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Telephone vs. face-to-face notification of HIV results in high-risk youth
JOURNAL OF ADOLESCENT HEALTH 2002;30:154–160
ORIGINAL ARTICLE
Telephone vs. Face-to-Face Notification of HIV Results in High-Risk Youth RACHEL C. TSU, B.A., MICHAEL L. BURM, M.P.H., JENNIFER A. GILHOOLY, P.N.P., AND C. WAYNE SELLS, M.D., M.P.H.
Purpose: To increase the number of high-risk and homeless youth who receive human immunodeficiency virus (HIV) test results and posttest counseling. Methods: Oral HIV testing and counseling were offered to high-risk and homeless youth at sites at which youth congregate throughout Portland, Oregon. Subjects were randomized to receive test results and posttest counseling either in a face-to-face manner or with the option of telephone notification. Self-reported demographic and risk-behavior information was collected prior to HIV testing. The differences in the proportion of youth who received their test results were analyzed according to the notification method and demographic characteristics using SPSS. Results: Among the 351 youth who were tested, 48% followed up to receive test results and posttest counseling. Adolescents most likely to receive their results were female, older (19 –24 years), and white and those who reported high-risk behaviors. Those given the option of telephone notification were significantly more likely to receive their results than those required to have face-toface notification (odds ratio ⴝ 2.301, 95% confidence interval of 1.499, 3.534). This was true regardless of age, race, history of previous HIV testing, or presence of high-risk behaviors. Two youths tested positive for HIV corroborating previous reports of low HIV prevalence in this population. Both were assigned to the face-to-face notification group and, therefore, no HIV positive results were given by telephone.
From the Division of Adolescent Health, Department of Pediatrics and Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland, Oregon. Address correspondence to: Dr. C. Wayne Sells, Director, Division of Adolescent Health, Oregon Health & Science University, 707 Southwest Gaines Road, CDRCP, Portland, Oregon 97201-3098. E-mail: [email protected]. Manuscript accepted August 23, 2001. 1054-139X/02/$–see front matter PII S1054-139X(01)00340-8
Conclusions: The option of telephone notification significantly increased the proportion of youth who received posttest counseling and results following community-based testing. © Society for Adolescent Medicine, 2002 KEY WORDS:
Adolescents HIV Homeless youth Telephone notification
Counseling and testing is a recognized method for delivering harm-reduction messages and accurate information in the prevention of infection by the human immunodeficiency virus (HIV) [1]. Data from national surveys indicate that by the mid-1990s, approximately 40% of the adults in the United States have been tested at least once for HIV, with testing rates at 70% among adults at increased risk for infection [2]. The study also showed that when efforts were made to increase the number of people receiving testing and counseling, a significant number failed to return to receive their results and posttest counseling. For persons at increased risk and below the poverty level, publicly funded clinics are important testing sources [2]. Among such testing sites in Oregon, approximately 40% of persons testing HIV positive and 38% of persons testing HIV negative did not return for their test results and posttest counseling in 1996 [3]. Previous studies have demonstrated that adolescents and young adults are at significant risk for contracting HIV infection [4,5]. Within these age groups, homeless youth and adolescents who partic-
© Society for Adolescent Medicine, 2002 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
March 2002
ipate in the street culture are at increased risk [6 –9]. These findings were corroborated among Oregon’s homeless youth aged 13–20 years in a 3-year longitudinal study conducted by the Oregon Research Institute [10]. The study reported high-risk sexual and substance use behaviors among this population. More than one in three youth reported ever using injection drugs and 9% reported exchanging sex for drugs, money, or shelter. The prevalence of sexually transmitted diseases (STDs) and blood-borne pathogens was considerable: chlamydia (5.4%), herpes simplex virus type II (8.1%), hepatitis B (3.1%), and hepatitis C (4.4%). Despite the persistent potential for HIV infection through unsafe sexual and drug use behaviors and the high prevalence of other STDs and blood-borne pathogens, the prevalence of HIV among homeless youth in Oregon was only 0.3%. It is roughly estimated that there are more than 1500 street youth in the Portland metropolitan area each year [11,12], representing a growing population with significant emotional and physical health needs. Unfortunately, street youth face a number of barriers to accessing conventional health care: cost of services, lack of insurance, transportation, unfamiliarity with, and intimidation of, health care systems, difficulty with making and keeping appointments, the hours of clinic operations, distrust of adults and health care providers, and fear of judgment by health care providers [13–15]. A multidisciplinary group of students, health care providers, and outreach workers sought to develop a community-based, peer-driven outreach HIV counseling and testing program. The project’s goal was to increase the number of youth who receive counseling, testing, results, referral, and treatment. In addition, they sought to test the efficacy of two methods of result notification.
Methods Study Design This project was reviewed and approved by the Institutional Review Boards of the Oregon Health Sciences University, Oregon Health Division, and Centers for Disease Control and Prevention (CDC). The project was a collaborative effort among Outside In Community Clinic, Oregon Health & Science University, National College of Naturopathic Medicine, Portland State University, Oregon Health Division, Multnomah County Health Department, and Epitope Corporation. All outreach testing sites were within the Portland
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metropolitan area. The goal of the testing events was to meet youth in an acceptable social setting without being intrusive. Events were scheduled, coordinated, and advertised to promote youth participation. The focus of this outreach project was to reach high-risk youth who may report barriers to traditional medical settings. Organizations and individuals were identified and approached for participation in this study on the basis of recommendations of youth and health care professionals who work with homeless and high-risk youth. Youth, health professionals, and community representatives participated in the identification of testing sites. Some testing sites were created specifically for this project, and others were incorporated into existing events. Mobile health vans allowed testing at sites that would have been otherwise unfeasible. Testing events were specific to highrisk youth and included: parks, community events, an all-ages dance club, alternative schools, and social service agencies serving street youth. Peer involvement was an essential component to program development, implementation, and operations. Youth identified within the community were employed for most testing events to assist the event coordinators. For each event the project staff searched for youth who were from the participating community and considered to be engaging with their peers. Peer leaders helped identify appropriate testing locations, involved the community, engaged participants, advertised the event, and acculturated the counselors to the population at the event. Pretest and posttest counseling was performed by medical and public health students and participating clinical staff. All counselors completed a comprehensive training provided by the Oregon Health Division, which is consistent with the CDC’s standards for HIV pretest and posttest counseling. Testing packets contained a consent form, a serology form with a unique identification number, OraSure HIV testing device and information sheet, a business card with important contact numbers, and a counselor check-off form. Testing kits were compiled and randomized prior to testing events using a randomization guide created by flipping a coin. Youth who had a testing packet with an odd serology number were assigned to the face-to-face notification group and were required to receive their results at the Outside In Community Clinic. Youth with an even serology number were assigned to the telephone notification group and had the option of face-to-face or telephone notification for HIV test results. The counselor check-off form was developed to assure consistency between counselors in pretest
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and posttest counseling and included points that needed to be covered with each counseling session.
