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Focus Area:Prevention
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Biomedical Interventions: HIV Testing and Counseling as Prevention
I. Definition of the Prevention Area
As a stand-alone intervention, HIV testing and counseling (HTC) contributes to prevention of HIV transmission by identifying and informing individuals, partners and couples, and families of their HIV status and counseling them to develop appropriate sexual, injection, or other risk-reduction measures. These measures differ according to the serostatus of the individual or of couples, be they seroconcordant (both partners test either HIV-positive or HIV-negative) or serodiscordant (one partner tests HIV-positive and the other tests HIV-negative).
HTC is also a prerequisite to accessing such services as antiretroviral therapy, prevention of mother-to-child transmission, and voluntary medical male circumcision. Successful linkages to clinical and community-based prevention, care and support, and treatment services are important for any effective HTC program.
II. Epidemiological Justification for the Prevention Area
The evidence on whether HTC directly affects HIV incidence is mixed. However, studies show that HTC may have the greatest effect on sexual transmission of HIV for two population groups in particular: adult individuals who test HIV-positive and serodiscordant couples. In addition, some studies show a reduction in sexual risk behaviors for HIV-negative concordant partners who are tested together using couples HTC. Other studies suggest reductions in risk behaviors after HTC (e.g., reduction of unprotected sex or in number of sexual partners).
Studies on HTC among people who inject drugs are usually conducted in the context of other services—such as detoxification or drug treatment centers, and needle and syringe exchange—and reveal mixed results. Findings suggest that safer injection practices following HTC may occur when HTC is available in the context of other harm reduction services. Serosorting, when HIV-positive persons seek sexual partners who are HIV-positive, is another demonstrated behavior following HIV testing. The literature is strongest among men who have sex with men, but recent discussions suggest that individuals in generalized epidemics may also use this strategy.
III. Core Programmatic Components
HTC is available through a wide variety of delivery models. HTC can be accessed through providers or can be initiated by clients. Provider-initiated HTC uses "opt-out" testing, which is when all adults and adolescents (with or without symptoms) are tested for HIV as part of their overall health care unless the patient declines. Informed consent is stressed for this method. Client-initiated HTC is when an individual wants to get tested and searches for the best HTC center for him or her. This could include a stand-alone voluntary counseling and testing site, provider-initiated HTC site, or a community-based HTC site such as a mobile or workplace HTC.
HTC should be specific to the type of epidemic, population, and level of risk. In concentrated epidemics, offering HTC at specific sites, such as outreach centers or mobile facilities, may be the most effective way to reach hard-to-reach populations. The World Health Organization (WHO) states that provider-initiated HTC should be considered for sexually transmitted infection and tuberculosis clinics, for services for most-at-risk populations, and for childbirth, antenatal care, and postpartum services for concentrated and low-level epidemics. In generalized epidemics, WHO recommends providing provider-initiated HTC at all clinical settings, including services for sexually transmitted infections, tuberculosis, and antenatal care, as well as in- and outpatient services. Offering stand-alone, mobile, and home-based testing for harder-to-reach populations—such as rural or higher-risk groups—in generalized epidemics has also demonstrated increased uptake of HTC. For mixed epidemics, HTC programming can use a range of these options based on the epidemiological and social context of the country.
HTC minimum standards follow international guidance and include pre- and post-test counseling or information as well as referral and linkage to HIV prevention, care, support, and treatment services. The type of test (e.g., rapid testing with same-day results) also affects how successful HTC is in delivering high-quality test results and services. WHO guidelines recommend that post-test counseling be provided regardless of test result and should include an explanation of the test result, advice on risk reduction, and the provision of condoms and referrals. For those testing HIV-positive, counseling should also include emotional support, discussion of the patient's safe disclosure to others of his or her HIV status, and referral of the patient's partners and children for testing
IV. Current Status of Implementation Experience
To resolve questions about the impact of community- versus clinic-based HTC on the behavior of HIV-negative individuals, the U.S. National Institute of Mental Health sponsored Project Accept, the first randomized controlled study to determine whether behavioral changes encouraged by HTC reduce HIV incidence. The study was conducted in 14 communities in Thailand and 34 communities in sub-Saharan Africa. Each community was randomized to receive both community- and clinic-based HTC or clinic-based HTC alone. The study ended in 2011. Incidence data are not yet available, but interim results show that uptake of first-time testers is greater in the community- and clinic-based HTC sites compared to clinic-based HTC alone. WHO is also coordinating the MATCH Study, a multi-country, mixed-methods study of HTC models evaluating a range of variables, including service quality, uptake, health behavior, and equity. In 2011, data collection was ongoing in four countries: Burkina Faso, Kenya, Malawi, and Uganda.
Changes in Sexual Risk Behavior Before and After HIV Seroconversion in Southern African Women Enrolled in a HIV Prevention Trial
Venkatesh, K. K., de Bruyn, G., Mayer, K. H., et al. Journal of Acquired Immune Deficiency Syndromes (2011), Vol. 57 No. 5, pp. 435-441.
The Correlates of HIV Testing and Impacts on Sexual Behavior: Evidence From a Life History Study of Young People in Kisumu, Kenya
Kabiru, C. W., Luke, N., Izugbara, C. O., et al. BioMed Central Public Health (2010), Vol. 10, p. 412.
This study used data from 600 young people aged 18 to 24 years collected using a 10-year, retrospective life history calendar. It found that 64 percent of females and 55 percent of males had tested for HIV at least once in the previous decade, and that 40 percent of the females were pregnant in the month of their first test. Among women who had ever been pregnant, a recent HIV test was associated with lower odds of unprotected sex, whereas among those who had never been pregnant, it was associated with higher odds of risky and unprotected sex. Among males, a recent HIV test was associated with increased likelihood of concurrent sexual partners. However, repeated HIV tests were associated with lower likelihood of concurrent partners or risky sex six months later. The authors conclude that while HIV testing and counseling (HTC) may not have any immediate impact on behavior, repeated HTC over the long-term may increase the adoption of safer sex practices. A primary weakness of the study was that authors did not know the HIV status of the respondents, which could have shed additional light on the sexual and HTC practices among these youth.
Behavioural Interventions for HIV Positive Prevention in Developing Countries: A Systematic Review and Meta-Analysis
Kennedy, C. E., Medley, A. M., Sweat, M. D., et al. Bulletin of the World Health Organization (2010), Vol. 88 No. 8, pp. 615-623.
This systematic review and meta-analysis of 19 studies assessed whether positive prevention programs in developing countries are effective and looked at the ways in which such programs differ from those targeted at HIV-negative individuals. Nearly all the studies reviewed were conducted in sub-Saharan Africa and examined HIV testing and counseling interventions, including HIV-positive and HIV-negative individuals and serodiscordant couples. Four pooled studies including over 4,000 participants found that condom use increased among HIV-positive individuals, but no change was evident among HIV-negative people. Among interventions targeting HIV-positive people, seven combined studies of 1,800 people found a strong and significant effect on condom use, with the greatest effect on serodiscordant couples. The researchers concluded that positive prevention indeed impacts HIV risk behavior, particularly in serodiscordant couples. Study limitations included few randomized trials, primarily self-reported outcomes, and studies that were generally not very rigorous. Furthermore, all but one study only included heterosexual couples, thus neglecting many important high-risk populations.
Initial Outcomes of Provider-Initiated Routine HIV Testing and Counseling During Outpatient Care at a Rural Ugandan Hospital: Risky Sexual Behavior, Partner HIV Testing, Disclosure, and HIV Care Seeking
Kiene, S. M., Bateganya, M., Wanyenze, R., et al. AIDS Patient Care and STDs (2010), Vol. 24 No. 2, pp. 117-136.
This study assessed behavioral outcomes after provider-initiated, routine HIV testing and counseling (HTC) while people were seeking care in an outpatient center of a rural hospital. The 245 participants underwent routine HTC and were followed up after three months, when they completed an interview about their sexual behavior since they were tested. Regardless of their own HIV status, at follow-up participants were significantly more likely to know their partners' HIV status than at baseline, but still only a third knew their partners' HIV status. Married or cohabitating individuals were more likely to find out their partners' HIV status, but women were two times less likely than men to know their partner's status after HTC. While HTC had an effect on risky and safe sexual behaviors among certain groups in this study, it was not statistically significant and reached only 4 percent across all study participants, with half of all participants still engaging in risky sex. The authors conclude that provider-initiated HTC has the potential to increase testing, especially among first-time testers. This study only followed participants for six months, limiting the degree to which the findings can be generalized.
Unprotected Sex Following HIV Testing Among Women in Uganda and Zimbabwe: Short- and Long-Term Comparisons with Pre-Test Behavior
Turner, A. N., Miller, W. C., Padian, N. S., et al. International Journal of Epidemiology (2009), Vol. 38, No. 4, pp. 997-1007.
This article presents the long-term findings from a prospective study of the pre- and post-test sexual behavior of 801 participants, of whom 151 were infected with HIV. It found that among women in this subgroup, the percentage who reported any unprotected sex in the previous month dropped from approximately three-quarters before they were diagnosed to just over half 12 to 16 months after diagnosis. This change occurred due to a reduction in overall frequency of sexual intercourse and also an increase in condom use. However, uninfected women did not report a change in their behavior pre- and post-test. One of the report's strengths is that its results are more generalizable to African women compared to previous research, which has focused on high-risk populations. However, the self-reported nature of the data means that it may be subject to bias.
