focuses specifically on preferences regarding the timing of receiving the HIV result.
I would like to acknowledge the contribution of my co-investigators. 

## Background

- Tested for HIV at enrollment
- 	- 50% result available same visit (rapid test) - 50% result available 5 to 10 days later (standard test)
- Investigators blind to HIV test assignment
- Tested for HIV at final 12-month visit using standard test

**Notes:**
As part of the study protocol, half the participants were randomized to receive a rapid HIV test at the enrollment visit, with results given the same visit. The other half were tested with a standard HIV test and were given an appointment to come back a week later to receive the result. They all received risk-reduction counseling. 
Because the study is still in progress, the investigators are still blinded as to test assignment.
All participants are tested for HIV at the final 12-month visit, using a standard test.  

## Differences in Site Characteristics

**Newark:** Busiest clinic, longest waiting times, highest STD prevalence. Standard HIV test: oral fluid EIA
**Long Beach:** Least busy, shorter waiting times. Standard HIV test: blood EIA
**Denver:** waiting times similar to Long Beach.Standard HIV test: blood EIA

**Notes:**
The characteristics of the STD clinics and the study population differ somewhat by site:
The Newark STD clinic is the busiest clinic with the longest waiting times. It also has the highest STD prevalence. This clinic uses an oral fluid EIA (OraSure) as the standard test. The other 2 sites use blood-based EIAs as the standard test.
The Long Beach site is least busy, and generally has short waiting times.
The Denver site is intermediate between Newark and Long Beach in terms of clinic attendance and STD prevalence. Waiting times are similar to Long Beach.

## Methods 

- Short addendum on test preferences added to CASI follow-up questionnaire
- Added to 3-mo questionnaire at 2 sites in November 2000
- Added to 12-mo questionnaire at all 3 sites in March 2001
- Analysis included all interviews up to July 27, 2001 (n = 863)

**Notes:**
We did a survey on test preference by adding a few questions to the end of the follow-up questionnaire. These questions were added to the CASI questionnaire while the study was in progress, and so was only asked of those who enrolled late in the study.

Two of the three sites, Newark and Long Beach, started asking the test preference questions at the 3-month visit in November last year.

Because we were forced to end enrollment earlier than planned because of problems in the availability of the rapid HIV test, all 3 sites added the test preference questions to the 12-month questionnaire in March this year, in order to attain a reasonable sample size.
This analysis looks at the responses of the 863 participants who had completed an interview by July 27.

## Respondent Characteristics

-  Visit type:   3-mo......28%                 12-mo......72%
-  Site:  Denver.............33%          Long Beach......27%          Newark............41%

**Notes:**
Approximately 3⁄4 of the interviews were done at the 12-month visit.
There was good representation from all three sites, with the Newark site providing the most responses, 41%, and the Long Beach site the fewest, 27%.

## Respondent Characteristics

- Gender:  51% male
- Race/ethnicity: 56% black, 21% white,			   16% Latino, 7% other
- Age: 15 – 39 yearsMedian age :  26 yrs (M), 23 yrs  (F)

**Notes:**
The survey population was similar to the overall study population in terms of gender, race/ethnicity, and age.
Around half of respondents were male. African-Americans were in the majority, and the median age was in the 20s, with the male respondents being slightly older than the female respondents overall.

## Test Preference“If you were to have another HIV test, which would you prefer?”

- Result the same day
- Result 1 week later
- No preference

**Notes:**
The survey posed a hypothetical question:
If you were to have another HIV test, which would you prefer?
The 3 response options were:
To receive the result the same day;
To receive the result 1 week later;
Or no preference.

## Test Preference

- Result the same day......78%
- Result 1 week later.........5%
- No preference.............17%

**Notes:**
The majority said that they would prefer to receive the result the same day (78%).
Only 5% said that they would prefer to receive the result one week later, and the remaining 17% stated that they had no preference.

## Associations with Test Preference

**Notes:**
We looked at factors associated with the stat test preference. Because most of the participants preferred to receive the result the same day, this limited our ability to make comparisons. 

## Test Preference Not Associated with...

- Visit type (3 mo vs. 12 mo)
- HIV testing history (prior to enrollment)
- Gender
- MSM

**Notes:**
Test preference was not associated with the visit type, 3 or 12 months, nor was it associated with HIV testing history prior to enrolling in the study, or gender.
In males, the responses of MSM were very similar to their counterparts who only had sex with women.  

## Differences in test preference by site

**Notes:**
We looked for differences  test preference by site. 

## Long Beach site had greater majority who preferred to receive their HIV result the same day than the other 2 sites (84% vs. 77%; p=0.02)

**Notes:**
The Long Beach site had a slightly greater majority who preferred to receive their HIV result the same day, 84%, compared to 77% for the other 2 sites combined. 

## Newark site had larger minority who preferred to return for their HIV result  than the other 2 sites(8% vs. 3.5%; p<0.01)

**Notes:**
The Newark site had a greater minority who said that they’d prefer to return for their HIV result, 8% compared to 3 1⁄2 %. 

Note that those who preferred to return for their result were a small minority, even at the Newark site. 

## Differences in Test Preference by “Stress” of having an HIV Test

**Notes:**
We also looked for differences in test preference by the self-reported level of “stress” associated with having an HIV test. Stress was measured on a 5 point Likert scale.  