Sampling Youth aged 13 to 24 years, who requested HIV counseling and testing, and were able to provide informed consent were eligible for the study. Both verbal and written consent was obtained from all youth prior to participation in this study. All outreach testing was done confidentially, with clientcentered, individualized counseling. Oral HIV testing, using the OraSure collection kit, provided a safe, accurate and noninvasive method that was well accepted by the youth. The OraSure oral testing device has been previously shown to be 99% sensitive and 99% specific for the detection of HIV 1 [16].
Testing A trained counselor performed confidential HIV counseling and testing with one youth at a time in a private area. Youth were advised of the nature of the study and risks involved in participating in the study and were then asked to read and sign a consent form. Next, there was a 5- to 10-min discussion of ways to reduce their risk of HIV infection. Testing followed this discussion. Upon conclusion of the testing, each study participant was given a business card with Outside In’s clinic times and phone number, the client’s unique identifying number from the serology form, and a list of community resources. Clients were told that their test results would be available 2 weeks from the testing date and were informed as to the methods of notification available to them. When seeking their results, youth were asked for their initials, date of birth, and unique number, regardless of notification method. Indeterminant or positive OraSure test results were to be confirmed by a serum HIV test. Confidential testing allowed for youth with positive or indeterminate HIV results to be contacted for follow-up if they did not receive their results within 6 weeks of the test date. Youth who failed to return for results were referred to an established county health department program experienced in contacting HIV positive persons in an effort to assure that they receive appropriate services.
Variables Information concerning demographics, risk behaviors, and HIV testing history were collected in an
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interview using a standardized Oregon Health Division serology form. Behaviors considered to be high risk included: injection drug use; sharing needles; trading sex for money, food, drugs, shelter, or protection; a sexual partner known to be HIV positive; men who have sex with men; and reporting high-risk sexual partners. Youth were asked to rate their perceived risk for contracting HIV, quantify their number of sexual partners in the previous 12 months, and provide information about their use of barrier protection during sexual activity and use of drugs and alcohol with sexual activity.
Data Analysis All analyses were performed using SPSS [17]. Oneway analysis of variance was used to analyze the time difference from testing to receiving results among the notification groups. Demographic information and behavioral characteristic frequencies were calculated. Standard Chi-square tests and associated p values were computed to describe youth characteristics by gender. Because of small cell sizes, variables were dichotomized for age (13–18 or 19 –24 years), race/ethnicity (white/non-white), residence (Multnomah County/other), drug use with sexual activity (“never”/“sometimes,” or “always”), selfidentified risk for HIV (“none,” “unsure,” or “low”/ “high”), number of sex partners in prior 12 months (“less than or equal to five”/“more than five”), and the presence of high-risk behavior (present/absent as defined above). Notification groups (face-to-face/ telephone option) were compared by Chi-square tests for differences in characteristics. To analyze the proportion of youth receiving posttest counseling and HIV results by notification group, odds ratios and 95% confidence intervals were calculated. Adjusted odds ratios and 95% confidence intervals were also calculated. Youth characteristics were adjusted for race/ethnicity, gender, and age.
Results Demographics Between September 1998 and October 1999, a total of 351 HIV tests were performed as a part of this study. The majority of youth identified themselves as white (71%), followed by African-American (9%), Native American (7%), Hispanic (5%), and Asian (1%). Six percent of youth identified their race/ethnicity as “other” and 1% did not report any race/ethnicity. There were similar proportions of females (49%) and
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males (51%) who participated. Among persons identifying with a race/ethnicity other than white, there was a significantly higher proportion of males than females (63% vs. 37%, p ⬍ .01). The majority of the youth resided in Multnomah County (75%), which includes the city of Portland. The youth ranged in age from 13 to 24 years with the following breakdown: 10% aged 13–15 years, 38% 16 –18 years, 33% aged 19 –21 years, and 19% aged 22–24 years. The median age of the youth was 19 years, SD ⫾ 2.67 years. There were no significant differences in demographic characteristics between those individuals assigned to the face-to-face or telephone notification groups with the exception of gender. There were significantly more females than males in the telephone option notification group (p ⬍ .01).
HIV Risk Behavior Nearly 52% of youth reported at least one of the following high-risk behaviors: men who have sex with men (MSM); injection drug use (IDU); sharing needles; trading sex for money, food, drugs, or shelter; a sexual partner who is HIV positive; or a sexual partner who is at high risk. Overall, males were significantly more likely to report high-risk behaviors than females (p ⬍ .01). However, when MSM was excluded, there was no significant difference between males and females in reporting highrisk behaviors. Fifty percent of youth reported that this was the first time they had received HIV counseling and testing. Youth for whom this was their first HIV test were significantly more likely to report no high-risk behaviors than youth who had tested previously for HIV (p ⬍ .01). There were no significant differences in the frequency of high-risk behaviors in terms of age group (13–18 vs. 19 –24 years old) or race (white vs. non-white) of the participants. There were no significant differences in risk-behavior characteristics between the face-to-face and telephone notification groups. Approximately 11% of youth identified themselves as high risk for acquiring an HIV infection. Self-identified risk for HIV did not necessarily correspond to reported high-risk behaviors. A substantial proportion of youth who reported high-risk behaviors, self-identified themselves as having “no risk,” “unsure of risk,” or “low risk”: 85% of MSM; 54% of IDU; 67% of youth reporting survival sex; 77% of youth with an HIV-positive sexual partner; 14% of youth who share needles; and 75% of youth who reported high-risk sexual partners.