Serosorting and the Evaluation of HIV Testing and Counseling for HIV Prevention in Generalized Epidemics
Reniers, G., & Helleringer, S. AIDS and Behavior (2010), Vol. 15 No. 1, pp 1-8.
This paper argues that serosorting, whereby people select their sexual partners so that that they share the same HIV status, should be included in evaluation studies on the impact of HIV testing and counseling (HTC). Serosorting as a HIV prevention strategy is typically associated with men who have sex with men, and sexual behavior surveys are not designed to detect this activity in generalized epidemics. The omission of this information so far has undermined the findings of HTC evaluations for two reasons, the authors state. First, it creates a bias by omitting a significant variable, as seroconcordant couples may not take precautionary measures. Second, concentrating on the impact of HTC on individual behavior ignores the potential benefits at the level of sexual networks and populations. Including serosorting in evaluations could overcome this limitation. If serosorting was included in the evaluation process, the impact of HTC interventions on behavioral change could be more accurate, the authors conclude.
HIV Voluntary Counseling and Testing and Behavioral Risk Reduction in Developing Countries: A Meta-Analysis, 1990-2005
Denison, J. A., O'Reilly, K. R., Schmid, G. P., et al. AIDS and Behavior (2008), Vol. 12 No. 3, pp. 363-373.
This paper reviewed the evidence for HIV testing and counseling (HTC) as prevention in developing countries/emerging economies between 1990 and 2005. Seven studies met the inclusion criteria for the meta-analysis. HTC had no effect on the number of sex partners among three pooled studies, but a statistically significant modest reduction in unprotected sex among seven pooled studies. Most of the people adopting condom use were HIV-positive individuals and serodiscordant couples. These studies all had a year or less of follow-up, took place before antiretroviral therapy became widely available, and were not very rigorously designed. The authors conclude that their analysis provides moderate evidence for HTC as an intervention strategy. However, there was no evidence that HTC caused an increase in risky behaviors.
Behaviour Change in Clients of Health Center-Based Voluntary HIV Counseling and Testing Services in Kenya
Arthur, G., Nduba, V., Forsythe, S., et al. Sexually Transmitted Infections (2007), Vol. 83 No. 7, pp. 541-546.
This study assessed integrating HIV testing and counseling (HTC) into two rural and one urban government primary health care centers in Kenya. Among 401 adults successfully followed up, there was a significant decrease in sexual partners among those who had two or more sex partners six months after the study. While unprotected sex with any partner decreased significantly from baseline, rates remained high at 89 percent. Although the mean number of sexual encounters remained the same for primary and nonprimary partners alike, there was a trend for increased condom use with nonprimary partners at follow-up. Like all studies using self-reported behavior, there is potential for misreporting, and this study would have been stronger had it used biological endpoints. Furthermore, people who obtain HTC may be different from the general population, limiting the generalizability of the findings. The authors conclude that HTC can be a valuable component in HIV prevention efforts in primary health care health centers.
HIV Incidence During a Cluster-Randomized Trial of Two Strategies Providing Voluntary Counseling and Testing at the Workplace, Zimbabwe
Corbett, E. L., Makamure, B., Chueng, Y. B., et al. AIDS (2007), Vol. 21 No. 4, pp. 483-489.
This analysis compared HIV infection rates among employees in 22 Zimbabwean businesses randomized to intensive HIV testing and counseling (HTC) or standard HTC. Among nearly 3,000 participants initially testing negative, 71 percent underwent HTC in the intervention arm compared to only 5 percent being tested in the standard arm. Despite this significant difference, HIV incidence remained the same in both arms after about 5,000 person-years of follow-up. Limitations of this study that must be considered include virtually all male participants, no couples counseling, and the inability to assess whether HIV-positive individuals transmitted HIV to others. Because this was only the second randomized controlled trial on this subject at publication, the authors concluded that more data are needed to understand the impact of a negative HIV test result on risk behavior so that HTC programs can maximize benefits while minimizing the potential for harm.
Voluntary Counseling and Testing: Uptake, Impact on Sexual Behaviour, and HIV Incidence in a Rural Zimbabwean Cohort
Sherr, L., Lopman, B., Kakowa, M., et al. AIDS (2007), Vol. 21 No. 7, pp. 851-860.
This study assessed HIV testing and counseling acceptance and its impact on the sexual behavior of rural Zimbabweans. Baseline and follow-up data were collected for nearly 6,000 participants who reported having an HIV test two or three years prior to being interviewed. Women who received a positive HIV test reported a significant reduction in risky behaviors, including fewer partners and more condom use than at baseline. Participants with a negative result were significantly more likely to have a partner in the last month, multiple concurrent partners, and a greater total number of partners than they did in the previous year. Despite these self-reported changes in behavior, HIV incidence was the same among all groups. The authors hypothesize that a negative HIV test result may have the unintended consequence of being interpreted as permission for future risky behavior. However, the study is considered to be highly controversial because most of the findings were not statistically significant. Moreover, it is not clear from the paper whether or not partner reduction was a critical message in the counseling process, conducted between 1998 and 2000. To date, the evidence of risk compensation as a result of HIV testing and counseling is inconclusive.
Condom Use After Voluntary Counseling and Testing in Central Mozambique
Mola, O. D., Mercer, M. A., Asghar, K. H., et al. Tropical Medicine & International Health (2006), Vol. 11 No. 2, pp. 176-181.
This longitudinal cohort study of 1,220 men and women looked at whether HIV testing and counseling (HTC) had an impact on risky sexual behavior by comparing responses from those who underwent HTC and those who did not. Participants were asked about condom use in both paid and unpaid sexual encounters. Both groups reported increased condom use at four months versus baseline, and the HTC group reported further increases from four to six months. HIV-positive participants reported a greater increase in condom use. However, those in the non-HTC group only reported an increase from baseline to four months. Moreover, whereas both men and women in the HTC group reported more condom use, only men did so in the non-HTC group. The study was subject to several limitations—sample size was small when the data were broken down by gender, site, or HIV status, for example, and the HTC group was self-selected, making it subject to bias.
Risk Reduction Counseling is Associated with Decreased HIV Transmission-associated Behaviors in High-risk Indian Heterosexuals
Solomon, S. S., Solomon, S., Masse, B. R., et al. Journal of Acquired Immune Deficiency Syndromes (2006), Vol. 42 No. 4, pp. 478-483.
This prospective cohort study conducted in Chennai, India, looked at the effect of risk-reduction counseling on HIV incidence among 500 men and women at high risk of HIV infection. The criteria for being at high risk of HIV were five or more sexual partners in the past six months, history of sexually transmitted infections and/or sexual intercourse once a week with a HIV-positive partner of the opposite sex. The participants received risk-reduction counseling at baseline and again at 6 and 12 months. Both men and women reported reduction in the number of sexual partners and fewer sexual encounters with primary partners. Those with multiple partners and those who engaged in paid sex reported the greatest reductions. The authors conclude that such counseling is a useful tool for reducing risky sexual behavior, but they concede that other factors (timely management of sexually transmitted infections, free condoms, regression to the mean) may have been responsible for the change.
Antenatal Couple Counseling Increases Uptake of Interventions to Prevent HIV-1 Transmission
Farquhar, C., Kiarie, J. N., Richardson, B. A., et al. Journal of Acquired Immune Deficiency Syndromes (2004), Vol. 37 No. 5, pp. 1620-1626.
This study sought to assess the impact of involving partners in antenatal HIV testing and counseling (HTC) to see if this could overcome the reluctance of women who test HIV-positive to inform their partners and lead to increased uptake of perinatal interventions and condom use. The researchers offered women seeking antenatal care in a Nairobi, Kenya clinic information about HIV transmission and encouraged them to inform their partners about HTC. They were invited to return for HTC and other routine antenatal tests with or without their partner. Between 2001 and 2002, about 300 women and their partners went to the clinic for HTC. Although the majority chose individual counseling over couples counseling for their post-test results (62 percent vs. 38 percent), there were benefits to involving men either way: maternal nevirapine uptake, compliance with the nevirapine regimen, and avoiding breastfeeding were highest among those attending couples HTC, and rates were higher for those attending individual HTC than those whose partners did not come in for HTC. Furthermore, couples counseling was associated with a six-fold increase in condom use among HIV-positive women. Male uptake of HTC was poor in this study population, however, with less than one in seven partners coming in for testing.
Effect of an HIV Counseling and Testing Program on AIDS-Related Knowledge and Practices in Tuberculosis Clinics in Abidjan, Cote d'Ivoire
Wiktor, S. Z., Abouya, L., Angoran, H., et al. International Journal of Tuberculosis and Lung Disease (2004), Vol. 8 No. 4, pp. 445-450.
