HIV counseling and testing in a tertiary care hospital in Ganjam district, Odisha, IndiaM Dash, S Padhi, S Sahu, I Mohanty, P Panda, B Parida, MK Sahoo
Department of Microbiology, Maharaja Krushna Chandra Gajapati Medical College and Hospital, Berhampur University, Berhampur, Odisha, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0022-3859.113831
Source of Support: None, Conflict of Interest: None
Background: Human immunodeficiency virus (HIV) counseling and testing (HCT) conducted at integrated counseling and testing centers (ICTCs) is an entry point, cost-effective intervention in preventing transmission of HIV. Objectives: To study the prevalence of HIV among ICTC attendees, sociodemographic characteristics, and risk behaviors of HIV-seropositive clients. Materials and Methods: It was hospital record-based cross-sectional study of 26,518 registered ICTC clients at a tertiary care hospital in Ganjam district, Odisha, India over a 4-year period from January 2009 to September 2012. Results: A total of 1732 (7.5%) out of 22,897 who were tested for HIV were seropositive. Among HIV-seropositives, 1138 (65.7%) were males, while 594 (34.3%) were females. Majority (88.3%) of seropositives were between the age group of 15-49 years. Client-initiated HIV testing (12.1%) was more seropositive compared to provider-initiated (2.9%). Among discordant couples, majority (95.5%) were male partner/husband positive and female partner/wife negative. Positives were more amongst married, less educated, low socioeconomic status, and outmigrants (P<0.0001). Risk factors included heterosexual promiscuous (89.3%), parent-to-child transmission 5.8%, unknown 3.1%, infected blood transfusion 0.8%, homosexual 0.5%, and infected needles (0.5%). Conclusions: There is need to encourage activities that promote HCT in all health facilities. This will increase the diagnosis of new HIV cases. The data generated in ICTC provide an important clue to understand the epidemiology in a particular geographic region and local planning for care and treatment of those infected with HIV and preventive strategies for those at risk especially married, young adults, and outmigrants to reduce new infections.
Keywords: Counseling, human immunodeficiency virus, integrated counseling and testing center, seroprevalence, testing
The global pandemic of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in its third decade has grown into a major public health program of alarming magnitude. According to Joint United Nations Programme on HIV/AIDS (UNAIDS) organization, approximately 34.2 million people are living with HIV/AIDS (PLHAs) worldwide as of 2012.  Though India is categorized as a low HIV prevalence nation, it has the third largest number of PLHAs.  There are an estimated 2.39 million PLHAs of which 39% are females and 3.5% are children with an adult prevalence of 0.31% among general population (2009).  This accounts for nearly 15% and 75% of the HIV burden of the world and South/Southeast Asia, respectively.  Odisha state (eastern India) with its population crossing 4.19 crore has an estimated 71,813 PLHAs with an adult prevalence of 0.29%.  The population of Odisha state is about 3.46% of the population of India, and there are an estimated 9% new infections in 2009. 
HIV counseling and testing (HCT) services were started in India in 1997. There are more than 9400 integrated counseling and testing centers (ICTCs), mainly located in the government hospitals.  Under the National AIDS Control Programme-III, voluntary counseling and testing centers and facilities providing prevention of parent-to-child transmission (PTCT) services are remodeled as a hub or ICTCs to provide services to all clients under one roof. ICTC is a part of HIV prevention program and is a place, where a person gets counseling and testing of its own will or as advised by a medical provider. ICTC for HIV is a cost-effective intervention in preventing the spread of HIV, promotes behavioral change to reduce vulnerability, and conducts HIV diagnostic tests in a comfortable, convenient, and confidential manner.  It also links people with care and treatment services. This is both the entry point to comprehensive HIV care and treatment as well as prevention; hence, awareness and acceptance of ICTC services is vital, if the HIV/AIDS epidemic is to be controlled. 
