10. Testing without counselling/minimal counselling

Home testing/home collection

Several different self-test kits have been developed allowing people to self-test at home. Home collection kits are also available and these allow users to collect their own sample (blood or saliva) at home and send it to a collecting facility for testing. The client telephones the centre after one week for the test result. If the result is negative he or she will receive the result via a recorded message. If the test result is seropos-itive he or she will be ‘counselled’over the telephone and referred for further follow-up if required. Although home-testing may improve accessibility and acceptability of HIV testing, it has been suggested to have limited HIV prevention benefits and may lead to undesired behaviour (Mertens et al., 1994²⁵²).

In the United States, 174 316 people used home sample testing during the first year of its introduction and 97% of these people phoned for their test results service. The percentage of those who were seropositive was 0.95%. This is three times that estimated for the general population, and a similar rate to that found in VCT centres in the United States. A sample of 70 620 seronegative and 865 seronegative people using this service has been reviewed (Branson, 1998²⁵³). Of all users 60% (and 49% who tested positive) had never tested before. Of those who tested seropositive, 65% accepted referral for counselling, 23% said that they already had some sort of follow-up and 5% put the phone down immediately. Although there are no follow-up data on the people using this service it is used by people who are at risk from HIV infection and by many people who did not use other testing facilities.

While there are advantages to using home-collection and self-testing kits - they offer privacy and may provide a service for people who do not seek testing at VCT sites - they should be used with caution. Users must understand the need for a confirmatory test and about the window period. Regulations must be in place to ensure their quality and kits should have clear instructions and be easy to use.

There are also worries that people using self-test kits have no pre-test counselling, or access to follow-up care and support, and that people may be coerced into testing (see section 5).

There are still many reports of HIV testing being carried out in medical institutions without counselling. In a study from the Kenyatta hospital in Kenya, 50% of those tested did not receive any pre- or post-test counselling (Mwaura et al., 1998²⁵⁴). A study from Russia indicated that in 80% of cases HIV testing was not accompanied by any pre- or post-test counselling (Nikitina, 1998²⁵⁵).

Peer education/counselling

A study that introduced peer educators to communicate risk reduction among gay men consistently produced reductions in high-risk sexual behaviour (unprotected anal intercourse was reduced to 15-29% of baseline levels) in the three intervention cities (Kelly et al., 1992²⁵⁶).