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HIV Result Notification Overall, 48% of the youth followed up to receive their test results and posttest counseling (Table 1). Thirty-seven percent of the youth in the face-to-face notification group, compared with 58% of youth in the telephone option group, followed up to receive their HIV test results (p ⬍ .001). Of the youth in the telephone option group who received their results, the majority did so via the telephone (88%). The length of time between the day of testing and receiving results ranged from 5 to 79 days, with a median of 17 days. The mean length of time between testing and receiving results varied significantly (p ⬍ .01) between the face-to-face notification group (24.11 days) and the telephone option notification group (18.63 days). Youth were told that results would be available 2 weeks after testing; however, results did become available earlier than 2 weeks in some cases. Only two youths (0.6%) tested positive, both of whom had been assigned to the face-to-face notification group. Neither youth followed up on his or her own to receive their results and required referral to the county health department program. Both males and females were more likely to receive results given the option of telephone notification; however, the difference was not statistically significant among females (Table 1). Participants between the ages of 19 and 24 years were more likely to obtain their HIV test results than youth 13 to 18 years (p ⬍ .01). The proportion of youth who received their results increased significantly in both age groups with the option of telephone notification. Youth who identified themselves as white were more likely to follow up for results than youth identifying themselves as non-white (p ⬍ .01), and the telephone option significantly increased result notification in both groups. The site of the outreach testing event in reference to the downtown area did not make a difference in the proportion of youth who received their test results. However, within the downtown testing group, youth who were given the option of telephone notification were significantly more likely to receive their results. There was no significant difference between youth who had tested previously for HIV and youth who were testing for the first time. However, the option of telephone notification significantly increased the proportion of youth who received their results regardless of testing history. There was no significant difference in receiving test results between youth who reported the use of any drug, compared with no drug, use in conjunction with sexual activity; how-
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Table 1. Analysis of the Proportion of Youth Who Received HIV Test Results a
Characteristic
Overall Gender Male Female Age (yrs) 13–18 19 –24 Race/ethnicity Non-white White Site of outreach event Downtown Not downtown Previous HIV test No Yes Use of drugs during sex Never Sometimes, always Alcohol and/or marijuana Cocaine, heroin, ecstasy Self-identified HIV risk None, unsure, low High Reported high-risk behavior Absent Present MSM No Yes IDU No Yes Partner at risk No Yes
Required Face-to-Face Notification (n ⫽ 168)
Telephone Option (n ⫽ 184)
Adjusted OR (95% CI)
n
(%)
n
(%)
62/167
37.1
106/184
57.6
2.264 (1.445, 3.547)
27/98 35/69
27.6 50.7
45/82 61/102
54.9 59.8
3.125 (1.656, 5.900) 1.763 (0.917, 3.388)
21/76 41/91
27.6 45.1
47/92 59/92
51.1 64.1
2.733 (1.386, 5.392) 2.124 (1.148, 3.932)
11/51 51/115
21.6 44.3
24/49 81/133
49.0 60.9
3.393 (1.373, 8.387) 1.962 (1.167, 3.299)
43/119 19/48
36.1 39.6
72/125 34/58
57.6 58.6
2.383 (1.401, 4.053) 2.043 (0.848, 4.921)
32/88 30/79
36.4 38.0
48/87 58/97
55.2 59.8
2.300 (1.195, 4.428) 2.374 (1.253, 4.498)
29/68 31/90 23/59 7/26
42.6 34.4 39.0 26.9
34/63 66/110 50/74 16/34
54.0 60.0 67.6 47.1
1.680 (0.804, 3.509) 2.549 (1.400, 4.634) 2.887 (1.367, 6.098) 2.367 (0.742, 7.553)
56/152 5/14
36.8 35.7
90/154 12/23
58.4 52.2
2.283 (1.414, 3.687) 2.451 (0.553, 10.870)
25/81 36/85
30.9 42.4
45/87 59/95
51.7 62.1
3.008 (1.464, 6.180) 2.244 (1.194, 4.217)
9/53 18/45
17.0 40.0
24/52 21/30
46.2 70.0
3.943 (1.569, 9.909) 3.393 (1.254, 9.181)
54/152 7/14
35.5 50.0
93/163 13/21
57.1 61.9
2.387 (1.483, 3.844) 1.691 (0.346, 8.267)
42/114 20/53
36.8 37.7
59/111 45/71
53.2 63.4
1.945 (1.108, 3.316) 2.761 (1.274, 5.983)
a
Adjusted for gender, age, race/ethnicity. The categories of gender, age, race/ethnicity were adjusted only for the other two variables. MSM adjusted for only age, race/ethnicity. IDU ⫽ injection drug use; HIV ⫽ human immunodeficiency virus; MSM ⫽ men who have sex with men.
ever, youth who said that they used alcohol and/or marijuana were more likely to receive their test result than youth reporting use of “harder” drugs with sexual activity (p ⬍ .05). Youth who identified their risk for HIV as “high” were not significantly more likely to receive their test results. However, youth who reported participating in high-risk behaviors were more likely to receive results than youth with no high-risk behaviors (p ⬍ .05). Men reporting having had sex with men were significantly more likely to receive their results than men who did not report sex with men (p ⬍ .01), and the option of telephone notification increased the proportion of youth receiving their results for both groups. Telephone notifica-
tion did not significantly increase the proportion of intravenous drug users who received their results. There were no significant differences in the proportion of youth who received their results regardless of their sexual partners perceived risk for HIV, but the option of telephone notification did increase the proportion of youth who received their results in both subgroups. Odds ratios did not change significantly when adjusted for gender, age, and race/ethnicity.