This study looked at the impact of HIV testing and counseling (HTC) on knowledge of HIV and sexual practices in a cohort of tuberculosis patients in Abidjan, Côte d'Ivoire. After HTC, a significantly higher proportion of participants correctly identified modes of HIV transmission and prevention, and these improvements were sustained after four months. Reported consistent condom use during unpaid sex more than doubled to 24 percent among men, but there was no such change among women. HTC in the setting of a tuberculosis clinic was well accepted, the authors note. They recommend that similar programs should maximize the benefits by targeting subgroups with the lowest knowledge of HIV. The study findings were undermined by loss to follow-up, which was very high, perhaps due to lack of HIV counseling training for tuberculosis clinic staff.
Sexual Behavior of HIV Discordant Couples After HIV Counseling and Testing
Allen, S., Meinzen-Derr, J., Kautzman, M., et al. AIDS (2003), Vol. 17 No. 5, pp. 733-740.
This study of 963 HIV-discordant heterosexual couples in Lusaka, Zambia, looked at the effect of HIV counseling and testing on sexual behavior. The participants self-reported condom use and underwent clinical tests for sperm detected on vaginal smears, pregnancy, and four sexually transmitted infections (HIV, gonorrhea, syphilis, and Trichomonas vaginalis). Prior to HIV counseling and testing, less than 3 percent of couples reported using condoms, whereas the number exceeded 80 percent after. Those who reported 100 percent condom use had reductions in biological markers ranging from 39 to 70 percent. The markers were able to detect under-reporting (e.g., sperm, pregnancies, and HIV transmissions were all detected among couples who reported consistent condom use). DNA sequencing showed that almost 90 percent of new infections were acquired from the spouse. The study shows that biological markers can help identify under-reporting, the authors conclude, and they urge more work on strategies to encourage participants in future studies to honestly report their behavior.
Efficacy of Voluntary HIV-1 Counseling and Testing in Individuals and Couples in Kenya, Tanzania, and Trinidad: A Randomized Trial
The Voluntary HIV-1 Counseling and Testing Efficacy Study Group. The Lancet (2000), Vol. 356 No. 9224, pp. 103-112.
To understand sexual risk behavior following HIV testing and counseling (HTC), over 3,000 individuals and nearly 600 couples in the capitals of Kenya, Tanzania, and Trinidad were randomized to HTC or information about HIV and condoms. At follow-up, approximately 7 and 14 months after baseline, couples and individuals in the HTC arm were both significantly less likely to have unprotected sex with nonprimary partners and less unprotected sex. Among HIV-negative participants, the proportion having unprotected sex fell by roughly a third for women and by a fifth for men, while among participants who were HIV-positive or who had HIV-positive partners, the reductions in unprotected sex were far more dramatic. Participants in the health information group who received HTC at first follow-up and were diagnosed as HIV-positive showed similarly reduced rates of unprotected sex at second follow-up. The authors conclude that HTC indeed helps motivate people to adopt protective behaviors and should be a standard component of HIV prevention strategies in developing countries.
Brief Cognitive Counseling with HIV Testing to Reduce Sexual Risk Among Men Who Have Sex with Men: Results from a Randomized Controlled Trial Using Paraprofessional Counselors
Dilley, J. W., Woods, W. J., Loeb, L., et al. Journal of Acquired Immune Deficiency Syndromes (2007), Vol. 44 No. 5, pp. 569-577.
Personalized cognitive counseling (PCC) targets the thoughts, attitudes, and beliefs that people employ when engaging in high-risk behaviors. This study of men who have sex with men attending publicly funded HIV testing and counseling sites in San Francisco assessed whether a single session of PCC was more effective than standard counseling in reducing unprotected anal intercourse among nonconcordant and nonprimary male partners. Men in the PCC arm reported statistically significant fewer episodes of high-risk sex at six months compared to baseline, with no change in the control group at this time. The PCC arm participants reported the same number of high-risk episodes at 12 months as they did at 6 months. Those in the control arm, however, reported a statistically significant decrease in high-risk sex acts from baseline. While the effectiveness of PCC needs to be validated among other populations, the authors posit that perhaps the emphasis of a specific, recent high-risk exposure was seen as more personally relevant. This may have offered participants the opportunity to understand something new about their decision making, prompting them to take action.
Sexual Risk Reduction in a Cohort of Injecting Drug Users in Bangkok, Thailand
Vanichseni, S., Des Jarlais, D. C., Choopanya, K., et al. Journal of Acquired Immune Deficiency Syndromes (2004), Vol. 37 No.1, pp. 1170-1179.
This study looked at whether the modest gains usually associated with interventions to reduce sexual risk taking among people who inject drugs were better over a longer timeframe. The study cohort comprised 800 HIV-negative people who inject drugs who were offered HIV testing and counseling and free condoms at regular intervals four times over a 16-month period. At each session, the participants self-reported their sexual behavior. There was no change in the proportion of participants—4 out of 10—who reported engaging in vaginal unprotected sex. However, participants who were identified as HIV-positive during the course of the study did report substantial increases in condom use with regular partners. There was an association between unprotected sex with casual partners and amphetamine use. The study shows that even over a longer timeframe, HIV testing and counseling does not reduce sexual risk taking among people who inject drugs, pointing to an urgent need for more effective interventions, the authors conclude.
Interventions with Injection Drug Users in Ukraine
Booth, R. E., Lehman, W. E., Dvoryak, S., et al. Addiction (2009), Vol. 104 No. 11, pp. 1864-1873.
This study of 1,800 people who inject drugs in Ukraine compared two models of HIV prevention: a standardized counseling and education intervention alone, or the intervention combined with individual outreach by former drug users. Both groups were interviewed using audio computer-administered self-interview to obtain information on demographics, health profile, use of drugs, and risk behaviors related to injection and sex. The participants were followed up after six months with a 90 percent recall rate. In both groups, there were significant reductions in needle and sexual risk behaviors, but younger people who inject drugs and those with a shorter history of injection drug use were more likely to engage in risky practices. While the findings were discouraging because they point to further escalation of the HIV epidemic among people who inject drugs in Ukraine, they were encouraging too because they proved that it is possible to implement community-based interventions in this setting.
Associations between Mode of HIV Testing and Consent, Confidentiality, and Referral: A Comparative Analysis in Four African Countries
Obermeyer, C.M., Neuman, M., Desclaux, A., et al. n.d. PLoS Medicine Vol. 9 No. 10.
The study sought to examine the differences between stand-alone voluntary counseling and testing (VCT), VCT offered through integrated facilities (provider- and client-initiated testing), and VCT offered through prevention of mother-to-child transmission services with regards to the various levels of consent, confidentiality, and referral to care offered by each and to assess if they met quality standards based on World Health Organization and Centers for Disease Control and Prevention guidelines. The study was conducted in four countries—Burkina Faso, Kenya, Malawi, and Uganda—to examine the differences across various settings. A client survey was administered to individuals at facilities who had either accessed VCT or had not. The survey included variables on socio-demographic information, HIV testing and counseling attitudes, and testing status. Those who were tested were asked about their experiences with pre- and post-testing, follow-up care, interaction with providers throughout the process, disclosure, and stigma. Data from 2,116 participants were included in the analysis. It was found that the majority of testers received the necessary components to HIV testing that are within the international guidelines, but improvements could be made. No one type of HIV testing service was found to be significantly better than the others. The study did not find breaches of conduct in terms of consent and confidentiality. In conclusion, based on this study, different types of HIV testing services can be scaled-up in countries to increase knowledge of HIV status and provide referrals to other HIV services.AIDS, Burkina Faso, counseling, HIV, Kenya, Malawi, prevention, testing, Uganda
Voluntary Counseling and Testing (VCT) for Changing HIV-related Risk Behavior in Developing Countries
Fonner, V.A., Denison, J., Kennedy, C.E., et al. Cochrane Database of Systematic Reviews (September 2012), Vol. 9.
Voluntary counseling and testing (VCT) has long been seen as a critical component of HIV prevention strategies worldwide, both as a first step to care and treatment and as a catalyst for behavior change. This systematic literature review and quantitative assessment examined VCT's efficacy in promoting change in HIV-related risk behaviors in low- and middle-income countries over a 20-year period (1990 to 2010). The authors chose 17 studies for qualitative synthesis (8 of which also underwent meta-analysis); all had either collected data on study participants before and after undergoing VCT, or compared individuals who had received VCT to those who hadn't. Five HIV-related outcomes were analyzed: HIV incidence, prevalence and incidence of other sexually transmitted infections (STIs), positive and negative life events, condom use and protected sex, and number of sex partners. The authors found no statistically significant differences in HIV incidence or in incidence or prevalence of STIs between participants who received or did not receive VCT. Of the two studies on life events, the authors found that individuals who didn't undergo VCT experienced a significant increase in negative life events. Other findings show that those who received VCT were more likely to disclose their HIV status, were significantly more likely to reduce their number of sex partners, and were more likely to use condoms.AIDS, counseling, HIV, testing
No "Magic Bullet": Exploring Community Mobilization Strategies Used in a Multi-Site Community Based Randomized Controlled Trial: Project Accept
Tedrow, V. A., Zelaya, C. E., Kennedy, C. E., et al. AIDS and Behavior (2011), Aug 6 e-publication ahead of print.