Ganjam district with its population of more than 3.5 million, is spread over a geographical area of 8070 square kilometer extending from 19.4° north latitude to 20.17° north latitude and 84.7° east longitude to 85.12° east longitude. According to Odisha state HIV statistics, 43% of all PLHAs are from Ganjam district alone. From a total of 640 districts in India, Ganjam has been identified as one of the 14 most critical districts affected by HIV in the country.  There are more than 0.1 million migrants and 90% of these migrate to high HIV destination areas (Surat district in Gujarat, Mumbai, and Thane district in Maharashtra).  With this background, the present study was undertaken to find the profile of people seeking ICTC services as also describing the prevalence of HIV among ICTC attendees and various sociodemographic and epidemiological characteristics.
The study area, population, and methodology
The present was carried out among ICTC attendees in the Department of Microbiology, ICTC unit, in a tertiary care referral hospital of Ganjam district, Odisha, India. A retrospective collection of data from available records of all clients who attended ICTC of our hospital between January 2009 and September 2012 was carried out after IRB approval. The present study included 26,518 ICTC attendees, who were either volunteers or referred by various departments of our institute. The ICTC counselors collected their anonymous and unlinked data in registers and logbooks as per National AIDS Control Organization (NACO) guidelines under strict confidentiality. Data accessed from the records included age, sex, marital status, education and occupational status, behavioral patterns and HIV status of the couples.
Sample collection and processing
All the ICTC attendees had relevant pretest counseling and written informed consent was sought before HIV testing was carried out. Five milliliters (mL) venous blood sample was collected in a sterile plain container from all clients who consented for HIV testing. Blood was allowed to clot for 30 min at room temperature (25-30°C) and serum was separated after centrifugation at low speed. The serum samples were then stored at 4°C and were tested within 24 h.
HIV antibodies were tested by the three rapid tests protocol as per the guidelines laid down by the World Health Organization (WHO testing strategy III) and the testing policy of NACO, Government of India.  All positive test results were disclosed only after posttest counseling of the patients. Antibodies to HIV (1 and 2) were tested initially with a SD BIOLINE HIV-1/2 3.0 rapid test (Standard Diagnostics, Inc. Korea). The samples tested positive in the first method were subjected to tests with two different rapid tests, that is, PAREEKSHAK HIV 1/2 Triline Card Test (Bhat Bio-Tech India (P) Ltd.) and PAREEKSHAK HIV 1/2 Rapid Test Kit (TRISPOT) (Bhat Bio-Tech India (P) Ltd.) The samples were considered as positive when found reactive by all three different methods. All tests were done according to manufacturer's instructions.
The data were analyzed using the Chi-square tests. The P values were calculated using GraphPad QuickCalcs statistical software. Statistical significance was defined when P value is less than 0.05.
A total of 26,518 clients accessed HCT services during the study period. Of these, 22,897 (86.3%) accepted HIV testing and rest 3621 (13.7%) clients did not agree for testing. Only 159 (0.7%) clients did not turn up to receive posttest counseling after HIV testing. Thus the uptake of HCT services was 85.6% [Table 1]. Out of total 22,897 clients tested, 1732 were HIV-seropositive giving a prevalence of 7.5% [Table 1]. Out of total 22,897 clients received HIV testing, 15,352 (67%) were males, while females constituted 7545 (33%). From 15,352 males, 1138 (7.4%) were positive, while 594 (7.9%) females out of 7545 were positive (P>0.05).
A majority (88.3%) of those who were HIV-seropositive were between the ages of 15 and 49 years. A total of 47.3% females were positive within the age group of 25-34 years followed by 174 (29.3%) within 35-49 years, while 553 (48.6%) of males were positive within the age group of 35-49 years followed by 25-34 years (33%).
Out of total 22,897 ICTC attendees those who received HIV testing, 11,654 (50.9%) were client-initiated counseling and testing (CICT) and among them, 1409 (12.1%) were HIV-seropositive. From 11,243 (49.1%) clients who received provider-initiated counseling and testing (PICT), only 323 (2.9%) were positive.
Evaluation of the 681 couples showed that 347 (51%) were concordant and 334 (49%) were discordant. Among discordant couples, 319 (95.5%) were male partner/husband positive and female partner/wife negative, while 15 (4.5%) were male partner/husband negative and female partner/wife positive.