Discussion This project was successful in establishing a collaborative, community-based, peer-driven HIV counsel-
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ing and testing project for high-risk and homeless youth. Relationships were developed and strengthened with other agencies, organizations, and individuals to reach youth, acquire resources, and plan outreach testing events. This project provided the opportunity to acknowledge and appreciate different strengths present in our community. By developing relationships with a variety of agencies, it was possible to better understand the current issues affecting street youth. Through collaboration, scarce resources could be maximized in the effort to expand outreach HIV testing and counseling among disenfranchised youth in the Portland metropolitan area. Youth in this study reported many high-risk sexual and substance using behaviors. Despite these risk behaviors, the prevalence of HIV remains low in this population, at less than 1%, which is consistent with previous studies among homeless adolescents in Oregon [10]. The use of less invasive technologies for HIV testing was well-received by the youth and facilitated community-based outreach testing. The project was also successful at reaching youth who had not previously sought testing, with half of the youth reporting first-time HIV counseling and testing. Failure of youth to follow up to receive their HIV results and posttest counseling remains a challenge for prevention programs. Previous studies have reported individuals least likely to return for results include females, younger youth, race other than white, and those testing negative for HIV [18 –20]. Our findings showed that younger adolescents, nonwhites, and those with lower risk behavior were less likely to receive their results. Unlike the previous studies, females overall were significantly more likely to receive their results than males in this study. Adding a telephone notification option increased the proportion of youth who received their results. A previous study evaluating the option of telephone notification for low-risk clients at a Denver STD clinic found that telephone posttest counseling was an effective way to increase follow-up for HIV test results [21]. This is consistent with the findings in the current study. Youth who were given the option of telephone notification were significantly more likely to receive their results than those required to receive face-to-face notification. This was true regardless of age, race, history of previous HIV testing, or presence of high-risk behaviors. Among participating males, those who had the option of telephone notification of test results were significantly more likely to receive their results, compared with males who were required to have face-to-face notification. Par-
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ticipating females who had the option of telephone notification were also more likely to receive their results than females who were required to have a face-to-face interaction; however, the difference was not statistically significant. There are several limitations to this study. We were not able to specifically look at telephone notification with HIV-positive youth because only two youth tested positive and both were assigned to the face-to-face notification group. Previous studies have suggested that individuals may receive HIV testing and counseling by telephone without adverse outcome [22]. Although the population involved in that study was demographically different from the present study (did not comment on homeless status and included only individuals over 18 years of age), the study did involve individuals from the Portland area and a substantial number of participants who were HIV positive. Allowing telephone notification clearly increased the number of youth who received their results as well as posttest counseling. Whether increasing the number of youth who received posttest counseling results in a reduction in high-risk behaviors was not evaluated in this study. Although there were similar proportions of males and females involved in the study, there was a higher proportion of females in the telephone option group. This may represent a possible failure in the randomization process; however, one would expect that the higher proportion of females would tend to decrease any differences between the face-to-face and the telephone option groups on the basis of our results. It was also somewhat surprising that there were no significant differences in risk behaviors noted between the age groups, 13–18 years and 19 –24 years. This may be owing to the fact that the small sample size did not allow for detection of differences between groups, or the grouping of ages together may have muted the differences. Another limitation was that this study used a convenience sample from sites in the Portland area and therefore may not be generalizable to other areas or other homeless or high-risk youth. In this study, HIV counseling and testing was brought to the youth instead of requiring them to seek it out in an effort to reach youth who were not accessing services. As a result, the youths’ motivation to receive test results may be different from those not performed in outreach settings and thus may not be generalizable. Although efforts were made to ensure consistency at the different testing events, there may have been differences, which may have affected follow-up rates among participating youth. Randomization at each
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site and the use of the counselor check-off form were used to reduce differences across events.
Conclusion This outreach effort was successful in providing high-risk and homeless youth access to HIV testing and counseling. The option of telephone notification in a low-prevalence HIV homeless and high-risk population of young people appears to be an effective way to increase the proportion who receive posttest counseling and test results. This outreach project was funded by generous grants from the Northwest Health Foundation, Cooperative Actions for Health Program, and Centers for Disease Control and Prevention. The Epitope Corporation donated the OraSure oral HIV testing devices for this study. We thank collaborating agencies: Outside In, Oregon Health Division, Multnomah County Health Department, National College of Naturopathic Medicine, Epitope Inc., Cascade AIDS Project, New Avenues for Youth, Open Meadow/C.R.U.E., Portland Parks and Recreation, Portland Youth Builder, Sexual Minority Youth Recreation Center, Willamette Bridge Yellowbrick Road, Adventist Healthvan, Northwest Medical Teams, and Misfits for their assistance with this project.
References 1. HIV Counseling, Testing, and Referral Standards and Guidelines. Atlanta, GA: Centers for Disease Control and Prevention, 1994:1–15. 2. Anderson JE, Carey JW, Taveras S. HIV testing among the general US population and persons at increased risk: Information from nation surveys, 1987–1996. Am J Public Health 2000;90:1089 –95. 3. HIV counseling and testing in publicly funded sites: 1996 Annual Report. Atlanta, GA: Centers for Disease Control and Prevention, 1997:21. 4. Raj R, Verghese A. Human immunodeficiency virus infections in adolescents. Adolesc Med 2000;11:359 –74. 5. Anderson M, Morris R. HIV and adolescents. Pediatr Ann 1993:22:436 – 46. 6. Ennett ST, Federman EB, Bailey SL, et al. HIV-risk behaviors associated with homelessness characteristics in youth. J Adolesc Health 1999;25:344 –53.
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7. Gleghorn A, Marx R, Vittinghoff E, et al. Association between drug use patterns and HIV risks among homeless, runaway, and street youth in Northern California. Drug Alcohol Depend 1998;51:219 –27. 8. Kipke M, O’Connor S, Palmer R, et al. Street youth in Los Angeles. Profile of a group at high risk for human immunodeficiency virus infection. Arch Pediatr Adolesc Med 1995;149: 513–9. 9. Goodman E, Berecochea JE. Predictors of HIV testing among runaway and homeless adolescents. J Adolesc Health 1994;15: 566 –72. 10. Noell J, Rhode P, Ochs L, et al. Incidence and prevalence of chlamydia, herpes, and viral hepatitis in a homeless adolescent population. Sex Transm Dis 2001;28:4 –10. 11. Evaluation of the downtown Portland homeless youth services continuum. Pacific Research and Evaluation. December 2000. 12. Services to homeless youth in Portland. Report of the Joint Homeless Youth Assessment Committee of the Citizens Crime Commission and the Association for Portland Progress. March 7, 1998. 13. Geber G. Barriers to health care for street youth. J Adolesc Health 1997;21:287–90. 14. Ensign J, Gittelsohn J. Health and access to care: Perspectives of homeless youth in Baltimore City, USA. Soc Sci Med 1998;47:2087–99. 15. Council on Scientific Affairs. Health care needs of homeless and runaway youths. JAMA 1989;262:358 – 61. 16. Gallo D, George JR, Fitchen JH, et al. Evaluation of a system using oral mucosal transudate for HIV-1 antibody screening and confirmatory testing. JAMA 1997;277:254 – 8. 17. SPSS 10.0 for Windows. Chicago, IL: SPSS Inc., 1999. 18. Slutsker L, Klockner R, Fleming D. Factors associated with failure to return for HIV post-test counseling. AIDS 1992;6: 1226 –7. 19. Valdiserri R, Moore M, Gerber A, et al. A study of clients returning for counseling after HIV testing: Implications for improving rates of return. Public Health Rep 1993;108:12– 8. 20. Wiley D, Frerichs R, Ford W, et al. Failure to learn human immunodeficiency virus test results in Los Angeles public sexually transmitted disease clinics. Sex Transm Dis 1998;25: 342–5. 21. Schluter WW, Judson FN, Baron AE, et al. Usefulness of human immunodeficiency virus post-test counseling by telephone for low-risk clients of an urban sexually transmitted diseases clinic. Sex Transm Dis 1996;23:190 –7. 22. Frank AP, Wandell MG, Headings MD, et al. Anonymous HIV testing using home collection and telemedicine counseling. Arch Intern Med 1997;157:309 –14.
