HIV Services in India Table 1. HIV testing and counseling services in 2001 among low volume (,10 HIV tests per month) and high volume laboratories (.10 HIV tests per month) (N = 1031). 2001 Labs ,10 HIV tests per month (Mean, %) 2001 labs .10 HIV tests per month (Mean, %) N = 891 N = 140 20.0 2.5 49.6 59.0 42.8 4.5 0.7 39.5 4.5 0.4 11.1 59.3 15.0 79.3 100.0 25.0 25.7 39.9 14.3 34.3 41.4 20.0 HIV Testing services HIV diagnostic tests offered by labs ELISA Western blot Tridot Lab conducted HIV testing in last month Males who came for HIV testing in the last month .5 6–10 .10 .5 6–10 .10 Females who came for HIV testing in the last month HIV Counseling Services Lab provided pre-test counseling doi:10.1371/journal.pone.0003471.t001 In addition to an increase in performing HIV testing, assays for other common pathogens significantly increased from 2001 to 2006: 87.8% to 100% offered screening tests for syphilis (RPR/ VDRL); 32.2% to 73.3% syphilis confirmatory testing, 31.1% to 81.1% Trichomonas wet mount, 74.4% to 97.8% Hepatitis B Surface Antigen (HBsAg), and 73.3% to 86.7% acid fast bacilli (AFB) smear (p,0.005). Discussion This study demonstrates that a considerable number of private laboratories in Chennai currently have the infrastructure to provide comprehensive STD and HIV testing services with a high volume of clients. Though in India public awareness and knowledge of HIV and AIDS remains relatively low [17], the labs in 2006 appear to have expanded their testing services since 2001, which may be reflected in increasing numbers of women seeking HIV testing, possibly as a result of recent regional efforts to increase antenatal testing. Labs performed a range of HIV testing services, with almost all labs providing ELISA, Western Blot, and Tridot, for their clients in 2006. Most labs followed Indian government National AIDS Control Organization (NACO) guidelines[21], which involved using a test with very high sensitivity followed by a second test with very high specificity. These tests generally include a rapid test, which can involve ELISA or Tridot-based technologies. In cases of indeterminate results, a Western Blot is used as a confirmatory test. However, most of these labs lack policies and procedures for quality assurance and quality control (QA/QC). The number of labs performing ELISA more than doubled and Western Blot increased by over six fold between 2001 and 2006, suggesting an increasing level of sophistication in HIV testing services. Increasing efforts in India have been underway to encourage general physicians to order HIV testing along with other routine PLoS ONE | www.plosone.org 3 October 2008 | Volume 3 | Issue 10 | e3471 p-value ,0.001 ,0.001 ,0.001 ,0.001 ,0.001 ,0.001 0.003 lab tests [22]. The majority of referrals to the surveyed labs came from physicians, and most of the physicians who made these referrals were located within the vicinity of the lab facility. It has been suggested that a major barrier to seeking VCT services in other resource-poor settings is logistical, including location of the testing center [16]. In light of the increasing availability of HIV testing services throughout Chennai in this study, it is probable that clients can conveniently access labs within their localities. However, it is estimated that 90% of HIV-infected Indians are unaware of their status [23], raising concerns that stigma and ignorance may be impeding wider access to testing. Over three fourths of labs reported over ten women seeking HIV testing in a month in 2006 compared to 2001 when less than a fourth of these same labs reported over ten women seeking HIV testing in a month. In contrast, only close to a third of labs in 2006 reported more than ten men seeking HIV testing in a month. It is possible that increasingly Indian women are seeking HIV testing services at private laboratories as part of antenatal screening. Also, most Indian men may be diagnosed with HIV after presenting to clinical care with an opportunistic infection, and their asymptom- atic wives may then be consequently tested for HIV[4,5,19,24]. Indian women have reported seeking VCT services as part of prenatal testing to protect their baby’s welfare [18]. Though some Indian women may be willing to be tested, others may be concerned about confidentiality and disclosing HIV serostatus out of fear of negative reactions from their husbands, parents, and community [25]. As more women seek VCT services, counseling approaches will need to be developed that ensure confidential couple/family based counseling. The labs surveyed in 2001 and 2006 reported that the reasons clients sought HIV testing was due to migratory and job-related reasons. Though the number of labs reporting migration significantly increased from 2001 to 2006 relative to job-related reasons, it is very likely that job-related reasons are the same as