own systems of counseling as part of offering more comprehensive testing services, and thus no longer required training for their staff. Though more labs offered counseling services to clients seeking HIV testing in 2006 than in 2001, only a third of labs had a system of counseling in place, either involving a permanent in-house counselor or a counselor that could be contacted on as-needed basis. HIV testing without appropriate follow-up counseling can pose risks to the physical, emotional, and psychological functioning of the client, especially within an Indian setting where AIDS- associated stigma is great. South Indian women have reported that a positive HIV test result included thinking you would die soon, suffering from psychological stress, and wanting to kill/hurt themselves [25]. With the high number of labs providing HIV rapid testing in this study, same day pretest and posttest counseling could be implemented. Though HIV testing services at the most experienced private laboratories have considerably expanded from 2001 to 2006, there is still a substantial underutilization of counseling services as part of HIV testing. As most of the assessed labs are structured primarily as testing centers that receive clients via physician referral, these facilities may not have experience in providing client-centered counseling. Health counseling itself is a relatively new concept in India where openly discussing sexual lifestyles is often taboo and patients may not be proactive in seeking health care services [14]. The disparity between centers providing HIV testing without commensurate voluntary pre- and post-testing counseling (VCT) suggests the increasing need for massive professional educational efforts of healthcare providers and lab personnel. In the context of a lack of adequate universal HIV/AIDS treatment, there are potentially many perceived deterrents to being tested for HIV which can outweigh the benefits of knowing one’s status. However it is possible with the increasing availability of ART, more individuals may seek VCT services [19]. Not seeking VCT services may also reflect social barriers to getting tested, especially AIDS-related stigma, rather than a lack of a perceived value of getting tested [7]. Within the Indian medical establishment, individuals may be routinely tested for HIV without References 1. UNAIDS (2007) UNAIDS/WHO AIDS epidemic update. UNAIDS/WHO. 2. NACO (2006) Facts and Figures. National AIDS Control Organization. 3. Solomon S, Kumarasamy N, Ganesh AK, Amalraj RE (1998) Prevalence and risk factors of HIV-1 and HIV-2 infection in urban and rural areas in Tamil Nadu, India. International Journal of STD & AIDS 9: 98–103. 4. Gangakhedkar R, Bentley ME, Divekar AD, Gadkari D, Mehendale SM, et al. (1997) Spread of HIV infection in married monogamous women in India. Journal of the American Medical Association 278: 2090–2092. 5. Newmann S, Sarin P, Kumarasamy N, Amalraj E, Rogers M, et al. (2000) Marriage, monogamy and HIV: a profile of HIV-infected women in south India. International Journal of STD & AIDS 11: 250–253. 6. WHO (2002) Increasing Access to HIV Testing and Counseling. 7. Kalichman S, Simbayi LC (2003) HIV testing attitudes, AIDS stigma, and voluntary HIV counseling and testing in a black township in Cape Town, South Africa. Sexually Transmitted Infections 9: 442–447. 8. The Voluntary HIV-1 Counseling and Testing Efficacy Study Group (2000) Efficacy of voluntary HIV-1 counseling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomized trial. The Lancet 356: 103–112. 9. UNAIDS (2000) Voluntary Counseling and Testing (VCT): UNAIDS Technical Update. 10. Sweat M, Gregorich S, Sangiwa G, Furlonge C, Balmer D, et al. (2000) Cost- effectiveness of voluntary HIV-1 counseling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania. The Lancet 356: 113–121. 11. Anvikar A, Chakma T, Rao VG (2005) HIV epidemic in Central India: Trends over 18 years (1986–2003). Acta Tropica 93: 289–294. 12. Sinha P, Ranjan A, Siddique NA, Anil CK, Priya A, et al. (2003) Usefulness of voluntary counseling and testing for HIV/AIDS: Bihar as an example. Journal of Acquired Immune Deficiency Syndrome 33: 407–408. 13. Kumarasamy N, Solomon S, Flanigan TP, Hemalatha R, Thyagarajan SP, et al. (2003) Natural history of human immunodeficiency virus disease in southern India. Clinical Infectious Disease 36: 79–85. HIV Services in India consent before undergoing elective surgery or delivery, and if found to be HIV infected may be refused care. Innovative models have been proposed for increasing uptake of VCT services in other settings, such as same-day rapid testing via a mobile VCT approach[16] and same-day results using rapid test kits, anon- ymized recordkeeping, lay counselors, and peer educators [15]. As the current study documents, VCT services have now become available in urban settings, but increasingly as HIV spreads to rural India, VCT services must also geographically expand. As developing countries, including India, are increasingly able to provide antiretroviral treatment, VCT will become an important tool for linking people to care. The current study showed an increased use of HIV rapid testing with same-day results, which may allow more individuals to receive their test results. It has been suggested that the cost-effectiveness of VCT services can be achieved through supporting VCT services in high- prevalence areas, by linking VCT services to reach high- prevalence populations, and by targeting individuals who are or were sexual contacts of known HIV-infected individuals [10]. In India, public health efforts to create more comprehensive VCT programs can be more effective by acknowledging and involving private clinical laboratories. Future national expansions of offering increased VCT services must develop methods of involving the Indian private sector, which is likely to remain the largest provider of HIV testing for the foreseeable future. Acknowledgments The authors are grateful to the research survey staff at the YRG Centre for AIDS Research and Education, VHS, Chennai, India, for their facilitation of the study. Author Contributions Conceived and designed the experiments: AKS SS PB KHM. Performed the experiments: AKS ET SA KGK PB. 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Brown H, Vallabhaneni S, Solomon S, Mothi S, McGarvey S, et al. (2001) Attitudes towards prenatal HIV testing and treatment among pregnant women in southern India. International Journal of STD and AIDS 12: 390–393. 19. Solomon S, Kouyoumdjian FG, Cecelia AJ, James R, James L, et al. (2006) Why are people getting tested? Self-reported reasons for seeking voluntary counseling and testing at a clinic in Chennai, India. AIDS and Behavior 10: 415–420. 20. Kumarasamy N, Solomon S, Chaguturu SK, Cecelia AJ, Vallabhaneni S, et al. (2005) The changing natural history of HIV Disease: Before and after the introduction of generic antiretroviral therapy in southern India. Clinical Infectious Disease 41: 1525–1528. 21. NACO HIV Testing Manual: Laboratory Diagnosis, Bio-Safety & Quality Control. 22. NACO (2001) Country Scenario 2000–2001. 23. UNAIDS (2004) From know more to no more AIDS. New Delhi: Veerendra Printers. 24. Bharucha K, Sastry J, Shrotri A, Sutar S, Joshi A, et al. (2005) Feasibility of voluntary counselling and testing services for HIV among pregnant women presenting in labour in Pune, India. International Journal of STD & AIDS 16: 553–555. PLoS ONE | www.plosone.org 5 October 2008 | Volume 3 | Issue 10 | e3471