ORIGINAL ARTICLE
Telephone vs. Face-to-Face Notification of HIV Results in High-Risk Youth RACHEL C. TSU, B.A., MICHAEL L. BURM, M.P.H., JENNIFER A. GILHOOLY, P.N.P., AND C. WAYNE SELLS, M.D., M.P.H.
Purpose: To increase the number of high-risk and homeless youth who receive human immunodeficiency virus (HIV) test results and posttest counseling. Methods: Oral HIV testing and counseling were offered to high-risk and homeless youth at sites at which youth congregate throughout Portland, Oregon. Subjects were randomized to receive test results and posttest counseling either in a face-to-face manner or with the option of telephone notification. Self-reported demographic and risk-behavior information was collected prior to HIV testing. The differences in the proportion of youth who received their test results were analyzed according to the notification method and demographic characteristics using SPSS. Results: Among the 351 youth who were tested, 48% followed up to receive test results and posttest counseling. Adolescents most likely to receive their results were female, older (19 –24 years), and white and those who reported high-risk behaviors. Those given the option of telephone notification were significantly more likely to receive their results than those required to have face-toface notification (odds ratio ⴝ 2.301, 95% confidence interval of 1.499, 3.534). This was true regardless of age, race, history of previous HIV testing, or presence of high-risk behaviors. Two youths tested positive for HIV corroborating previous reports of low HIV prevalence in this population. Both were assigned to the face-to-face notification group and, therefore, no HIV positive results were given by telephone.
From the Division of Adolescent Health, Department of Pediatrics and Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland, Oregon. Address correspondence to: Dr. C. Wayne Sells, Director, Division of Adolescent Health, Oregon Health & Science University, 707 Southwest Gaines Road, CDRCP, Portland, Oregon 97201-3098. E-mail: [email protected]. Manuscript accepted August 23, 2001. 1054-139X/02/$–see front matter PII S1054-139X(01)00340-8
Conclusions: The option of telephone notification significantly increased the proportion of youth who received posttest counseling and results following community-based testing. © Society for Adolescent Medicine, 2002 KEY WORDS:
Adolescents HIV Homeless youth Telephone notification
Counseling and testing is a recognized method for delivering harm-reduction messages and accurate information in the prevention of infection by the human immunodeficiency virus (HIV) [1]. Data from national surveys indicate that by the mid-1990s, approximately 40% of the adults in the United States have been tested at least once for HIV, with testing rates at 70% among adults at increased risk for infection [2]. The study also showed that when efforts were made to increase the number of people receiving testing and counseling, a significant number failed to return to receive their results and posttest counseling. For persons at increased risk and below the poverty level, publicly funded clinics are important testing sources [2]. Among such testing sites in Oregon, approximately 40% of persons testing HIV positive and 38% of persons testing HIV negative did not return for their test results and posttest counseling in 1996 [3]. Previous studies have demonstrated that adolescents and young adults are at significant risk for contracting HIV infection [4,5]. Within these age groups, homeless youth and adolescents who partic-
© Society for Adolescent Medicine, 2002 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
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ipate in the street culture are at increased risk [6 –9]. These findings were corroborated among Oregon’s homeless youth aged 13–20 years in a 3-year longitudinal study conducted by the Oregon Research Institute [10]. The study reported high-risk sexual and substance use behaviors among this population. More than one in three youth reported ever using injection drugs and 9% reported exchanging sex for drugs, money, or shelter. The prevalence of sexually transmitted diseases (STDs) and blood-borne pathogens was considerable: chlamydia (5.4%), herpes simplex virus type II (8.1%), hepatitis B (3.1%), and hepatitis C (4.4%). Despite the persistent potential for HIV infection through unsafe sexual and drug use behaviors and the high prevalence of other STDs and blood-borne pathogens, the prevalence of HIV among homeless youth in Oregon was only 0.3%. It is roughly estimated that there are more than 1500 street youth in the Portland metropolitan area each year [11,12], representing a growing population with significant emotional and physical health needs. Unfortunately, street youth face a number of barriers to accessing conventional health care: cost of services, lack of insurance, transportation, unfamiliarity with, and intimidation of, health care systems, difficulty with making and keeping appointments, the hours of clinic operations, distrust of adults and health care providers, and fear of judgment by health care providers [13–15]. A multidisciplinary group of students, health care providers, and outreach workers sought to develop a community-based, peer-driven outreach HIV counseling and testing program. The project’s goal was to increase the number of youth who receive counseling, testing, results, referral, and treatment. In addition, they sought to test the efficacy of two methods of result notification.
Methods Study Design This project was reviewed and approved by the Institutional Review Boards of the Oregon Health Sciences University, Oregon Health Division, and Centers for Disease Control and Prevention (CDC). The project was a collaborative effort among Outside In Community Clinic, Oregon Health & Science University, National College of Naturopathic Medicine, Portland State University, Oregon Health Division, Multnomah County Health Department, and Epitope Corporation. All outreach testing sites were within the Portland
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metropolitan area. The goal of the testing events was to meet youth in an acceptable social setting without being intrusive. Events were scheduled, coordinated, and advertised to promote youth participation. The focus of this outreach project was to reach high-risk youth who may report barriers to traditional medical settings. Organizations and individuals were identified and approached for participation in this study on the basis of recommendations of youth and health care professionals who work with homeless and high-risk youth. Youth, health professionals, and community representatives participated in the identification of testing sites. Some testing sites were created specifically for this project, and others were incorporated into existing events. Mobile health vans allowed testing at sites that would have been otherwise unfeasible. Testing events were specific to highrisk youth and included: parks, community events, an all-ages dance club, alternative schools, and social service agencies serving street youth. Peer involvement was an essential component to program development, implementation, and operations. Youth identified within the community were employed for most testing events to assist the event coordinators. For each event the project staff searched for youth who were from the participating community and considered to be engaging with their peers. Peer leaders helped identify appropriate testing locations, involved the community, engaged participants, advertised the event, and acculturated the counselors to the population at the event. Pretest and posttest counseling was performed by medical and public health students and participating clinical staff. All counselors completed a comprehensive training provided by the Oregon Health Division, which is consistent with the CDC’s standards for HIV pretest and posttest counseling. Testing packets contained a consent form, a serology form with a unique identification number, OraSure HIV testing device and information sheet, a business card with important contact numbers, and a counselor check-off form. Testing kits were compiled and randomized prior to testing events using a randomization guide created by flipping a coin. Youth who had a testing packet with an odd serology number were assigned to the face-to-face notification group and were required to receive their results at the Outside In Community Clinic. Youth with an even serology number were assigned to the telephone notification group and had the option of face-to-face or telephone notification for HIV test results. The counselor check-off form was developed to assure consistency between counselors in pretest
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and posttest counseling and included points that needed to be covered with each counseling session.