The distribution of cases according to their marital status showed that 1488 (8.4%) out of all married persons were HIV-seropositive. Majority of HIV-seropositives, that is, 1704 (6.9%) were less educated. Outmigrants showed high positivity (7.8%) relative to others. Clients who stayed away from their family were more likely to be HIV positive. The number of HIV-seropositivity among ICTC attendees based on socio-demographic variables, that is, marital status, occupation, socioeconomic status, education, and living status were statistically significant (P<0.0001) [Table 2].
The pattern of risk behavior among HIV-seropositive males was heterosexual with multiple sex partners 1021 (58.9%), followed by unprotected heterosexual route in females 526 (30.4%). The next common route was PTCT 5.8% followed by unknown routes (3.1%). The least common risk behavior patterns were infected blood and blood products (0.8%), homosexual behavior (0.5%), and through infected needles and syringes (0.5%) [Figure 1].
HIV prevention through the process of counseling and testing is an important tool of intervention and control especially in the absence of an effective vaccine or curative treatment. Counseling for HIV consists of pretest, posttest, and follow-up counseling. Pretest counseling plays an important role in improving the acceptability for HIV testing. ''Opt-in'' or ''opt-out'' approaches have been used while offering HIV testing. In the ''opt-in'' approach, clients are given pretest counseling and offered an HIV test. If they choose to get a test done, consent is taken usually in writing. In the ''opt-out'' approach, the clients are told about the HIV tests and they must explicitly refuse the test. Centers for disease control and prevention (CDC) recommends an ''opt-out'' approach, as the testing rate with it is 85%-98% but with an ''opt-in'' the testing rate ranges from 25% to 83%.  In the present study, the overall acceptance for the HIV testing with ''opt-out'' approach was 86.3% (22,897/26,518). The studies conducted by Joshi et al., and Kawatra et al., the acceptance for HIV testing in ''opt-out'' approach were 83% and 82.4%, respectively, similar to our study. , But Solomon et al.,  reported high uptake of HCT was 99.9% in Nigeria. This emphasizes there is need for good counseling and proper communication skills by the counselor to achieve both counseling and testing close to 100%. As the rapid HIV tests provide results within few hours, clients are expected to collect the report on the same day and undergo posttest counseling. In this present study, it was observed that only 0.7% (159/22,897) of ICTC attendees did not receive either HIV test report or posttest counseling. There are many reasons for this noncompliance. There is always an element of fear of the test result being positive. Inadequate emphasis regarding the importance of posttest counseling during pretest could be the another reason for nonattendance at posttest counseling.
CICT are the clients who present themselves at the ICTC of their own will. The advantages of CICT are client is emotionally ready to do the test, more time can be given to the client, and more importantly couple counseling and testing is usually available. It remains as the dominant form of testing in many sub-Saharan countries.  But the global coverage of HCT remains low. In PICT, clients are referred from medical providers such as those associated with tuberculosis, sexually transmitted infections as well as pregnant women for active screening of HIV irrespective of their risk behaviors. The WHO, UNAIDS, and CDC recommend PICT as a cost-effective and ethical way of improving access to HIV testing during general epidemics.  The introduction of routine ''opt-out'' PICT would offer additional point of entry to HIV care and treatment for affected individuals. In our study, 11,654 (50.9%) of ICTC attendees were CICT and from these 1409 (12.1%) were HIV-seropositive. PICT constituted 11,243 (49.1%) clients, but only 323 (2.9%) was positive. The study conducted by Langare et al.,  at Sangli district of Maharashtra revealed 85.8% of clients were PICT and only 14.2% were CICT. This may be attributed to stigma, fear, and ignorance associated with HIV/AIDS among general population. Similar to our study, Langare et al.,  observed HIV-seropositivity was more among CICT (17.1%) when compared with PICT (8.3%). CICT group presents voluntarily themselves to ICTC and is more likely to practice high-risk behavior.
