title: A comparison of HIV detection rates using routine opt-out provider-initiated HIV testing and counseling versus a standard of care approach in a rural African setting.
abstract: BACKGROUND
  Routine opt-out provider-initiated HIV testing and counseling (PITC) remains underutilized in sub-Saharan Africa. By selectively targeting clients who either volunteer or have clinical indications of HIV disease, standard approaches to HIV counseling and testing are presumed more cost-efficient than PITC.
  
  
  METHODS
  One thousand two hundred twenty-one patients aged 15– 49 years were seen by 22 practitioners in a mobile clinic in southern Zambia. A random sample of physicians was assigned to administer PITC, whereas the remaining practitioners offered standard non- PITC (ie, voluntary or diagnostic). Questionnaires assessed patient demographics and attitudes toward HIV. HIV detection rates were stratified by referral type, demographics, and HIV-related knowledge and attitudes.
  
  
  RESULTS
  HIV prevalence was 10.6%. Infection rates detected using PITC [11.1%; 95% confidence interval (CI): 8.8% to 13.5%] and standard non-PITC (10.0%; 95% CI: 7.5% to 12.5%) did not significantly differ (odds ratio = 1.01; 95% CI: 0.67 to 1.52; P = 0.95). Patients who did not request testing or demonstrate clinical indicators of HIV did not have significantly higher HIV prevalence than those who did (odds ratio = 0.83; 95% CI: 0.55 to 1.24; P = 0.36). Implementation of PITC was highly acceptable and produced a 3-fold increase in patients tested per practitioner compared with standard non-PITC (114 vs. 34 patients per practitioner, respectively).
  
  
  CONCLUSIONS
  PITC detected a comparable HIV infection rate as a standard non-PITC approach among rural adults seeking primary care services. Widespread implementation of PITC may therefore lead to significantly more cases of HIV detected.
authors.affiliation: Institute for Global Health, Vanderbilt University School of Medicine, Nashville, TN 37232-0242, USA. david.silvestri@vanderbilt.edu
authors.forename: David M
authors.initials: DM
authors.lastname: Silvestri
authors.forename: Kayvon
authors.initials: K
authors.lastname: Modjarrad
authors.forename: Meridith L
authors.initials: ML
authors.lastname: Blevins
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Halale
authors.forename: Sten H
authors.initials: SH
authors.lastname: Vermund
authors.forename: Jeffry P
authors.initials: JP
authors.lastname: McKinzie
mesh_terms: D015492:AIDS Serodiagnosis / Q000379:methods* / Q000523:psychology / Q000706:statistics & numerical data; D000293:Adolescent; D000328:Adult; D001294:Attitude to Health; D016009:Chi-Square Distribution; D016001:Confidence Intervals; D003376:Counseling; D005260:Female; D015658:HIV Infections / Q000175:diagnosis*; D006679:HIV Seropositivity / Q000175:diagnosis / Q000453:epidemiology; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D012424:Rural Population / Q000706:statistics & numerical data; D059039:Standard of Care; D011795:Surveys and Questionnaires; D035141:Voluntary Programs; D055815:Young Adult; D015024:Zambia / Q000453:epidemiology