Sampling Youth aged 13 to 24 years, who requested HIV counseling and testing, and were able to provide informed consent were eligible for the study. Both verbal and written consent was obtained from all youth prior to participation in this study. All outreach testing was done confidentially, with clientcentered, individualized counseling. Oral HIV testing, using the OraSure collection kit, provided a safe, accurate and noninvasive method that was well accepted by the youth. The OraSure oral testing device has been previously shown to be 99% sensitive and 99% specific for the detection of HIV 1 [16].
Testing A trained counselor performed confidential HIV counseling and testing with one youth at a time in a private area. Youth were advised of the nature of the study and risks involved in participating in the study and were then asked to read and sign a consent form. Next, there was a 5- to 10-min discussion of ways to reduce their risk of HIV infection. Testing followed this discussion. Upon conclusion of the testing, each study participant was given a business card with Outside In’s clinic times and phone number, the client’s unique identifying number from the serology form, and a list of community resources. Clients were told that their test results would be available 2 weeks from the testing date and were informed as to the methods of notification available to them. When seeking their results, youth were asked for their initials, date of birth, and unique number, regardless of notification method. Indeterminant or positive OraSure test results were to be confirmed by a serum HIV test. Confidential testing allowed for youth with positive or indeterminate HIV results to be contacted for follow-up if they did not receive their results within 6 weeks of the test date. Youth who failed to return for results were referred to an established county health department program experienced in contacting HIV positive persons in an effort to assure that they receive appropriate services.
Variables Information concerning demographics, risk behaviors, and HIV testing history were collected in an
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interview using a standardized Oregon Health Division serology form. Behaviors considered to be high risk included: injection drug use; sharing needles; trading sex for money, food, drugs, shelter, or protection; a sexual partner known to be HIV positive; men who have sex with men; and reporting high-risk sexual partners. Youth were asked to rate their perceived risk for contracting HIV, quantify their number of sexual partners in the previous 12 months, and provide information about their use of barrier protection during sexual activity and use of drugs and alcohol with sexual activity.
Data Analysis All analyses were performed using SPSS [17]. Oneway analysis of variance was used to analyze the time difference from testing to receiving results among the notification groups. Demographic information and behavioral characteristic frequencies were calculated. Standard Chi-square tests and associated p values were computed to describe youth characteristics by gender. Because of small cell sizes, variables were dichotomized for age (13–18 or 19 –24 years), race/ethnicity (white/non-white), residence (Multnomah County/other), drug use with sexual activity (“never”/“sometimes,” or “always”), selfidentified risk for HIV (“none,” “unsure,” or “low”/ “high”), number of sex partners in prior 12 months (“less than or equal to five”/“more than five”), and the presence of high-risk behavior (present/absent as defined above). Notification groups (face-to-face/ telephone option) were compared by Chi-square tests for differences in characteristics. To analyze the proportion of youth receiving posttest counseling and HIV results by notification group, odds ratios and 95% confidence intervals were calculated. Adjusted odds ratios and 95% confidence intervals were also calculated. Youth characteristics were adjusted for race/ethnicity, gender, and age.
Results Demographics Between September 1998 and October 1999, a total of 351 HIV tests were performed as a part of this study. The majority of youth identified themselves as white (71%), followed by African-American (9%), Native American (7%), Hispanic (5%), and Asian (1%). Six percent of youth identified their race/ethnicity as “other” and 1% did not report any race/ethnicity. There were similar proportions of females (49%) and
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males (51%) who participated. Among persons identifying with a race/ethnicity other than white, there was a significantly higher proportion of males than females (63% vs. 37%, p ⬍ .01). The majority of the youth resided in Multnomah County (75%), which includes the city of Portland. The youth ranged in age from 13 to 24 years with the following breakdown: 10% aged 13–15 years, 38% 16 –18 years, 33% aged 19 –21 years, and 19% aged 22–24 years. The median age of the youth was 19 years, SD ⫾ 2.67 years. There were no significant differences in demographic characteristics between those individuals assigned to the face-to-face or telephone notification groups with the exception of gender. There were significantly more females than males in the telephone option notification group (p ⬍ .01).
HIV Risk Behavior Nearly 52% of youth reported at least one of the following high-risk behaviors: men who have sex with men (MSM); injection drug use (IDU); sharing needles; trading sex for money, food, drugs, or shelter; a sexual partner who is HIV positive; or a sexual partner who is at high risk. Overall, males were significantly more likely to report high-risk behaviors than females (p ⬍ .01). However, when MSM was excluded, there was no significant difference between males and females in reporting highrisk behaviors. Fifty percent of youth reported that this was the first time they had received HIV counseling and testing. Youth for whom this was their first HIV test were significantly more likely to report no high-risk behaviors than youth who had tested previously for HIV (p ⬍ .01). There were no significant differences in the frequency of high-risk behaviors in terms of age group (13–18 vs. 19 –24 years old) or race (white vs. non-white) of the participants. There were no significant differences in risk-behavior characteristics between the face-to-face and telephone notification groups. Approximately 11% of youth identified themselves as high risk for acquiring an HIV infection. Self-identified risk for HIV did not necessarily correspond to reported high-risk behaviors. A substantial proportion of youth who reported high-risk behaviors, self-identified themselves as having “no risk,” “unsure of risk,” or “low risk”: 85% of MSM; 54% of IDU; 67% of youth reporting survival sex; 77% of youth with an HIV-positive sexual partner; 14% of youth who share needles; and 75% of youth who reported high-risk sexual partners.