The Project Accept randomized controlled trial tested the hypothesis that voluntary HIV counseling and testing together with community mobilization would shift community norms and reduce HIV incidence. This paper is a qualitative examination of the seven community mobilization strategies used in the trial. Using semistructured interviews, the study found that no single strategy (out of stakeholder commitment, community coalition formation, community engagement, participation or awareness raising, involvement of leaders and partnership building) was used alone. The study identified three elements that are crucial to the success of community mobilization efforts. First, strategies evolved over time and were adapted during the process of community involvement. It also took time for acceptance to develop in communities. In addition, each intervention site had unique characteristics requiring tailored community mobilization efforts. Involving lay community members was crucial, the study found.
Community-Based Intervention to Increase HIV Testing and Case Detection in People Aged 16-32 Years in Tanzania, Zimbabwe, and Thailand (NIMH Project Accept, HPTN 043): A Randomised Study
Sweat, M., Morin, S., Celentano, D., et al. The Lancet Infectious Diseases (2011), Vol. 11 No. 7, pp. 525-532.
This paper presents interim analysis of randomized controlled trial, Project Accept. The trial compared the impact on HIV incidence of clinic-based HIV testing and counseling (HTC) versus community-based HTC. The study covered 32 communities, 10 in Tanzania, 8 in Zimbabwe, and 14 in Thailand with the intervention running over three years from 2006 to 2009. Those in the community-based HTC areas had a mean 40 percent higher likelihood of undergoing their first HIV test, compared to those in the community-based HTC areas. Uptake increased 4-fold in Tanzania, 10-fold in Zimbabwe, and 3-fold in Thailand. Almost four times more cases of HIV were detected in the community-based HTC areas, even though HIV prevalence was higher in the clinic-based HTC areas. The study's ability to mobilize large numbers of people to get tested has important implications for future HIV programming, the authors conclude.
Project Accept (HPTN 043): A Community-Based Intervention to Reduce HIV Incidence in Populations at Risk for HIV in Sub-Saharan Africa and Thailand
Khumalo-Sakutukwa, G., Morin, S., Fritz, K., et al. Journal of Acquired Immune Deficiency Syndromes (2008), Vol. 49 No. 4, pp. 422-431.
This paper reports the first year results of a unique study: an international, multisite, community randomized control trial of a multilevel HIV structural prevention intervention. This community-level approach had three strategies: (1) community mobilization to increase HIV testing and counseling (HTC); (2) community-based mobile HTC; and (3) comprehensive post-test services. The study assesses whether, compared to people living in communities with standard HTC, those living in communities where community-based HTC is offered will have lower incidence of HIV and experience less stigma, fewer risk behaviors, higher rates of HIV testing, and more accepting social norms related to HIV. It also assessed the cost-effectiveness of the intervention. In the first year of the intervention, about three times more members living in intervention communities in Tanzania and Thailand sought out HIV testing; in Zimbabwe, the increase was 10-fold. First-year data suggest that this community-level intervention can create changes in social norms about HIV, and because of its low cost, can be replicated in resource-poor settings.
Home-based HIV Voluntary Counselling and Testing in Developing Countries
Bateganya, M. H., Abdulwadud, O. A., & Kiene, S. M. Cochrane Database of Systematic Reviews (2007), Vol. 4, CD006493.
This review looked for randomized and nonrandomized (e.g., cohort and pre-/post-test) controlled trials of home-based voluntary HIV testing and counseling (HTC) in the published literature; the authors found only two studies from developing countries, and none from developed countries, that met inclusion criteria. The randomized controlled trial compared optional location-based and clinic-based HTC, and found that uptake was substantially higher in the optional location group. The pre-/post-test study found similar results: uptake of home HTC was higher than facility-based HTC. The authors conclude that given the lack of methodologically sound evidence, more studies are needed to determine the efficacy and cost-effectiveness of clinic-based testing versus testing on other sites, including the home. The review gives a useful summary of the different modes of HTC, including mandatory, voluntary, opt-out, and home-based testing and counseling.
Promotion of Couples' Voluntary HIV Counseling and Testing
The Rwanda Zambia Research Group, Rollins School of Public Health, Emory University.
The Rwanda Zambia Research Group at Emory University has several research projects underway to understand factors related to HIV transmission. This webpage summarizes a five-year project to promote HIV testing and counseling among cohabitating couples in Kigali, Rwanda, and Lusaka, Zambia. The group planned two community-oriented interventions to increase couples HIV testing and counseling, and also studied psychosocial and structural factors influencing condom use, regular follow-up, and biological outcomes of unprotected sex in serodiscordant couples, including couple communication, alcohol use, intimacy, and gender roles. Links to the project's progress reports can also be found from this page.
Scaling up HIV Testing and Counseling in the WHO European Region as an Essential Component of Efforts to Achieve Universal Access to HIV Prevention, Treatment, Care and Support: Policy Framework
World Health Organization. (2010).
This document lays out a policy framework for countries to increase access to HIV testing and counseling (HTC), a key element of attaining the goal of universal access to HIV care. The target audience includes policymakers, national AIDS program planners, health care providers, and nongovernmental organizations in the HIV field in Europe. It is built around 10 principles, such as the position that scaling up of HTC is not only a public health priority but must also be a part of broader HIV prevention, treatment, care, and support efforts, and that HTC must take diverse settings and populations into account. It spells out the need to increase uptake of HTC among most-at-risk populations, the importance of informed consent, confidentiality, and elimination of coercive testing. The document also makes detailed recommendations to World Health Organization member states for each of the principles covered.
Guidance on Testing and Counselling for HIV in Settings Attended by People Who Inject Drugs: Improving Access to Treatment, Care and Prevention
World Health Organization, World Health Organization Regional Office for South-East Asia, & World Health Organization Regional Office for the Western Pacific. (2009).
This document provides policymakers, HIV program planners, care providers, nongovernmental organizations, and civil society groups with information on how health care providers can initiate HIV testing and counseling among people who inject drugs. Developed specifically for the Asia-Pacific context, it can be used to help most-at-risk populations know their HIV status and access treatment and care. The document balances medical ethics and clinical, public health, and human rights objectives for reaching this special population. The primary components of this guidance include recommendations for testing and counseling people who inject drugs; process and elements of HIV testing and counseling; and programmatic considerations.
HIV Testing and Counselling in Prisons and Other Closed Settings
Jürgens, R., World Health Organization, United Nations Office on Drugs and Crime, & Joint United Nations Programme on HIV/AIDS. (2009).
This technical paper systematically reviews the literature to identify best practices and recommendations on HIV testing and counseling (HTC) in prisons and other closed settings. Due to a lack of documentation of this issue in many low-resource settings, the literature review was augmented by findings from a discussion among experts. In addition to providing the findings of the literature review, this document provides 11 recommendations on providing HTC to this population. Recommendations include scaling up HTC, key principles of informed consent, code of conduct for health personnel in prison systems, and continuity of care once prisoners are released back into the community.
Guidance on Provider-Initiated HIV Testing and Counselling in Health Facilities
World Health Organization & Joint United Nations Programme on HIV/AIDS. (2007).
In support of multiple approaches to help people find out about their HIV status, the World Health Organization has published guidance on implementing provider-initiated HIV testing and counseling in health facilities. The guidance is divided by category of HIV epidemic: generalized, concentrated, or low level. It discusses to whom providers should recommend HIV testing and counseling as standard of care. Furthermore, the document covers the enabling environment needed for such a program and provides guidance on post-test counseling, frequency of testing, HIV testing technologies, programmatic considerations, and monitoring and evaluation. Any level audience, from policymaker to health care provider, can find useful information in this document.
Home-based HIV Testing and Counseling in Rural and Urban Kenyan Communities
Dalal W., Feikin, D.R., Amolloh, M., et al. 2012. Journal of Acquired Immune Deficiency Syndromes [Epub ahead of print].
A home-based HIV testing and counseling (HBHTC) intervention was implemented in two sites in Kenya to determine the up-take of testing as well as to assess HIV prevalence and referral success rates. Individuals were offered voluntary counseling and testing through counselors and, if they consented, data was collected on any previous testing and access to care and treatment services. All adults received HIV test results in their homes as well as risk reduction counseling. Those who tested positive were counseled and provided information on HIV services, offered a free CD4 count test, referred to the nearest facility for free care and treatment, and visited by a counselor one month after the test. There was an 81.7 percent acceptance rate of HBHTC in the participating communities (19,966 accepted out of 24,450 offered). The motivation for testing by the majority (84.9 percent) of acceptors was their desire to plan for the future. HIV prevalence was 16.3 percent among the participants, and the majority of those found to be HIV-positive were first time testers. About a third (38 percent) of those reporting to be in a couple were counseled and tested together, and 84.3 percent were HIV-concordant negative. Half of those who tested positive were visited one month after their tests. About a half reported attending a patient support center. In conclusion, the intervention was successful in contacting individuals who had never been tested and in identifying newly diagnosed HIV-positive individuals and linking them to care and treatment services.
