to fully implement VCT programs and societal stigma associated with HIV. Multiple studies in other settings have documented the barriers that hinder individuals from accessing VCT services, including denial of HIV risk, fear of stigma, discrimination, disease, and death [7,15,16]. Recent studies in India have demonstrated that ongoing counseling and testing can lead to reduced risk taking behaviors and increased condom use[17]. A study at our center examined the acceptability of prenatal HIV testing among pregnant women in which 86% of women were willing to accept VCT [18]. Another recent study at our center examined the different reasons why men and women attended VCT services [19]. In this study, we describe the changes in services provided and the patient population utilizing VCT services at private testing laboratories in Chennai, India in 2001 and 2006. Understanding the availability of current VCT services offered by private laboratories has implications for the further development of education, outreach, and other HIV prevention services. Methods Setting The study was conducted by YRG Centre for AIDS Research and Education, a large tertiary HIV care facility in South India [13,20]. YRG CARE provides comprehensive care and support services to over 10,000 HIV-infected persons, including anony- mous voluntary counseling and testing (VCT), integrated medical services for the treatment of HIV and related illnesses, prevention programs, and nutrition education. There is no formal advertising about YRG CARE or VCT services; however, the organization’s activities are often featured in the local and regional news and VCT services are discussed as part of YRG CARE’s educational and outreach services. Survey In 2001, a cross-sectional descriptive survey was conducted to assess the services provided and client population of 1,031 private laboratories in Chennai, the capital of Tamil Nadu state in southeastern India with a population of over 7 million. The Chennai metropolitan area was divided into eight zones in which field workers identified private laboratories street by street. Hospitals, nursing homes, and other clinical facilities that may also provide laboratory testing services were also identified within each zone. All consenting laboratory testing facilities were then administered the survey. Labs that performed greater than 10 HIV tests per month in 2001 were defined as high-volume facilities (N = 140), and those with less than 10 HIV tests per month in 2001 were defined as low-volume facilities (N = 891). A subset of labs (9%) that had been surveyed in 2001 were also studied in 2006. This study was conducted among privately operated labs because the primary source of healthcare for Indians has been private facilities. The survey assessed the current availability of basic clinical testing services, STD testing, HIV testing, counseling services, and willingness to build skills in offering VCT services. The survey was administered by outreach staff to consenting lab personnel who provided written consent to take part in the survey. This study received institutional review board (IRB) approval at both the free- standing YRGCARE IRB and the Brown University-affiliated Miriam Hospital IRB. Statistical Analysis Descriptive statistics were used to calculate the frequency, mean, median, and standard deviation (SD). Diagnostic tests were HIV Services in India performed, and the mean+/2SD was used for variables that were normally distributed; and the median and interquartile range (IQR) were calculated for variables that were influenced by extreme variables. To compare proportions, chi-square (x2) statistics and independent t-tests were used. A p value of less than 0.05 was considered statistically significant. Data entry, database management, and statistical analyses were performed with SPSS software (version 13.0; SPSS, Chicago, IL). Results In 2001 (N = 1031), 64.7% of survey respondents were lab technicians, 20.4% were owners/directors, and 9.2% were physicians; the breakdown of respondents was similar in 2006. The median number of years of operation was 6 years (IQR: 3–12) for low volume labs and 10 years (IQR: 5–17) for high volume labs. The median number of employees was 2 personnel (IQR: 1– 3) for low volume labs and 5 personnel (IQR: 2–10) for high volume labs. The mean length of time counselors had been with the lab was 0 years for low volume labs and 1.4 years for high volume labs. In 2001, labs offered the following basic testing services: 68.6% liver function testing, 95.5% hemoglobin, 81.1% complete heamogram, 93.8% renal function testing, 92.1% cholesterol, and 81.0% triglycerides; there were modest increases in these basic testing services in 2006 (N = 90). In 2001, significantly more high volume labs offered HIV diagnostic tests than low volume labs, including ELISA (59.3% vs. 20.0%), Tridot (79.3% vs. 49.6%), and Western Blot (15.0% vs. 2.5%) (p,0.001) (See Table 1). Significantly more high volume labs reported more than ten men (41.4%) and ten women (39.9%) accessing their facilities for HIV testing in the last month than low volume labs (0.7% men; 0.4% women) (p,0.001). More high volume labs (20.0%) provided pre-test counseling as part of HIV testing than low volume labs (11.1%) (p = 0.003). Between 2001 and 2006, the number of labs that provided HIV diagnostic testing significantly increased, including ELISA (87.8% vs. 40.0%), Western Blot (84.4% vs. 13.3%), and Tridot (98.9% vs. 72.2%) (p,0.001) (See Table 2). In 2006, all of the surveyed labs performed greater than 10 HIV tests per month, while in 2001, 42.2% of these labs provided greater than 10 HIV tests per month (p,0.001). Between 2001 and 2006, the number of labs that reported greater than 10 women seeking HIV testing per month significantly increased from 14.5% to 79.0% (p = 0.006). The number of labs receiving greater than 10 physician referrals for HIV tests significantly increased between 2001 (30.0%) and 2006 (78.9%) (p,0.001); and the number of labs receiving greater than 10 walk-ins for HIV testing also significantly increased between 2001 (5.5%) and 2006 (14.4%) (p = 0.034). From 2001 to 2006, labs increasingly received referrals from physicians not in the same area as the lab facility (5.6% to 37.8%) (p,0.001). In 2006, significantly fewer labs (40.0%) referred clients testing positive for HIV to a physician or another institution than in 2001 (57.7%) (p = 0.025). A small minority of labs (,5%) referred clients testing positive for HIV to alternative medical providers both in 2001 and in 2006. More labs provided pre-test counseling in 2006 (34.4%) than in 2001 (21.1%) (p = 0.046). Between 2001 and 2006, more labs reported that the reason clients sought HIV testing was due to migration (8.9% vs. 27.8%), and fewer labs reported job related reasons (91.1% vs. 70.0%) (p = 0.001). In 2001, more high volume labs (60.7%) expressed interest in having a staff member trained in counseling than low volume labs (38.3); however among the 90 labs assessed in both 2001 and 2006, fewer labs (6.7%) in 2006 were interested in having a staff member trained in counseling than in 2001 (58.9%). PLoS ONE | www.plosone.org 2 October 2008 | Volume 3 | Issue 10 | e3471