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HIV Result Notification Overall, 48% of the youth followed up to receive their test results and posttest counseling (Table 1). Thirty-seven percent of the youth in the face-to-face notification group, compared with 58% of youth in the telephone option group, followed up to receive their HIV test results (p ⬍ .001). Of the youth in the telephone option group who received their results, the majority did so via the telephone (88%). The length of time between the day of testing and receiving results ranged from 5 to 79 days, with a median of 17 days. The mean length of time between testing and receiving results varied significantly (p ⬍ .01) between the face-to-face notification group (24.11 days) and the telephone option notification group (18.63 days). Youth were told that results would be available 2 weeks after testing; however, results did become available earlier than 2 weeks in some cases. Only two youths (0.6%) tested positive, both of whom had been assigned to the face-to-face notification group. Neither youth followed up on his or her own to receive their results and required referral to the county health department program. Both males and females were more likely to receive results given the option of telephone notification; however, the difference was not statistically significant among females (Table 1). Participants between the ages of 19 and 24 years were more likely to obtain their HIV test results than youth 13 to 18 years (p ⬍ .01). The proportion of youth who received their results increased significantly in both age groups with the option of telephone notification. Youth who identified themselves as white were more likely to follow up for results than youth identifying themselves as non-white (p ⬍ .01), and the telephone option significantly increased result notification in both groups. The site of the outreach testing event in reference to the downtown area did not make a difference in the proportion of youth who received their test results. However, within the downtown testing group, youth who were given the option of telephone notification were significantly more likely to receive their results. There was no significant difference between youth who had tested previously for HIV and youth who were testing for the first time. However, the option of telephone notification significantly increased the proportion of youth who received their results regardless of testing history. There was no significant difference in receiving test results between youth who reported the use of any drug, compared with no drug, use in conjunction with sexual activity; how-
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Table 1. Analysis of the Proportion of Youth Who Received HIV Test Results a
Characteristic
Overall Gender Male Female Age (yrs) 13–18 19 –24 Race/ethnicity Non-white White Site of outreach event Downtown Not downtown Previous HIV test No Yes Use of drugs during sex Never Sometimes, always Alcohol and/or marijuana Cocaine, heroin, ecstasy Self-identified HIV risk None, unsure, low High Reported high-risk behavior Absent Present MSM No Yes IDU No Yes Partner at risk No Yes
Required Face-to-Face Notification (n ⫽ 168)
Telephone Option (n ⫽ 184)
Adjusted OR (95% CI)
n
(%)
n
(%)
62/167
37.1
106/184
57.6
2.264 (1.445, 3.547)
27/98 35/69
27.6 50.7
45/82 61/102
54.9 59.8
3.125 (1.656, 5.900) 1.763 (0.917, 3.388)
21/76 41/91
27.6 45.1
47/92 59/92
51.1 64.1
2.733 (1.386, 5.392) 2.124 (1.148, 3.932)
11/51 51/115
21.6 44.3
24/49 81/133
49.0 60.9
3.393 (1.373, 8.387) 1.962 (1.167, 3.299)
43/119 19/48
36.1 39.6
72/125 34/58
57.6 58.6
2.383 (1.401, 4.053) 2.043 (0.848, 4.921)
32/88 30/79
36.4 38.0
48/87 58/97
55.2 59.8
2.300 (1.195, 4.428) 2.374 (1.253, 4.498)
29/68 31/90 23/59 7/26
42.6 34.4 39.0 26.9
34/63 66/110 50/74 16/34
54.0 60.0 67.6 47.1
1.680 (0.804, 3.509) 2.549 (1.400, 4.634) 2.887 (1.367, 6.098) 2.367 (0.742, 7.553)
56/152 5/14
36.8 35.7
90/154 12/23
58.4 52.2
2.283 (1.414, 3.687) 2.451 (0.553, 10.870)
25/81 36/85
30.9 42.4
45/87 59/95
51.7 62.1
3.008 (1.464, 6.180) 2.244 (1.194, 4.217)
9/53 18/45
17.0 40.0
24/52 21/30
46.2 70.0
3.943 (1.569, 9.909) 3.393 (1.254, 9.181)
54/152 7/14
35.5 50.0
93/163 13/21
57.1 61.9
2.387 (1.483, 3.844) 1.691 (0.346, 8.267)
42/114 20/53
36.8 37.7
59/111 45/71
53.2 63.4
1.945 (1.108, 3.316) 2.761 (1.274, 5.983)
a
Adjusted for gender, age, race/ethnicity. The categories of gender, age, race/ethnicity were adjusted only for the other two variables. MSM adjusted for only age, race/ethnicity. IDU ⫽ injection drug use; HIV ⫽ human immunodeficiency virus; MSM ⫽ men who have sex with men.
ever, youth who said that they used alcohol and/or marijuana were more likely to receive their test result than youth reporting use of “harder” drugs with sexual activity (p ⬍ .05). Youth who identified their risk for HIV as “high” were not significantly more likely to receive their test results. However, youth who reported participating in high-risk behaviors were more likely to receive results than youth with no high-risk behaviors (p ⬍ .05). Men reporting having had sex with men were significantly more likely to receive their results than men who did not report sex with men (p ⬍ .01), and the option of telephone notification increased the proportion of youth receiving their results for both groups. Telephone notifica-
tion did not significantly increase the proportion of intravenous drug users who received their results. There were no significant differences in the proportion of youth who received their results regardless of their sexual partners perceived risk for HIV, but the option of telephone notification did increase the proportion of youth who received their results in both subgroups. Odds ratios did not change significantly when adjusted for gender, age, and race/ethnicity.
