We compared the reported gender of sex partners in 2 statewide HIV databases that contained individual-level risk behavior data on newly diagnosed young men in North Carolina. PCRS records, which document postdiagnosis interviews for partner notification, provided higher levels of self-report of nonheterosexual behaviors than CTR data collected at the time of testing.
The difference may be partially attributed to the different rationales for the PCRS and CTR risk assessments. During PCRS counseling, complete risk assessment information is needed so that all sex partners can be notified. Alternatively, CTR counselors use the risk assessment for prevention counseling and may not focus on obtaining complete information on sex partners. As a result, PCRS and CTR counselors use different techniques and may have different levels of persistence in obtaining sensitive information from clients. PCRS counselors also have the opportunity to meet with clients multiple times in different locations, whereas CTR counselors usually have limited time for test counseling. Additionally, at the time of the CTR risk assessment, clients may perceive themselves as HIV uninfected, whereas at the time of the PCRS interview they have been diagnosed. The knowledge of the infection likely affects clients’ reflections on their past behaviors and may influence disclosure.
Social exchange theory proposes that persons choose when, and with whom, to disclose sensitive or stigmatizing information on the expected benefits and anticipated costs of disclosure.22
As accurate disclosure during partner notification helps ensure that all past partners can be tested and receive treatment if infected, clients may feel that it is socially desirable to provide accurate information on all sex partners or feel legally obligated to disclose. Alternatively, for some men, the perceived costs of complete disclosure might be higher during PCRS counseling (e.g., fear of partner retribution23
) than during CTR counseling (e.g., perceived as more anonymous).
MSMW behavior had the lowest level of agreement between the databases and the lowest sensitivity measure in the CTR database. Patterns of disclosure were varied, with some men naming sex partners of both genders during PCRS and disclosing only MSM behavior to their CTR counselor. This suggests that for some men, disclosing MSM behavior is different from disclosing MSMW behavior. Differences in disclosure patterns of MSMW behavior by race may indicate different social norms around reporting these behaviors.
This analysis was limited to young men. Patterns of disclosure of the gender of sex partners may vary for women and older men. In this sample, men diagnosed at CTR sites differed from men testing in private facilities by demographics and reported risk behaviors. It is possible that they also differed in the disclosure patterns of those behaviors. The analysis was limited to cases that were reported to the NCDHHS and entered into the PCRS system. However, with over 90% of all cases contacted, the PCRS is the most comprehensive statewide behavioral database of HIV-infected persons.10
Data missing on specific variables, including cases that could not be linked between PCRS and CTR, were less than 5% and should have a minimal impact on the results. Additionally, it is theoretically possible that a client changed behaviors during the time between the CTR session and the PCRS interview (e.g., he reported no sex partners, but had sex immediately after the test counseling session); unfortunately, we were not able to assess this possibility.
Although the risk assessment time frame differed between the data sets (past year versus lifetime), resulting in possible misclassification of noncongruence of reported gender of sex partners, we adjusted agreement statistics using a sample with perfect assessment period overlap. The majority of estimates changed only slightly, suggesting that nonconcordance was probably not influenced by assessment period issues. The validation sample was not random, but rather based on the last 6 months of the study period when the risk assessment period had changed. Consequently, the validity of our corrected estimates rests on the assumption that the validation sample represents the true congruence between the data sets over the entire study period.
After comparing the gender of sex partners disclosed by clients during HIV test counseling and during postdiagnosis interviews, we observed that many clients disclosed the gender of sex partners differently, which suggests that self-reported behavioral data should be interpreted with caution. In this sample, CTR data on the gender of sex partners appears less complete than PCRS data. The inaccurate disclosure of the gender of sex partners during testing may affect the efficacy of prevention counseling. A male client may have unprotected sex with men and women, but only disclose that he has sex with women. In this case, there is a missed opportunity to provide risk education and develop a risk reduction plan specific to same-gender sexual contact (e.g., the differential risks related to insertive versus receptive sex).
At a population level, the misreporting of risks affects the evaluation of the CTR programs, as the database may not accurately describe the population testing at CTR sites. In this study, 28% of the men classified as heterosexual on the basis of CTR data were reclassified when PCRS data were used to assign risk categories. If CTR data are used exclusively to inform mode of transmission, surveillance data in the HIV/AIDS Reporting System may be skewed as well. Our findings also suggest the ineffectiveness of using a risk assessment to screen for testing. For example, the 25 men who reported no lifetime sex partners may not have been tested and subsequently diagnosed.
Although the CDC no longer recommends pretest counseling,24
prevention counseling is encouraged for high-risk clients, such as patients in STD clinics,25
and current HIV-testing guidelines for NCDHHS-funded clinics require that a risk assessment be documented for each test.16
NCDHHS guidelines suggest that the assessment can be performed in a variety of ways, including a self-administered questionnaire. 16
One method that may allow for more complete risk disclosure is audio- and computer-assisted self-interviews. In a survey of blood donors using audio- and computer-assisted self-interviews, 67% said they were more truthful than in face-to-face interviews and thought the methods were clear (91.8%) and private (92.3%).26
Among clients using audio-and computer-assisted self-interviews in an STD clinic, 56% reported preference for audio- and computer-assisted self-interviews compared with face-to-face interviews and 82% reported more honest responses.6
This analysis highlights the differences between client-reported gender of sex partners during the CTR and PCRS risk assessments. Further research is needed to understand barriers and facilitators to disclosure of risk behaviors. Investigation of the feasibility and cost-effectiveness of widespread use of audio- and computer-assisted self-interviews for risk assessments during HIV test counseling in publicly funded clinics may be warranted.