A common assumption is that outreach-based HIV counseling and testing services reach a clientele with a higher HIV seroprevalence than clinic-based counseling and testing. To examine this assumption, we analyzed Wisconsin's anonymous counseling and testing client records for 62,299 contacts (testing episodes) from 1992 to 1995. Bivariate analysis of counseling and testing service setting (outreach-based or clinic-based) and HIV test results suggested that outreach contacts were 23% (odds ratio [OR], 1.23; 95% confidence interval [95% CI], 1.0-1.5) more likely to test HIV-seropositive than clinic-based contacts. Relations between HIV test outcome and variables for client age, race, gender, previous testing history, mode of risk exposure, and region, as well as service setting, were examined by logistic regression. An inverted relation between service setting and seropositivity (OR, 0.65; 95% CI, 0.5-0.8) indicated that, within some subpopulations, outreach contacts were significantly less likely to test HIV-positive than clinic-based contacts. Analysis of interactions among the covariates identified race as a critical codeterminant in the relation between service setting and test outcome. These results support retargeting outreach services to enhance their overall effectiveness. Specific recommendations include the need for aggressive strategies to better "market" HIV counseling and testing to nonwhite populations, and to focus resources more selectively on gay/bisexual men of all races.
PIP: The assumption that outreach-based HIV counseling and testing services reach a clientele with a higher HIV seroprevalence than similar clinic-based services was investigated as part of a comprehensive evaluation of the state of Wisconsin's (US) HIV counseling and testing program in 1992-95. Client records were available for 62,299 anonymous outreach- and clinic-based testing episodes. 0.9% of outreach and 0.8% of clinic clients tested HIV-positive. Although contacts in the high-exposure risk group were 13.7 times more likely to be HIV-infected than those in lower risk categories, they were only 1.9 times more likely to have been served in an outreach setting. Among non-White counseling and testing clients, the odds of selection through outreach (odds ratio (OR), 3.34; 95% confidence interval (CI), 3.2-3.5) was similar to the overall seropositivity risk (OR, 3.01; 95% CI, 2.5-3.6). An inverted relation between service setting and seropositivity (OR, 0.65; 95% CI, 0.5-0.8) indicated that, within some subpopulations, outreach contacts were significantly less likely to test HIV-positive than clinic clients. In fact, multivariate analysis revealed a negative association between HIV positivity and outreach when demographic and contextual factors were controlled. 22% of HIV-positive White male clients who reported sex with men were identified through outreach, but this was the only risk exposure category for Whites in which the proportion of outreach among seropositive cases exceeded the overall success rate for outreach (20.5%). Men reporting sex with men represented 41.5% of all seropositive cases among non-Whites. These findings indicate a need to re-target outreach services, especially toward non-Whites and gay/bisexual men, to enhance their overall effectiveness.