Discussion This project was successful in establishing a collaborative, community-based, peer-driven HIV counsel-
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ing and testing project for high-risk and homeless youth. Relationships were developed and strengthened with other agencies, organizations, and individuals to reach youth, acquire resources, and plan outreach testing events. This project provided the opportunity to acknowledge and appreciate different strengths present in our community. By developing relationships with a variety of agencies, it was possible to better understand the current issues affecting street youth. Through collaboration, scarce resources could be maximized in the effort to expand outreach HIV testing and counseling among disenfranchised youth in the Portland metropolitan area. Youth in this study reported many high-risk sexual and substance using behaviors. Despite these risk behaviors, the prevalence of HIV remains low in this population, at less than 1%, which is consistent with previous studies among homeless adolescents in Oregon [10]. The use of less invasive technologies for HIV testing was well-received by the youth and facilitated community-based outreach testing. The project was also successful at reaching youth who had not previously sought testing, with half of the youth reporting first-time HIV counseling and testing. Failure of youth to follow up to receive their HIV results and posttest counseling remains a challenge for prevention programs. Previous studies have reported individuals least likely to return for results include females, younger youth, race other than white, and those testing negative for HIV [18 –20]. Our findings showed that younger adolescents, nonwhites, and those with lower risk behavior were less likely to receive their results. Unlike the previous studies, females overall were significantly more likely to receive their results than males in this study. Adding a telephone notification option increased the proportion of youth who received their results. A previous study evaluating the option of telephone notification for low-risk clients at a Denver STD clinic found that telephone posttest counseling was an effective way to increase follow-up for HIV test results [21]. This is consistent with the findings in the current study. Youth who were given the option of telephone notification were significantly more likely to receive their results than those required to receive face-to-face notification. This was true regardless of age, race, history of previous HIV testing, or presence of high-risk behaviors. Among participating males, those who had the option of telephone notification of test results were significantly more likely to receive their results, compared with males who were required to have face-to-face notification. Par-
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ticipating females who had the option of telephone notification were also more likely to receive their results than females who were required to have a face-to-face interaction; however, the difference was not statistically significant. There are several limitations to this study. We were not able to specifically look at telephone notification with HIV-positive youth because only two youth tested positive and both were assigned to the face-to-face notification group. Previous studies have suggested that individuals may receive HIV testing and counseling by telephone without adverse outcome [22]. Although the population involved in that study was demographically different from the present study (did not comment on homeless status and included only individuals over 18 years of age), the study did involve individuals from the Portland area and a substantial number of participants who were HIV positive. Allowing telephone notification clearly increased the number of youth who received their results as well as posttest counseling. Whether increasing the number of youth who received posttest counseling results in a reduction in high-risk behaviors was not evaluated in this study. Although there were similar proportions of males and females involved in the study, there was a higher proportion of females in the telephone option group. This may represent a possible failure in the randomization process; however, one would expect that the higher proportion of females would tend to decrease any differences between the face-to-face and the telephone option groups on the basis of our results. It was also somewhat surprising that there were no significant differences in risk behaviors noted between the age groups, 13–18 years and 19 –24 years. This may be owing to the fact that the small sample size did not allow for detection of differences between groups, or the grouping of ages together may have muted the differences. Another limitation was that this study used a convenience sample from sites in the Portland area and therefore may not be generalizable to other areas or other homeless or high-risk youth. In this study, HIV counseling and testing was brought to the youth instead of requiring them to seek it out in an effort to reach youth who were not accessing services. As a result, the youths’ motivation to receive test results may be different from those not performed in outreach settings and thus may not be generalizable. Although efforts were made to ensure consistency at the different testing events, there may have been differences, which may have affected follow-up rates among participating youth. Randomization at each
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site and the use of the counselor check-off form were used to reduce differences across events.
Conclusion This outreach effort was successful in providing high-risk and homeless youth access to HIV testing and counseling. The option of telephone notification in a low-prevalence HIV homeless and high-risk population of young people appears to be an effective way to increase the proportion who receive posttest counseling and test results. This outreach project was funded by generous grants from the Northwest Health Foundation, Cooperative Actions for Health Program, and Centers for Disease Control and Prevention. The Epitope Corporation donated the OraSure oral HIV testing devices for this study. We thank collaborating agencies: Outside In, Oregon Health Division, Multnomah County Health Department, National College of Naturopathic Medicine, Epitope Inc., Cascade AIDS Project, New Avenues for Youth, Open Meadow/C.R.U.E., Portland Parks and Recreation, Portland Youth Builder, Sexual Minority Youth Recreation Center, Willamette Bridge Yellowbrick Road, Adventist Healthvan, Northwest Medical Teams, and Misfits for their assistance with this project.
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7. Gleghorn A, Marx R, Vittinghoff E, et al. Association between drug use patterns and HIV risks among homeless, runaway, and street youth in Northern California. Drug Alcohol Depend 1998;51:219 –27. 8. Kipke M, O’Connor S, Palmer R, et al. Street youth in Los Angeles. Profile of a group at high risk for human immunodeficiency virus infection. Arch Pediatr Adolesc Med 1995;149: 513–9. 9. Goodman E, Berecochea JE. Predictors of HIV testing among runaway and homeless adolescents. J Adolesc Health 1994;15: 566 –72. 10. Noell J, Rhode P, Ochs L, et al. Incidence and prevalence of chlamydia, herpes, and viral hepatitis in a homeless adolescent population. Sex Transm Dis 2001;28:4 –10. 11. Evaluation of the downtown Portland homeless youth services continuum. Pacific Research and Evaluation. December 2000. 12. Services to homeless youth in Portland. Report of the Joint Homeless Youth Assessment Committee of the Citizens Crime Commission and the Association for Portland Progress. March 7, 1998. 13. Geber G. Barriers to health care for street youth. J Adolesc Health 1997;21:287–90. 14. Ensign J, Gittelsohn J. Health and access to care: Perspectives of homeless youth in Baltimore City, USA. Soc Sci Med 1998;47:2087–99. 15. Council on Scientific Affairs. Health care needs of homeless and runaway youths. JAMA 1989;262:358 – 61. 16. Gallo D, George JR, Fitchen JH, et al. Evaluation of a system using oral mucosal transudate for HIV-1 antibody screening and confirmatory testing. JAMA 1997;277:254 – 8. 17. SPSS 10.0 for Windows. Chicago, IL: SPSS Inc., 1999. 18. Slutsker L, Klockner R, Fleming D. Factors associated with failure to return for HIV post-test counseling. AIDS 1992;6: 1226 –7. 19. Valdiserri R, Moore M, Gerber A, et al. A study of clients returning for counseling after HIV testing: Implications for improving rates of return. Public Health Rep 1993;108:12– 8. 20. Wiley D, Frerichs R, Ford W, et al. Failure to learn human immunodeficiency virus test results in Los Angeles public sexually transmitted disease clinics. Sex Transm Dis 1998;25: 342–5. 21. Schluter WW, Judson FN, Baron AE, et al. Usefulness of human immunodeficiency virus post-test counseling by telephone for low-risk clients of an urban sexually transmitted diseases clinic. Sex Transm Dis 1996;23:190 –7. 22. Frank AP, Wandell MG, Headings MD, et al. Anonymous HIV testing using home collection and telemedicine counseling. Arch Intern Med 1997;157:309 –14.