NIMH Project Accept (HPTN 043) HIV/AIDS Community Mobilization to Promote Mobile HIV Voluntary Counseling and Testing in Rural Communities in Northern Thailand: Modifications by Experience
Kawichai, S., Celentano, D., Srithanaviboonchai, K., et al. 2012. Project Accept Study Team. Collaborators (61) AIDS Care [Epub ahead of print]
The intervention strove to increase the up-take of HIV testing through its mobile voluntary counseling and testing (MVCT) centers by implementing community mobilization (CM) activities. The intervention was implemented in communities in rural Thailand from 2006 to 2009. Communities were randomly selected as control or intervention sites and were similar on measures including ethnicity, livelihoods, and health care services. Community Working Groups were established at each intervention site to increase involvement and facilitate activities. For intervention rounds one to three in the intervention communities, the CM teams went door-to-door and conducted small meetings to educate individuals about HIV and inform them about the MVCT centers. The MVCT services followed a few days later. Since the number of participants accessing MVCT was decreasing, the project's strategy was modified to implement larger-scale events, coupled with MVCT, during the last rounds of the project. It was found that about 17,000 individuals were tested, with the majority first time testers (61.1 percent). The project identified 136 individuals who were HIV-positive, and the majority did not have any signs or symptoms of AIDS. Participation did increase during the last rounds of the project based on the change of the CM strategy. Participants were younger in the later phases as well. It was found that CM can help educate communities about HIV and reduce stigma. When coupled with MVCT, up-take of testing can increase the identification of new HIV cases.
An Incentivized HIV Counseling and Testing Program Targeting Hard-to-Reach Unemployed Men in Cape Town, South Africa
Nglazi, M.D., van Schaik, N., Kranzer, K., et al. 2012. Journal of Acquired Immune Deficiency Syndromes Vol. 59 No.3, pp. e28-34.
Men access HIV counseling and testing (HCT) services less than women do. Innovative strategies are sought to increase the uptake of HCT services by men. Past studies have demonstrated success in attracting men when HCT services were coupled with a conditional case transfer program. The retrospective observational study combined the use of incentives with a mobile HCT clinic. It then compared the enhanced intervention to a non-incentivized mobile HCT site and a stationary non-incentivized HCT site to explore which service was most accessed by men. All services were operating in poor underserved peri-urban sites. The stationary site included all men who came for testing on their own initiative. The mobile non-incentive site did not advertise or actively recruit clients. The mobile incentive-based HCT partnered with a local organization that worked with unemployed or under-employed men to encourage them to access the services. The incentive to accessing HCT was receiving a food voucher worth about US$10.00. Only men were included in the data analysis. All women, young men under age 15, and those of known HIV status were excluded from the data analysis. A total of 9,416 first-time testers accessed one of the three HCT services, with a higher proportion of self-reported first-time testers using the incentivized site compared to the non-incentivized mobile site. It was found that HIV prevalence among testers was the highest among those who received testing from the incentivized site (16.5 percent) compared to the stationary clinic (10.2 percent) and the non-incentivized site (5.5 percent). The incentive-based mobile HCT was successful in reaching higher-risk men who have never tested for HIV.AIDS, Cape Town, counseling, HCT, HIV, mobile, South Africa, testing
A Handbook for Improving HIV Testing and Counseling Services: Field-Test Version
World Health Organization. (2010).
This handbook is a practical guide for those involved in the improvement of HIV testing and counseling (HTC) services. It describes the quality assurance cycle and how to construct a quality improvement framework. To meet the needs of both public health systems and nongovernmental organizations involved in the delivery of HIV services, it spans the whole process of HTC, from point of entry to successful onward referral. Of particular interest to program managers is the outline of the main components of quality improvement in HTC, whereas service providers can make use of its practical tools such as logbooks, interview forms, and site assessment forms. There are also examples of a quality monitoring system and illustrations of the framework in action at service delivery level. A bibliography of recommended core and additional resources, as well as an extensive glossary, completes the document.
HIV Counselling Resource Package for the Asia-Pacific
United Nations Children's Fund, Family Health International, & World Health Organization. (2009).
This set of resources can help trainers and counselors provide high-quality HIV testing and counseling services. The authors emphasize evidence-based counseling strategies that may reduce HIV transmission and include focused guidance on working with drug users and other most-at-risk populations. The HIV counseling handbook is a comprehensive resource package providing HIV counselors easy reference to key basic counseling processes and procedures. The trainer's manual has everything needed for an eight-day training course, including seven classroom days and one day for site visits. It contains 16 modules with session plans and interactive sessions and learning activities for the trainees. The toolkit includes useful forms and protocols, client education charts, and screening/assessment tools that can be used while counseling patients.
Couples HIV Counseling and Testing Intervention and Training Curriculum
U.S. Centers for Disease Control and Prevention. (2008).
Developed primarily for experienced HIV prevention counselors, this curriculum and materials can be adapted to various country contexts when providing couples HIV counseling and testing. There is a manual for participants in training and another for trainers. The materials cover essential topics and activities for those counseling couples, and include prevention messages tailored to couples' life stages, mitigating tension and diffusing blame, and creating an environment safe for HIV disclosure to partners.
Positive Prevention Counseling: A Training Course for HIV/AIDS Counselors
EngenderHealth, Ministry of Health, Uganda, U.S. Agency for International Development, & Centers for Disease Control and Prevention. (2007).
This manual and related materials form the basis of a comprehensive training course for HIV counselors in positive prevention. The positive prevention program aims to reduce HIV transmission by building the capacity of service providers to scale up HIV prevention counseling skills, integrating family planning and reproductive health needs, and involving people living with HIV as partners in health. This 10-day course includes 8 days of classroom work and 2 days of practicum. Modules address topics such as disclosure counseling, sex and sexuality, counseling serodiscordant couples, alcohol and substance use, and adolescent counseling. Participants develop action plans for integrating positive prevention counseling into their workplace once they return. There are downloadable manuals for trainers and participants.
HIV Counseling and Testing for Youth: A Manual for Providers
Fischer, S., Reynolds, H., Yacobson, I., et al. (2007).
Counseling youth about HIV requires different knowledge and skills than when counseling adults. This manual is a resource of best practices for offering HIV testing and counseling (HTC) services to youth for service providers at all levels. There are chapters on the differences in counseling youth compared to adults and specifically on HTC. Sexually transmitted infections, pregnancy prevention, life skills, and creating a referral network are also covered. A training guide is also available with this manual for use in training experienced HIV counselors on offering HTC to youth. Among other tools, the training guide includes slides, interactive exercises, and practice sessions.
Scaling-up HIV Test and Counseling (TC) Services: TC Toolkit: An Annotated Bibliography of Peer-reviewed Resources and Tools
World Health Organization. (2007).
This toolkit contains resources for those setting up or scaling up HIV testing and counseling services. Developed for program managers, implementers, and their partners, the selected resources offer practical guidance on planning and implementing HIV testing and counseling services in resource-limited settings and also includes tools for monitoring and evaluation. This document will be updated regularly to keep resources current.
Testing and Counselling for Prevention of Mother-to-Child Transmission of HIV (TC for PMTCT): Support Tools
U.S. Centers for Disease Control and Prevention. (2005).
This set of tools was developed to guide the delivery of essential prevention of mother-to-child transmission (PMTCT) messages. Answering the need for more educational resources for resource-constrained settings, they were developed specifically for both clinical and nonclinical health care workers, program managers, and trainers in the field of PMTCT. The goal is to increase the uptake of HIV testing by pregnant women and also their partners, increase the number of women who are aware of their HIV status, and facilitate PMTCT interventions. There are flipcharts, wall charts, brochures, and a reference guide. There are specific support tools for antenatal, labor and delivery, and postnatal PMTCT support. The resources are available on CD-ROM and also for download in low, medium, and high resolution.
Can Couples Testing Contribute to Achieving the AIDS Transition?
Over, M. (2010).
This study examines couples counseling within the context of the economic theory of asymmetric information as well as epidemiologic findings on its efficacy. Using observational data from several different countries, it suggests that the primary hurdle to HIV prevention is the lack of couples counseling. The problem of asymmetric information, when two people engaging in a transaction have differing amounts of information, is a driver to the HIV epidemic, the authors argues. Not knowing one another's status discourages the formation and survival of monogamous partnerships. Based on data from studies that find lower HIV transmission rates among serodiscordant couples than among couples who do not know their partners' status and from studies that find the majority of people obtain HIV tests individually, couples testing should be a priority for helping reduce the HIV epidemic, the author writes. In addition, he states that more rigorous research is needed around this issue of couples testing.
Behavioural Strategies to Reduce HIV Transmission: How to Make them Work Better
Coates, T. J., Richter, L., & Caceres C. The Lancet (2008), Vol. 372 No. 9639, pp. 669-684.
This article argues that the radical behavioral change that is needed to reduce HIV transmission requires radical commitment. Reviewing 25 years of HIV prevention efforts, the authors identify successful HIV prevention efforts and ways to improve behavioral strategies to reduce HIV transmission. They argue for the need to combine behavioral, biomedical, and structural approaches to effectively fight HIV transmission. To date, behavioral changes have reduced HIV in certain countries, regions, or subpopulations due to significant behavior changes taking place among a majority of the population; a mix of communication channels providing clear, actionable risk reduction and health-seeking messages that people can choose from; and local involvement in developing, producing, and disseminating the right messages. Sustained changes in risk behavior, however, have not been found anywhere, they note. The authors conclude that behavioral strategies must take place combined with different approaches and at multiple levels of influence.
