Perceptions of HIV rapid testing among injecting drug users in Brazil

OBJECTIVE: To describe perceptions, experiences, knowledge, beliefs and the willingness of injecting drug users to be HIV tested by using rapid tests. METHODS: A qualitative exploratory study was carried out among injecting drug users from December 2003 to February 2004 in fi ve Brazilian cities, located in four regions of Brazil. A semi-structured interview guide containing both closed and open-ended questions was used to address perceptions about non-conventional testing procedures, and non-traditional ways to provide testing access to injecting drug users. A total of 106 interviews, about 26 per region, were conducted. RESULTS: Characteristics of the population studied, common thoughts about HIV rapid testing, preference for using blood or saliva specimens, and other testing preferences, were presented together with reported advantages and disadvantages of each option. The study fi ndings showed that the use of rapid tests among these users is feasible and that they are willing to be tested using rapid HIV tests, especially if some issues related to privacy and reliability of the test could be addressed. CONCLUSIONS: The study fi ndings showed that rapid tests may be well accepted for this population. These tests can be considered a valuable tool, allowing a more injecting drug users to learn their HIV status and possibly be referred to treatment and should support more effective testing strategies for them.


INTRODUCTION
Injecting drug users (IDUs) are a population especially vulnerable to HIV infection, with high prevalence rates of infection in Brazil, 4, * marginalized, and "hard to reach".As such, they are less likely to benefi t from public health facilities or to get HIV testing.In contrast to other countries, IDUs epidemic in Brazil is mostly concerned with the cocaine users. 6Consistent with the experience of other settings. 1,20Brazilian cocaine users are characterized by high frequency of injection, rapid sexual partner turnover, frequent participation in high risk sex and participation in sex work or sex drug exchange.**As such, this population is of strategic importance in understanding and infl uencing AIDS epidemic in Brazil, due to IDUs' potential of HIV diffusion related to injection risk practices, besides the potential of HIV diffusion associated with sexual risk practices to their non-injection sexual partners ("bridging effect"). 19pid HIV testing does not require venous blood draw, yields results in 20 minutes, is portable and easy to perform, making it possible to be carried out in testing and counseling at alternative settings.Rapid testing algorithms have showed sensitivity and specifi city similar to the standard testing in whole blood. 9In Brazil, a signifi cant proportion of IDUs is unaware of their HIV status. 8For these reasons, rapid testing might be a valuable tool for allowing more IDUs to learn their HIV status and possibly access to treatment.
Studies have shown the willingness of different populations -clients at a sexually transmitted disease clinic, gay men, and injecting drug users -to participate on rapid HIV testing strategies. 17,18Other studies suggest that rapid HIV testing is feasible and acceptable to different vulnerable populations under fi eld conditions in developing countries, and showed an increase in the proportion of subjects who learned their serostatus and received counseling in health services or alternative testing settings. 11,16pid testing eliminates the waiting time and thus there is no need for tested people to come back for test results.Additionally, it may increase the effectiveness of testing strategies and reduce its related costs, 7 although these assertions have not been exhaustively studied among IDUs.
The objectives of the present study were to describe perceptions, thoughts, knowledge and beliefs regarding HIV rapid testing among IDUs and to determine the willingness of IDUs to be tested by utilizing these tests.

METHODOLOGICAL PROCEDURES
A qualitative study was carried out among IDUs, from December 2003 to February 2004, in fi ve cities: Rio de Janeiro, Salvador, Campo Grande, Ponta Porã and Porto Alegre, located in four regions of Brazil.
A qualitative design was consistent with the nature of the subject matter studied.A semi-structured interview guide containing both closed and open-ended questions was used to elicit perceptions about non-conventional testing procedures, and non traditional ways to provide testing access to IDUs.The interviews shed light on perceptions, thoughts and feelings of the study population about rapid testing.The inclusion criteria were: ≥18 year-old individuals who reported injection drug use in the last 12 months.At each site, IDUs were invited to participate in the study by local outreach workers.A total of 106 interviews (about 26 interviews per region) were conducted in private rooms.The interviews were recorded and transcribed, and took an average of 40 minutes.
Participants were reimbursed for travel expenses and given lunch.The interview guide was pre-tested and adapted to meet the study objectives and interview's estimated time.
The main themes probed were: knowledge of sexually transmitted infections (STI)/HIV/AIDS, STI prevention, sexual and injecting drug use risk behavior, history of STI/AIDS testing and treatment, thoughts on rapid HIV testing/counseling, suggestions for new HIV testing strategies and thoughts on non-conventional settings for rapid testing.
Although the IDUs were not tested, detailed information on rapid testing procedures, including rapid tests using saliva or fi nger prick blood samples, was presented to the participants via a story book with pictures, during the interviews.The central team of the study was responsible for training, supervising and revising the transcription work.All transcriptions were coded for content analysis. 3,14Transcription coding was performed by two coders simultaneously, using AnSWR (Analysis Software for Word-based Records) analysis software. 13hree researchers, one from the central team (PI) and two external to the project (CDC -Centers for Disease Control and Prevention Brazil), examined, interpreted and performed content analysis on the data.
Participants signed an informed consent using their initials and were not identifi ed by names during interviews.The study was approved by the Ethics Committee on Medical Research of the State University of Rio de Janeiro and Centers for Disease Control and Prevention (CDC -Atlanta, USA) Institutional Review Board.