## Those who considered HIV test “stressful” more likely to prefer to receive the result the same day than those who did not	(83% vs. 76%; p = 0.03)

**Notes:**
Those whose considered having an HIV test stressful, that is the top 2 of the 5 levels of stress, were more likely to prefer to receive the result the same day, 83% compared to 76%.

## Those who considered HIV test “not stressful” less likely to have a test preference than the rest   (21% vs. 12%; p < 0.001)

**Notes:**
Those who did not consider having an HIV test to be particularly stressful, the lowest 2 of the 5 stress levels, were less likely to have a test preference than the rest - 21% compared to 12%. 

## Differences in test preference small in absolute terms -Majority preferred to receive HIV result the same day, irrespective of the characteristic considered

**Notes:**
All these differences in test preference were small in absolute terms, despite being statistically significant.
I’d like to stress that the majority of respondents in every subgroup considered, stated that they would prefer to receive their HIV result the same day. 

## Reasons for Test Preference

**Notes:**
Next we looked at reasons for test preference. 
Respondents were asked about the reasons for preferring whichever test that they preferred. This was asked using a checklist of reasons where respondents were instructed to “check all that apply”. 
Those who stated that they didn’t have a test preference weren’t asked these questions.

## Reasons for Preferring Result Same Day (n = 677) 

- Less stressful................................56%
- Result known sooner.............. ......43%
- Not having to come back to clinicfor result................................ ...22%
- Result more accurate.................... ...4%
- No reason given...13%

**Notes:**
The reasons given for preferring to receive the HIV result the same day were:
That it was less stressful – 56%
That they would know their result sooner – 43%
That they would not have to return to the clinic for the result – 22%
And a few, 4 %, stated that they thought the result would be more accurate.
13% did not give any reason for their preference.

## Reasons for Preferring Result a Week Later (n = 46) 

- Less stressful.................................30%
- More time to prepare for result.........30%
- Result more accurate......................26%
- Not having to wait at clinic for result...15%
- No reason given...9%

**Notes:**
Of the 46 respondents who stated that they would prefer to come back to the clinic one week later for the result, the most common reasons were that they considered it less stressful and that they would have more time to prepare themselves for the result, 30% each.
26% said that they would consider the result more accurate than a rapid HIV test.
15% stated that they would prefer to come back to the clinic for the result, to avoid having to wait during the initial testing visit.
9% did not give any reason for their preference.

##  Limitations 

- Generalizability and selection bias
- Limited ability to study associations
- Could not look at test preference by HIV test type at enrollment
- Could not look at test preference by otherhigh-risk behaviors (IDU, CSW)
- Questioned at end of a long interview

**Notes:**
This analysis has some important limitations:
Because this was a select group of attenders at 3 STD clinics, who had consented to be in the RESPECT-2 study, these findings may not be generalizable to all STD clinic populations.
There is some degree of selection bias in this sample, favoring those who preferred to receive their HIV result the same day, because all participants in the survey had consented to be randomized to receive either a rapid HIV test or a standard HIV test at enrollment. The standard HIV test was available to those who did not join the study, but the rapid test was not. Anecdotally, some participants were motivated to join the study because of the possibility of receiving their HIV result the same day.
Because a large majority preferred to receive the results the same day, we were limited in our ability to study associations with test preference.
We were also unable to look at whether test preference was associated with the type of HIV test received at enrollment because we are still blinded. However we will be able to look at this at the end of the study, once we’re unblinded.
There were too few IDUs and commercial sex workers in the sample to see whether their test preference and reasons for test preference differed from the rest.
And the last limitation, is that they were questioned at the end of a long interview. This may have influenced responses, particularly the reporting of no test preference, and also may have contributed to the failure to give any reason for their test preference among some of those who reported a preference.
Despite these limitations I think the survey results provide useful information to consider when devising HIV testing policy. 

## Conclusions 

- Most would prefer HIV result same day
- Most considered receiving result the sameday less stressful
- Those who found HIV test most stressful weremore likely to prefer the result the same day
- Those who found HIV test least stressful were less likely to have a test preference
-  Minor differences in test preference by site

**Notes:**
In conclusion:
Most participants would prefer to receive their HIV result the same day as testing.
Most consider this less stressful than waiting for the result.
Those who found testing most stressful were more likely to prefer their result the same day; and
Those who considered testing least stressful were less likely to state a test preference.
There were minor differences in test preference by site.

## In addition to client preferences, also need to consider....

- Relative effectiveness of testing and counseling interventions
- Relative cost-effectiveness
- Logistics of doing rapid HIV test (e.g. clinic flow)

**Notes:**
However, in devising HIV testing policy in STD clinic populations, there are other things to consider, in addition to client preferences:
The relative effectiveness of different testing and counseling strategies at preventing HIV and other STDs;
The relative cost-effectiveness of different strategies; and
Practical considerations such as clinic flow.
The logistics of using a rapid HIV test will vary depending on the type of rapid test, and its complexity.  At present there is only one licensed HIV test in the US, the SUDS test. This isn’t widely used partly because of its complexity. Other less complex tests are currently undergoing evaluation, and some of these are likely to be licensed at some point.
The RESPECT-2 study addresses the first 2 bullets, as it looks at both the effectiveness and cost-effectiveness of different testing and counseling interventions.
Thank you. I’m happy to take questions.