World Health Organization, Department of HIV/AIDS
World Health Organization. (n.d.).
This webpage of the World Health Organization's Department of HIV/AIDS lists all testing and counseling publications starting from 2000. Readers can link back from here to the department's main counseling and testing page, which includes policy and guidance, advocacy, training materials, data on HIV counseling and testing, and more.
Zimbabwe HIV Prevention e-Toolkit
K4Health, 2012.
The toolkit offers a selection of different materials including research papers, books, training materials, and behavior change communication materials across the spectrum of HIV prevention topics. Readers can access materials and resources on behavior change communication, condom use, family planning and HIV service integration, male circumcision, multiple and concurrent partners, prevention of mother-to-child transmission, and voluntary counseling and testing.


text:
COLUMBIA — South Carolina's unemployment agency is laying off at least 100 employees in June as part of a statewide reorganization that directs anyone seeking jobless benefits to use its upgraded online system, the agency's interim director announced Tuesday.
John Finan said the Department of Employment and Workforce will eliminate one-on-one help with unemployment claims June 10, and the number of local offices offering job training and other re-employment services will shrink.
Twelve offices are expected to remain open. Besides the Aiken office, others include office in Lancaster, Greenville, Beaufort, Aiken, Columbia, Florence, Sumter, North Charleston, Greenwood, Spartanburg, Conway and Anderson. These sites will offer all re-employment services, as well as computer access and help with online claims filing. Local officials are choosing various ways to continue services throughout their region, from mobile units to satellite offices, he said.
Finan said the department's declining workload – processing 50,000 claims that were filed weekly compared to nearly 140,000 in early 2011 – required a statewide restructuring that brings South Carolina in line with how most states already handle claims, he said. "We were way out of touch with other states in the country. We're coming up to modern times with technology," Finan said. He insists that the continued downsizing creates an opportunity to shift the agency's focus. "We're trying to refocus from unemployment, which has been the mantra for the office, to re-employment," Finan said.
"We need to work on innovative things the state can do and locals can do to really put people to work."
Affected workers will receive notices this week. The vast majority of layoffs will come from local offices.
The agency is partnering with technical schools, libraries, churches and community groups to provide computer access in all counties.
Legislators have complained that many laid off workers may lack the computer skills to file online. The upgraded website now includes a tutorial, and people can call a toll-free number to guide them through the steps. Statewide, 98 percent of initial claims already are filed online, according to the agency.
The upcoming layoffs will reduce agency costs by $5 million to $6 million, Finan said.
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subset: commoncrawl


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Frank Mir Receives TRT Exemption for UFC 169 Fight with Alistair Overeem
Frank needs all the help he can get.
Frank Mir has been granted a therapeutic-use exemption for testosterone-replacement therapy for his fight with Alistair Overeem this Saturday at UFC 169.
The heavyweight fighter today confirmed the news to MMAjunkie. A representative of the New Jersey State Athletic Control Board did not immediately respond to requests for confirmation.
Mir will enter the event on a three-fight losing streak, including defeats to former champion Junior dos Santos, Daniel Cormier and Josh Barnett.
The former heavyweight titleholder also received an exemption for his UFC 164 bout with Barnett, which he lost via controversial first-round knockout this past August. That was the second time that Mir has publicly received a TUE for one of his fights. He was also granted one for his UFC 146 championship contest against dos Santos in Las Vegas.
The matchup with Overeem (36-13 MMA, 1-2 UFC) is significant for Mir (16-8 MMA, 14-8 UFC) and his future, as a loss could mark the end of a UFC tenure that dates back to 2001 and includes more than 20 bouts inside the octagon.
UFC 169 takes place Saturday at Prudential Center in Newark, N.J. The main card airs on pay-per-view following prelims on FOX Sports 1 and UFC Fight Pass.
UFC President Dana White has had a back-and-forth stance on TRT, the latest change coming after the Association of Ringside Physicians began a push to eliminate all therapeutic-use exemptions from the sport.
Other known users of TRT currently on the UFC roster include Vitor Belfort, Chael Sonnen and Dan Henderson. Overeem in 2012 tested positive for elevated testosterone-to-epitestosterone levels and was removed from a title fight with dos Santos and replace by Mir. When Overeem returned for a fight in Las Vegas against Antonio Silva, a third-round loss, he tested with lower than normal T-E levels.


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A genealogy blog focused on families settling in East Tennessee and the Northern Neck of Virginia with explorations of Rusyn roots.
Wednesday, March 28, 2012
New Sister - Wordless Wednesday
My grandmother, Iva Williams Sawyer, with her eldest daughter and my mother, Carolyn Sawyer, c. March 1929. This is the first picture we have of Mother.
9 comments:
What a precious portrait!ReplyDelete
I love this -- and since we're both new grandmothers, we can appreciate the sentiment.ReplyDelete
awwww, what a great photo with you baby mother looking right at her older sister.ReplyDelete
Very sweet photo of your family here. Thanks for sharing!ReplyDelete
Agree with the others, this is a great photo! Brimming with emotion and awe.ReplyDelete
- AnonymousMarch 28, 2012 at 10:53 PM
Simply beautiful!ReplyDelete
Priceless! Love the soft background and the way they are both looking at the baby. Hope you have it in a frame somewhere.ReplyDelete
Beautifully composed -- all the attention toward the baby whose face is the only one we see in its entirety. A precious family artifact. Hope all is well with you, Susan. Sorry I haven't caught up in a while.ReplyDelete
A beautiful photo Susan, so sweet!ReplyDelete
Comments related to the information shared here are most appreciated. All comments are moderated, and since I am not actively researching right now it many take a day or two for your comment to post. Please know that it will post, and that I much appreciate the feedback.


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A Prophetic Dream
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Topic: A Prophetic Dream (Read 1084 times)
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< Moderator >
Posts: 8522
A Prophetic Dream
November 25, 2009, 05:16:00 AM »
This prophetic dream was posted by a FB friend of mine........
To the Five Fold Ministry.
Last night I had a very prophetic profound dream that I believe I've ever had. I woke up with that mere thought quite deeply. I was supposed to take the weekend off but the Lord had me to stop and share this with you.
The Dream
"The Red Carpet!"
"I was in view of the earth (globe) as a whole. And as I took a closer look, I saw the worlds largest Red Carpet! It extended from one end of the earth to the other! As I took a closer look, there were people walking on it, kind of like walking down the run way of a red carpet. Yes, they look quite prestigious and in control, confident, head lifted high. And as I took a closer look, I realized that these people were Ministers, Preachers, and Pastors etc.
And all of a sudden a wind came rushing down and the heavens thundered the earth shook! Many began to waiver! And many remained still unmoved, and some had no body control so they just fell straight to the ground!
And all of a sudden there was a loud sound like someone moving a large piece of furnisher on wooden floors from end of the room to the other! You could hear the loud screech on the floor. And then loud foot steps were heard, like walking down a flight of old wooden steps! Stomp! Stomp! Stomp! I recognized those steps so I fell to my face! I knew those were the steps of a BIG GOD! Some of the preachers on the red carpet looked up, some were clueless and some didn't care. And low and behold, God himself had walked down, HE came down! He stood there in silence for a brief moment and watched their reactions. And he then bent down. He took his right hand and grabbed one end of the carpet and He yanked out from under their feet! Everyone heard the whsss..! Some preachers fell to their face! Bam! Some stood there unmoved. I then noticed that the ones that were unmoved were floating on the carpet, their feet did not touch the ground, and I knew that these were the ones that were standing on the true supernatural power of God! Some I recognized. Some I didn't. God then brushed aside the ones that fell and didn't touch the others that were floating.
God then did the most amazing thing He took the red carpet and made it supernaturally disappear! With the snap of his finger, it was gone! Snap! And then He brought out a new carpet! It was a super white carpet. It was so white that it hurt the natural eye by just looking at it! He then gently and so purely rolled it out... It was so white, clean and pure. He then spoke and said;
"It is clean and pure. Keep it clean and pure. I AM."
The ones that were standing on the white carpet were so aware of what was going on They feared God! And all of a sudden their feet hit the ground! They all immediately began taking their shoes off one at a time. And they began walking in the most "pure humility" because they knew that God had raised the standard of holiness in the most pure way. The carpet was narrow and they walked on it with bare feet, it was the only way."
Church as we know it, no longer is, it no longer works. God is know shifting the spiritual atmosphere. God has come down to judge the secret things. Judgment first comes to the house of the Lord.
Last Edit: November 25, 2009, 05:35:36 AM by Cardinal
"I would rather train twenty men to pray, than a thousand to preach; A minister's highest mission ought to be to teach his people to pray." -H. MacGregor
Posts: 11318
Re: A Prophetic Dream
Reply #1 on:
November 25, 2009, 05:29:29 AM »
8And an highway shall be there, and a way, and it shall be called The way of holiness; the unclean shall not pass over it; but it shall be for those: the wayfaring men, though fools, shall not err therein.
9No lion shall be there, nor any ravenous beast shall go up thereon, it shall not be found there; but the redeemed shall walk there:
10And the ransomed of the LORD shall return, and come to Zion with songs and everlasting joy upon their heads: they shall obtain joy and gladness, and sorrow and sighing shall flee away.