ANALYSIS OF RESULTS
Table 1 shows the characteristics of the study population.Participants aged between 18 and 63 years old.The average monthly income was about US$85.00.Source of income is noteworthy, 42% of the sample reported exchanging bus transportation passes for drugs and other goods, and 24% reported the same using food coupons (obtained from government assistance programs).About a third of the subjects were living with a partner at the time of the interview and nearly four out of fi ve had less than seven years of education.Over half of the subjects mentioned injecting drugs in the month prior to the interview.
After being provided with information on rapid testing and non-rapid testing procedures (via a detailed story book) participants welcomed the possibility to perform rapid HIV testing.They considered it a better option than the currently available standard tests and also expressed the belief that other IDUs would welcome the rapid testing initiative.The IDUs mentioned several advantages that rapid tests could offer over non-rapid tests: the results could be obtained in as fast as 20 minutes; more people would know their HIV status without waiting for test results, in general spent with fear and anxiety.
Additionally, a collecting method that does not require venous blood draw was regarded as an advantage, especially for those who had damaged veins due to drug injection or who were afraid of needles or venous blood draw (a condition not rarely mentioned in the interviews).
Contrary to the fi ndings above, a small number of participants voiced their concerns regarding rapid HIV test reliability: "How can it be reliable if the results are delivered that fast?"Others said that, even if it was easy-to-perform and rapid, they would not be prepared to learn results: "People fear and get panicked of being infected and of getting to know it that fast." When asked about their willingness to be tested based on saliva or fi ngerstick blood, two thirds of the participants stated they would prefer the fi ngerstick.Most interviewees said they believe the results would be more accurate if using blood.Some argued that HIV virus "runs in the blood not in the saliva" (e.g., "A blood testing would be more reliable; we don't get AIDS through kissing!How come that our saliva would be tested?").Some participants voiced concerns about their saliva being "contaminated," for instance, after kissing someone, or after eating or drinking, right before being tested which they said could interfere with the test results.Finally, some participants expressed that they were more confi dent and felt safer with blood tests, simply because they were more like the standard testing used for detecting other diseases.Those who would prefer the oral test stressed that it would be "less painful".
Great variability and even some confl ict were seen among the participants, regarding preference for day and time for testing.Some suggestions were: • during weekends and night hours (best option for those having regular work shifts); • during weekdays and regular hours (best option for those who usually consume drugs and alcohol during weekends and have no jobs); • at night (best option for those who have privacy concerns -"Less people would notice you doing the test").Preference for the third option, i.e., testing facilities located in health centers or hospitals, were mainly due to greater privacy (e.g., "Neighbors and friends don't see you there," "far from family and your neighborhood"), greater confi dence in the infrastructure of the facility and the idea that those institutions could provide better medical/psychological support services ("Health centers have medical teams available," "Health centers have good equipment," "Sick people seek health centers").
The most frequent drawbacks of being tested in hospitals included transportation costs and time, especially waiting time associated with the bureaucracy, common to larger health units.However, privacy concerns were not an issue associated with this option, i.e., people would not be "labeled" at these settings and they believe they would have a better chance to be seen at private rooms for consultations/sessions.Participants mentioned that the health care providers at those settings would be better prepared to address emotional issues and could refer them to other specialty services.For these reasons, some participants said they would prefer to get their test results in hospitals.