The HIV seroprevalence among ICTC attendees in our study was 7.5% (1732/22,897), higher than the overall adult prevalence among general population for the state of Odisha (0.29%).  In comparison, lower prevalence of 1.44% were observed by Biswas et al., at Rajasthan, India, 4.8% by Sharma et al., at Ahmadabad, India, 5.1% by Kommula et al., at Andhra Pradesh, India, and 5.6% by Akhigbe et al., at Kwara, Nigeria. ,,, The studies conducted by Langare et al., at Maharashtra, India, Gupta et al., at Udupi, Karnataka, India and Mallick et al., at Surat, Gujarat, India showed higher prevalence of 9.5%, 9.6%, and 20.5% respectively. ,, A very high prevalence of 50.2% and 38% were noted by Solomon et al., at Lafia, Nigeria, and Wanyenze et al., at Uganda, respectively. , The difference in HIV seroprevalence in these studies may be attributed to the difference in health-seeking and risk behaviors in different parts within and outside India, which mostly depends on sociocultural milieu of the community.
Our study revealed that males contributed to 67% of the total case load in ICTC with 33% being females. Similar findings were observed by Gupta et al., and Langare et al., where more number of males attended ICTC. , In comparison, Solomon et al.,  found 57.7% were females, while males constituted 42.3%.
According to the present study, 88.3% of HIV-seropositive clients belonged to the age group of 15-49 years, the most sexually active group. Similar results were obtained by Gupta et al., and Langare et al., that is, 88.7% and 86.6%, respectively. , These values are slightly lower than the study (92.4%) conducted at ICTC, Darjeeling, India.  HIV/AIDS threatens the most productive segment of the society in the prime of their working life. This emphasizes the need of youth specific interventions or some high school and college-based sex education, whereby these young adults can be prepared beforehand.
Couple counseling and testing and partner notification is an important tool in prevention and transmission of HIV/AIDS. Once the couple status is known, spouse can decide to access available HIV prevention, counseling, and testing services. This present study showed 347 (51%) were concordant couples and 334 (49%) were discordant couples. Among discordant couples, majority 319 (95.5%) were male partner/husband positive, female partner/wife negative, while only 15 (4.5%) were male partner/husband negative, female partner/wife positive. Langare et al., observed that from total 21 discordant couples, 16 (76.2%) were male partner/husband positive, female partner/wife negative, and 5 (23.8%) were male partner/husband negative, female partner/wife positive.  Early diagnosis of HIV cases is key to prevention of HIV transmission, especially when issues of HIV serodiscordance in relationships are considered. 
Our study revealed majority of seropositives were married, males, less educated, lower socioeconomic status, mostly stayed away from their family or single and outmigrants. Greater access to higher education could facilitate the spread of HIV awareness and increase the use of barrier contraceptives.  In our study, majority of married men were outmigrants to Surat in Gujarat, Mumbai, and Thane in Maharashtra and work in the unorganized sector in the power loom, diamond polishing, and construction industries. Migration into the other cities enhances casual and commercial contacts, because of spousal separation and weaker social control.  Moreover, migration increases the size of sexual networks by linking networks from different locations.  Although migrant men are believed to acquire HIV infection in destination areas and transmit the virus to their sexual partners upon returning to their home towns. , The high volume of returned migrants and their spouses in their hometown reflect the urgent need to provide HIV prevention and treatment services in these areas. 
The pattern of risk behavior showed that majority of heterosexual transmission (58.9%) in males had multiple sex partners and unprotected heterosexual contacts among females (30.4%). This was followed by PTCT (5.8%), nonspecific/unknown (3.1%), infected blood and blood products (0.8%), homosexual (0.5%), and through infected needles and syringes (0.5%). Similar findings to our study were noted by Langare et al.,  and study from Eastern India.  This present study was limited by incomplete documentation as also missing information. The results are based on reporting and data collection by personnel employed in the ICTC; thus bias. The data used are from a tertiary care facility and would not be a true representation of the community. The study however can help local planning and contribute data for policy makers to improve the existing national HIV/AIDS intervention strategies.
The authors gratefully acknowledge the National AIDS Control Organization (NACO) for providing HIV test kits and the guidelines laid down to conduct such tests.The authors also wish to thank all the staff of ICTC, Department of Microbiology for their support and contribution.
[Table 1], [Table 2]