--Isa 35
Posts: 1830
I watch, & am as a sparrow alone upon the rooftop.
Re: A Prophetic Dream
Reply #2 on:
November 25, 2009, 05:32:09 AM »
Well, Amen. One day, we will all be thoroughly humbled and will see Him, and we'll ALL fall face down. But you are right, let the dross in us be burned, and that goes also for the "leaders, pastors, preachers, etc." like you mentioned. The prosperity preachers, the fake healers, the ET fear preachers, and those who are fleecing their flock, selling God for a few bits of gold. We all will be purified of that within us that does not reflect Him.
In the end, once all the dross is finally burned away, we'll realize that we are all brothers and sisters. We are all children of God.
"I knelt to drink,
And knew that I was on the brink
Of endless joy. And everywhere
I turned I saw a wonder there."
If I speak in the tongues of men and of angels, but have not love, I am a noisy gong or a clanging cymbal. And if I have prophetic powers, and understand all mysteries and all knowledge, and if I have all faith, so as to remove mountains, but have not love, I am nothing. If I give away all I have, and if I deliver up my body to be burned, but have not love, I gain nothing.
Posts: 11318
Re: A Prophetic Dream
Reply #3 on:
November 25, 2009, 05:38:36 AM »
I liked this part--
Some stood there unmoved. I then noticed that the ones that were unmoved were floating on the carpet, their feet did not touch the ground, and I knew that these were the ones that were standing on the true supernatural power of God!
]Malachi 3:2
But who may abide the day of his coming? and who shall stand when he appeareth? for he is like a refiner's fire, and like fullers' soap:
< Moderator >
Posts: 8522
Re: A Prophetic Dream
Reply #4 on:
November 25, 2009, 06:05:46 AM »
Me too..........standing just like Jesus stood on the water.
"I would rather train twenty men to pray, than a thousand to preach; A minister's highest mission ought to be to teach his people to pray." -H. MacGregor
Posts: 499
Re: A Prophetic Dream
Reply #5 on:
November 25, 2009, 07:58:50 PM »
yup...we know it is going to happen!
the only thing that rises up as a warning in me(very strong)...is the friends we have in the old church system.They will become very mean and all I want to say is be very wary.They will want to hurt you ,they will despise you so be very careful.
This will happen I sense it deeply again.It is very sad to see our friends go through this but keep hope God will reconcile all things
< Moderator >
Posts: 5576
Grace & Peace be multiplied unto you, in Jesus
Re: A Prophetic Dream
Reply #6 on:
November 25, 2009, 09:31:20 PM »
Behold, the axe is laid to the root of the trees
I am the vine, ye are the branches: He that abideth in me, and I in him, the same bringeth forth much fruit: for without me ye can do nothing. If a man abide not in me, he is cast forth as a branch, and is withered; and men gather them, and cast them into the fire, and they are burned.
(Joh 15:5-6)
And the Lord said, Who then is that faithful and wise steward, whom his lord shall make ruler over his household, to give them their portion of meat in due season? Blessed is that servant, whom his lord when he cometh shall find so doing. Of a truth I say unto you, that he will make him ruler over all that he hath. But and if that servant say in his heart, My lord delayeth his coming; and shall begin to beat the menservants and maidens, and to eat and drink, and to be drunken; The lord of that servant will come in a day when he looketh not for him, and at an hour when he is not aware, and will cut him in sunder, and will appoint him his portion with the unbelievers.
(Luke 12:42-46)
Now if any man build upon this foundation gold, silver, precious stones, wood, hay, stubble; Every man's work shall be made manifest: for the day shall declare it, because it shall be revealed by fire; and the fire shall try every man's work of what sort it is. If any man's work abide which he hath built thereupon, he shall receive a reward. If any man's work shall be burned, he shall suffer loss: but he himself shall be saved; yet so as by fire.
(1Co 3:12-15)
The Logos is complete, but it is not completely understood.
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Drug Compare
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- Basic Info
Generic: potassium phosphate
It is used to treat or prevent low phosphate levels in the body
What is this medicine?PHOSPHORUS SALTS (FOS fer uhs sawlts) are used to increase the amount of phosphorus in the body. It is used to treat or prevent low phosphate levels in the body.
What should I tell my health care provider before I take this medicine?They need to know if you have any of these conditions:
How should I use this medicine?This medicine is for infusion into a vein. It is given by a health care professional in a hospital or clinic setting.
Talk to your pediatrician regarding the use of this medicine in children. Special care may be needed.
What if I miss a dose?This does not apply.
What may interact with this medicine?Do not take this medicine with any of the following medications:
This medicine may also interact with the following medications:
What should I watch for while using this medicine?Your condition will be monitored carefully while you are receiving this medicine.
What side effects may I notice from receiving this medicine?Side effects that you should report to your doctor or health care professional as soon as possible:
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About Mumbai
Mumbai is a city of sharp contrasts. By day - as the country's commercial hub - it pumps vast amounts of cash into India's booming economy. By night, its vibrant nightclubs throng with fashionistas and film stars. Yet despite having the honour of being the largest and richest city in India, more than half of Mumbai's 12 million inhabitants live in slum conditions.
Originally a fishing colony spread over seven islands on the Konkan coastline, Bombay (as it was previously known) was controlled by a series of indigenous empires before being ceded first to the Portuguese, and eventually to the British. India achieved independence in 1947 but it was not until 1995 that the city was renamed Mumbai.
Today the cosmopolitan, multicultural city is home to striking colonial architecture, Bollywood – the globally-influential Hindi film and TV industry, and is the perfect springboard for regional Indian travel.
With 21 million people in its metropolitan area, Mumbai is a vast and sprawling city. It doesn't offer the wealth of historical attractions of Kolkata or Delhi, but there are a number of attractions which are well worth visiting.
An architectural highlight in Colaba – and usually the first place tourists head to – is the Gateway of India. The most recognisable remnant of the British Raj, the yellow basalt Gateway marked the final departure point of the British when they left in 1947. From here, take a boat to Elephanta Island, 6km offshore. The island is famous for the UNESCO World Heritage Site caves which contain rock-hewn sculptures that date back to the 5th century.
Back on dry land, visit another UNESCO World Heritage Site: the Chhatrapati Shivaji Terminus, formerly known as Victoria Terminus Station. An outstanding example of Victorian 'Gothic Revival' architecture, its remarkable stone dome, turrets, pointed arches and eccentric ground plan are an example of the meeting of two cultures, as British architects worked with Indian craftsmen to create a masterpiece.
Finally, see how the other half – literally – live with a tour of Dharavi. Featured heavily in the Danny Boyle film, Slumdog Millionaire, Asia's largest slum is an eye-opening insight to how more than six million Mumbaikers exist. Most tours are run by local students and include a trip to Mahalaxmi's Dhobi Ghat, the world's largest open air laundry.
Dining and Nightlife
If you search hard enough you'll find food from all over the world – including China, Japan, Italy, Lebanon and Iran – in Mumbai. Decadent European-style brunches are popular in areas such as Bandra and Juhu, but to get a real flavour of the city it pays to sample Indian food. Delicacies from all over the country are widely available, plus, of course, Mumbai's traditional coastal (Konkan) cuisine.
Restaurants can be found on virtually every street, but good areas include Matunga and Fort (for Udipi and Goan), King's Circle (Madras) and Colaba (Mughlai and Punjabi). If you're ravenous, consider a Thali restaurant and hope you've got a few extra holes left on your belt.
While out and about it's likely you'll be tempted by the delicious aroma of the street food; snacks such as vada pav and pani puri are perfect for a traveller on the go. But, as with elsewhere in India, be careful where you eat – hygienic versions of street food are available from take-away windows in areas such as Tardeo, Bandra and Chowpatty and provide all the flavour with none of the ill effects.
Mumbai by night is just as busy as by day. The best way to navigate the best bars, nightspots and live music venues (which tend to be centred in Bandra, Juhu and Colaba) is via a local listings magazine. Be warned, the nightclubs in the 'city that loves to party' close earlier than their Western counterparts.
Beyond Mumbai
Take a day trip to Matheran, a Hill Station around two hours from Mumbai. At 800 metres above sea level, the temperature at the plateau is pleasant year round and its lush greenery, waterfalls and lakes make for scenic viewing. Motorised vehicles are banned in Matheran, ensuring visitors enjoy some needed tranquillity after the crowds and chaos of Mumbai. Walking, hiking and horse riding are popular and relaxing activities, and a number of lookout points provide spectacular views of the surrounding hills and valley.
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American Lung Association
Family Doctor—American Academy of Family Physicians
The College of Family Physicians of Canada
The Lung Association
2015 Immunization schedules. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/vaccines/schedules/easy-to-read/index.html. Updated January 26, 2105. Accessed February 18, 2015.
Blasi F, Aliberti S, et al. 100 years of respiratory medicine: Pneumonia.
Respir Med. 2007;101(5):875-881.
Braunwald E, Harrison TR, et al.
Harrison's Principles of Internal Medicine. 17th
ed. Columbus, OH: McGraw-Hill; 2008.