FINAL CONSIDERATIONS
The study fi ndings show that the use of rapid tests among IDUs is feasible and that IDUs are willing to be tested using rapid HIV tests, especially if some issues related to the procedure and the test settings could be addressed.Results from this study in general agree with other studies on willingness carried out in other countries with syringe exchange program clients, STD clinic patients, men who have sex with men 17,18 and adolescents. 15Feasibility and acceptability studies with the rapid test showed an increase in the proportion of clients who learned their serostatus and received counseling. 2,11,12,16Potential advantages of rapid tests included their rapidness, practicability, portability, and ease of administration without the need of collecting blood with a syringe.
Two strategies were used to assess preferred setting for rapid testing: direct questions and presentation of three vignettes (Table 2).
Interviewees were directly asked to indicate the preferred setting for HIV testing: a health care facility or community center in their neighborhood.Regarding a local health care facility, they mentioned as advantages: easy access, the availability of qualifi ed health providers, adequate medical equipment/material, availability of individual consultation rooms and no or low transportation costs.
On the other hand, the main negative aspect identifi ed regarding testing in their neighborhood was the lack of privacy: "My neighbors may know I'm getting tested".
Preferences were somewhat dissimilar, when interviewees were presented three vignettes.The vignettes were hypothetically shaped by the research team to reproduce different testing situations (Table 2).Most participants chose the options where testing was offered closer to their homes (mobile units, community centers or local health care facilities).
As the advantages of easy access and no transportation costs were frequently contrasted with concerns regarding lack of privacy, insuffi cient infrastructure, and adequacy of required health providers and equipment, clearly indicating that these negative aspects would need to be addressed if this option was offered.
The option "community center, basic care unit or health care facility" was also associated with easy access, and adequate privacy (e.g., "Differently from vans, health centers would have individual rooms for consultations/ sessions"; "Going to a health center is not necessarily associated with getting tested or having a shameful lifestyle").For the same reasons, some participants said they would prefer to get a test result in theses facilities.Conversely, some interviewees were not satisfi ed with care delivered in these units (long waiting time, staff not paying due attention to patients, among others).
Table 2. Scenarios presented to participants to be chosen as the best sites for rapid HIV testing.
Scenario 1 A health team visits your neighborhood and word is spread that rapid HIV testing is available in a van that will be parked all week long at the same site.A visit would include talking with a team member, drawing a small amount of blood (fi nger sticking) or collecting saliva and then you would get your test results and attend a counseling session.
Scenario 2 The new rapid HIV testing is available in a community center or health care facility in your neighborhood, close to where you live.Testing is offered during working days and, from now on, this service will be offered at this site for a few months.A visit would include drawing a small amount of blood (fi nger sticking) or collecting saliva and then you would get your test results and attend a counseling session.
Scenario 3 The new rapid HIV testing is available in a health center or hospital that is a few miles from where you live.
To get there, you have to get a bus (you will have to pay for the bus fair).This service is open fi ve days a week, from 8 am to 8 pm.A visit would include drawing some blood (fi nger sticking) or collecting saliva and then you would get your test results and attend a counseling session.
Studies in Brazil among IDUs showed that over 30% of them are unaware of their HIV status and approximately 20% of the IDUs who had been tested for HIV failed to return for the result. 8The rapid test avoid this problem, increasing the value of this testing strategy, which may improve access to a larger number of IDUs knowing their HIV status and possibly access treatment.
No waiting time for getting test results eliminates a period of time regarded by most participants as "emotionally stressful".The majority of participants indicated they preferred learning their results quickly to waiting anxiously.Conversely, a few participants reported that the waiting time for the results is psychologically important.Therefore, all preparation for getting test results must be done at the time of testing.Additionally, some IDU preferred to receive test results in health facilities.So, counseling is crucial for a good implementation of rapid testing strategy.This situation was mentioned in other study, 10 which emphasized the importance of highly skilled counselors at testing sites.Counselors must prepare testees to get tested, provide prevention information, and ensure they are ready to know their test results in a very short time period.They must also be prepared to offer emotional support in case of possible untoward reactions.Additionally, if a counselor believes a testee is not fi t to get his/her results, testing should be stopped.Based on concerns raised regarding confi dentiality, counselors should have special training to address these issues if testing is being done in the testee community.
In addition to insights on the feasibility and willingness to perform the rapid HIV testing, the present study provides recommendations on how rapid testing programs could be more effectively developed and more attractive to target populations.Despite saliva and blood were acceptable, blood was regarded as the most reliable method for rapid testing according to two thirds of the IDUs interviewed, as they believed the results would be "more accurate" if using blood.
As in other study, 5 there were concerns about taking saliva samples among participants.Some argued that HIV virus "runs in the blood not in the saliva" or raised beliefs that if saliva can be tested it may transmit HIV; or even that their saliva might be "contaminated," after kissing someone, allowing false results.These beliefs suggest the importance of enhanced HIV counseling in case of using oral HIV testing.
Concerns with the reliability of rapid HIV tests should be addressed in media campaigns (e.g.posters, brochures) and counseling, with thorough explanations, targeting to eliminate the common myths associated with rapid testing.
Implementing HIV testing strategies that are well-accepted by IDUs is crucial to increasing access to testing.Tests could be offered in a variety of settings as long as related concerns are addressed.
A greater than expected proportion of previously tested IDUs were selected to participate in this study.Despite this fact, the number of interviewees who had not participated in prevention programs was considered adequate to investigate the cultural context of this subgroup.
The results from the present study allowed us to identify aspects related to potential barriers to initiating rapid HIV testing among IDUs, and combined with suggestions posed by this population, will allow the National AIDS Program to develop more effective testing strategies for IDUs.