Carpenter CC, Andreoli TE, et al.
Cecil Essentials of Medicine. Philadelphia, PA: Elsevier Science; 2003.
Community-acquired pneumonia in adults. EBSCO DynaMed website. Available at:
http://www.ebscohost.com/dynamed. Updated December 5, 2014. Accessed February 18, 2014.
De Roux A, Marcos MA, et al. Viral community-acquired pneumonia in non-immunocompromised adults.
Chest. 2004;125(4):1343-1351.
Explore pneumonia. National Heart Lung Blood Institute (NHLBI) website. Available at:
http://www.nhlbi.nih.gov/health/health-topics/topics/pnu. Updated March 1, 2011. Accessed February 18, 2015.
Niederman MS. Recent advances in community-acquired pneumonia inpatient and outpatient.
Chest. 2007;4:1205-1215.
Niederman MS. Review of treatment guidelines for community-acquired pneumonia.
Am J Med. 2004;117:Suppl 3A:51S-57S.
10/29/2009 DynaMed Systematic Literature Surveillance
http://www.ebscohost.com/dynamed: Hemila H, Louhiala P. Vitamin C for preventing and treating pneumonia.
Cochrane Database Syst Rev.
10/21/2013 DynaMed's Systematic Literature Surveillance
http://www.ebscohost.com/dynamed: Hemilä H, Louhiala P. Vitamin C for preventing and treating pneumonia. Cochrane Database Syst Rev. 2013;8:CD005532.
3/10/2014 DynaMed's Systematic Literature Surveillance
http://www.ebscohost.com/dynamed: Su VY, Liu CJ, et al. Sleep apnea and risk of pneumonia: A nationwide population-based study. CMAJ. 2014;186(6):415-421.
6/17/2014 DynaMed's Systematic Literature Surveillance
http://www.ebscohost.com/dynamed: Reissig A, Copetti R, et al. Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: A prospective, multicenter diagnostic accuracy study. Chest. 2012;142(4):965-972.
2/3/2015 DynaMed's Systematic Literature Surveillance
http://www.ebscohost.com/dynamed: Rantala A, Jaakkola JJ, et al. Respiratory infections in adults with atopic disease and IgE antibodies to common aeroallergens. PLoS One. 2013;8(7):e68582.
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With Kidkraft's new Dora the Explorer™ Play Kitchen, young girls get to cook up a good time with one of their favorite TV characters. With its precious artwork and interactive features, this wooden play kitchen is simply a-Dora-ble!
- Burners light up and make realistic cooking sounds
- Molded plastic terracotta style roof
- Knobs clock and turn
- Removeable sink
- Oven, microwave, and cabinet doors open
- Licensed Nickelodeon Dora the Explorer product


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CHATTANOOGA, Tenn. --- The University of Tennessee at Chattanooga women's soccer team posted a 5-0 win over Tennessee Temple Friday night at Finley Stadium, scoring all five goals in the first half. The Mocs improve to 1-1 on the year and Tennessee Temple drops below .500 at 1-2.
Sophomore Hannah Wyatt (Soddy Daisy, Tenn.) led Chattanooga with a pair of goals and an assist for five points, tied for 10th most in school history in a single game.
Junior Crystal Mackezyk (Columbia, Tenn.) got the scoring started with a goal in the 10th minute on a feed up the middle from freshman Monica Speth (Janesville, Wisc.), beating out the defense for the score. Just over two minutes later, sophomore Clare Latham (Cordova, Tenn.) connected on a goal on an assist from Wyatt from the left side to the middle of the box.
Wyatt took a pass from Speth on the left side into the box for her first goal and was fed by Mackezyk up the middle on her second in the 22nd minute. Sophomore Melanie Arredondo (Tampico, Mexico) lofted a pass from near midfield over the heads of the Temple defenders and it bounced past the keeper and into the lower right side for the score.
The Mocs outshot the Crusaders 11-1 in the first half but the two evened out the second half with each getting three shots. Chattanooga keeper Lauren Thomas (Germantown, Tenn.) played all 90 minutes in goal and pulled in three saves on four shots by Tennessee Temple.
Mackezyk had a game-high four shots with one goal and one assist. Speth took three shots on the night, including one that glanced off the post, and assisted on two goals. Both of Wyatt's shots found the back of the net and Latham took two shots with both on goal, including one into the net.
The Mocs will head out for their first road game of the season. They will take on Alabama State Sunday afternoon at 1 p.m.


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English, English as a Second Language, Math, Science, Spanish as a Foreign Language, Special Education
Detailed information about eligibility and requirements is available here.
Program Stats:
- TEACH Charlotte launched in 2011
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- 230 participants trained to date
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The curriculum aims to help children be successful learners, confident individuals and responsible citizens. Talking about different families is very important in order to achieve these aims. Children will learn better and will be more engaged if they find their experiences and their family reflected in class and they will grow up to be more confident if they feel included. In order to prepare children for the diverse society they live in and to prevent poor behaviour and bullying, it is important to talk about difference in general and different families in particular.
In 2010 Stonewall published a report on Different Families based on interviews of children with lesbian and gay parents. In this report children explain why they think it is important to talk about these issues in class. In the Teachers' Report, based on a survey with over 2,000 primary and secondary school staff, teachers explain why they think talking about these issues is important.
Talking about different families, including those with lesbian and gay parents, doesn't have to be difficult. Stonewall's Education Guide Including Different Families provides advice on how to address gay and lesbian issues in the classroom, and how to ensure your teaching reflects the reality of life in the 21st century. In fact talking about different relationships is part of the curriculum. It also doesn't require teaching anything special or differently – it simply means being aware that some children have lesbian, gay or bisexual parents, accepting that civil partnerships are a reality and answering questions and challenging assumptions in a language children understand. Books about different relationships and families can be discussed as part of circle time or can be used as part of literacy.
Many primary school teachers are already laying the foundations for a society without discrimination and where everybody can be themselves. The Teachers' Report features some good practice examples on how to talk about different families or lesbian and gay issues in class.
The primary curriculum includes topics like family, relationships, difference and bullying. Especially in SEAL, PSHEE and literacy but also during circle time and in any other subjects, teachers can make clear that everyone is different and talk about the fact that civil partnership is marriage between two men or two women.
It is important to work with parents and carers to promote good behaviour and to establish an inclusive learning environment. Many parents are supportive of this kind of work and understand how it relates to creating a society without discrimination. Every school has their own way of engaging and communicating with parents and while some schools choose to involve parents in many different aspects of their work, others might have a different approach. It is important that the senior management team is on board and behind the work and that the school is prepared to have a dialogue with parents if there are any concerns. You can also direct them to the parent and carer section of our website for more information.
Schools should be aware that some of their pupils will have gay, lesbian and bisexual parents and these parents deserve to feel welcome. The parents should also be reassured that their child is welcome to talk about their family in school, that pupils will be taught about lesbian and gay relationships and that homophobic language and bullying will be tackled, should it arise. There is legislation in place which makes it illegal for schools to discriminate against lesbian, gay and bisexual people.


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Google found an interesting way to launch the Google Wallet app for Android: as an over-the-air update for Sprint Nexus S 4G phones. Google Wallet makes use of the NFC chip from Nexus S phones and allows you to make credit card payments at physical stores using your Android smartphone.
"Google Wallet enables you to pay with your Citi MasterCard credit card and the Google Prepaid Card, which can be funded with any of your existing plastic credit cards. As a thanks to early adopters, we're adding a $10 free bonus to the Google Prepaid Card if you set it up in Google Wallet before the end of the year," informs Google. The Google Prepaid Card is powered by MasterCard and Money Network and it's a temporary solution until you can add credit cards from other companies. Google says that the application could add support for Visa, Discover and American Express cards in the future.
Google Wallet is more than a contactless payment solution: it's a virtual wallet that could store information about your credit cards, coupons, loyalty cards, gift cards, tickets and much more. It's also a great opportunity for Google to integrate Google Offers and make it easier to use by allowing consumers to pay, redeem offers and earn loyalty points in a single step using their mobile phone. Google says that it doesn't have access to the list of products you buy, but this feature could be added in the future.
While Google Wallet seems to be a convenient solution, many people might not use it because of privacy or security reasons. Google says that the payment credentials are stored in a separate chip called Secure Element and only authorized programs can initiate transitions. Google Wallet users need to enter the PIN to confirm a payment, so someone who finds an Android phone can't use the app because he doesn't know the code.
Google's vision is to create "an open commerce ecosystem" that will support many payment instruments, APIs that enable adding loyalty points, transferring offers, receipts and more. Google Wallet is Google Checkout's extension to offline payments and it's a big opportunity for Google to create a successful payment system. PayPal will soon offer a similar service and Apple's iPhone 5 could include a NFC chip, so Google Wallet will have some competition.
Answer: Identify these three insects
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Only hotels in Everman are listed below. Find discounted hotel accommodations in or close to Everman, TX for your upcoming personal or group travel. We show the best Everman, Texas hotel and motel rooms. Browse the Everman area hotels to find the perfect lodging! Please use the provided map of the Everman hotels.The Everman center is around 4 miles from Fort Worth Spinks Airport and 5 miles from Kennedale Performing Arts Center.
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