2. HIV counseling and testing in a tertiary care
hospital in Ganjam district, Odisha, India
Dash M, Padhi S, Sahu S, Mohanty I, Panda P, Parida B, Sahoo MK
ABSTRACT
Background: Human immunodeficiency virus (HIV) counseling and testing (HCT) conducted at integrated
counseling and testing centers (ICTCs) is an entry point, cost‑effective intervention in preventing transmission of
HIV. Objectives: To study the prevalence of HIV among ICTC attendees, sociodemographic characteristics, and
risk behaviors of HIV‑seropositive clients. Materials and Methods: It was hospital record‑based cross‑sectional
study of 26,518 registered ICTC clients at a tertiary care hospital in Ganjam district, Odisha, India over a 4‑year
period from January 2009 to September 2012. Results: A total of 1732 (7.5%) out of 22,897 who were tested
for HIV were seropositive. Among HIV‑seropositives, 1138 (65.7%) were males, while 594 (34.3%) were
females. Majority (88.3%) of seropositives were between the age group of 15‑49 years. Client‑initiated HIV
testing (12.1%) was more seropositive compared to provider‑initiated (2.9%). Among discordant couples,
majority (95.5%) were male partner/husband positive and female partner/wife negative. Positives were more
amongst married, less educated, low socioeconomic status, and outmigrants (P<0.0001). Risk factors
included heterosexual promiscuous (89.3%), parent‑to‑child transmission 5.8%, unknown 3.1%, infected blood
transfusion 0.8%, homosexual 0.5%, and infected needles (0.5%). Conclusions: There is need to encourage
activities that promote HCT in all health facilities. This will increase the diagnosis of new HIV cases. The data
generated in ICTC provide an important clue to understand the epidemiology in a particular geographic region
and local planning for care and treatment of those infected with HIV and preventive strategies for those at
risk especially married, young adults, and outmigrants to reduce new infections.
KEY WORDS: Counseling, human immunodeficiency virus, integrated counseling and testing center,
seroprevalence, testing
Department of
Microbiology, Maharaja
Krushna Chandra
Gajapati Medical College
and Hospital, Berhampur
University, Berhampur,
Odisha, India
Address for correspondence:
Dr. Muktikesh Dash,
E‑mail: mukti_mic@yahoo.
co.in
Received : 25‑12‑2012
Review completed : 04‑03‑2013
Accepted : 05‑04‑2013
Introduction
Original Article
T he global pandemic of human immunodeficiency virus/
acquired immunodeficiency syndrome (HIV/AIDS) in
its third decade has grown into a major public health program
of alarming magnitude. According to Joint United Nations
Programme on HIV/AIDS (UNAIDS) organization,
approximately 34.2 million people are living with HIV/AIDS
(PLHAs) worldwide as of 2012.[1] Though India is categorized as
a low HIV prevalence nation, it has the third largest number of
PLHAs.[2] There are an estimated 2.39 million PLHAs of which
39% are females and 3.5% are children with an adult prevalence
of 0.31% among general population (2009).[2] This accounts for
nearly 15% and 75% of the HIV burden of the world and South/
Southeast Asia, respectively.[3] Odisha state (eastern India)
with its population crossing 4.19 crore has an estimated 71,813
PLHAs with an adult prevalence of 0.29%.[4] The population
of Odisha state is about 3.46% of the population of India, and
there are an estimated 9% new infections in 2009.[4]
HIV counseling and testing (HCT) services were started in
India in 1997. There are more than 9400 integrated counseling
and testing centers (ICTCs), mainly located in the government
hospitals.[5] Under the National AIDS Control Programme‑III,
voluntary counseling and testing centers and facilities providing
prevention of parent‑to‑child transmission (PTCT) services are
remodeled as a hub or ICTCs to provide services to all clients
under one roof. ICTC is a part of HIV prevention program
and is a place, where a person gets counseling and testing of
its own will or as advised by a medical provider. ICTC for HIV
is a cost‑effective intervention in preventing the spread of
HIV, promotes behavioral change to reduce vulnerability, and
conducts HIV diagnostic tests in a comfortable, convenient,
and confidential manner.[5] It also links people with care
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DOI:
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 110 Journal of Postgraduate Medicine April 2013 Vol 59 Issue 2

3. Dash, et al.: HIV counseling and testing
and treatment services. This is both the entry point to
comprehensive HIV care and treatment as well as prevention;
hence, awareness and acceptance of ICTC services is vital, if
the HIV/AIDS epidemic is to be controlled.[6]
Ganjam district with its population of more than 3.5 million,
is spread over a geographical area of 8070 square kilometer
extending from 19.4° north latitude to 20.17° north latitude
and 84.7° east longitude to 85.12° east longitude. According to
Odisha state HIV statistics, 43% of all PLHAs are from Ganjam
district alone. From a total of 640 districts in India, Ganjam has
been identified as one of the 14 most critical districts affected
by HIV in the country.[7] There are more than 0.1 million
migrants and 90% of these migrate to high HIV destination
areas (Surat district in Gujarat, Mumbai, and Thane district
in Maharashtra).[7] With this background, the present study
was undertaken to find the profile of people seeking ICTC
services as also describing the prevalence of HIV among ICTC
attendees and various sociodemographic and epidemiological
characteristics.
Materials and Methods
The study area, population, and methodology
The present was carried out among ICTC attendees in
the Department of Microbiology, ICTC unit, in a tertiary
care referral hospital of Ganjam district, Odisha, India.
A retrospective collection of data from available records of all
clients who attended ICTC of our hospital between January
2009 and September 2012 was carried out after IRB approval.
The present study included 26,518 ICTC attendees, who were
either volunteers or referred by various departments of our
institute. The ICTC counselors collected their anonymous
and unlinked data in registers and logbooks as per National
AIDS Control Organization (NACO) guidelines under strict
confidentiality. Data accessed from the records included
age, sex, marital status, education and occupational status,
behavioral patterns and HIV status of the couples.
Sample collection and processing
All the ICTC attendees had relevant pretest counseling and
written informed consent was sought before HIV testing was
carried out. Five milliliters (mL) venous blood sample was
collected in a sterile plain container from all clients who
consented for HIV testing. Blood was allowed to clot for 30 min
at room temperature (25‑30ºC) and serum was separated after
centrifugation at low speed. The serum samples were then stored
at 4ºC and were tested within 24 h.
HIV serology
HIV antibodies were tested by the three rapid tests protocol
as per the guidelines laid down by the World Health
Organization (WHO testing strategy III) and the testing
policy of NACO, Government of India.[8] All positive test
results were disclosed only after posttest counseling of the
patients. Antibodies to HIV (1 and 2) were tested initially
with a SD BIOLINE HIV‑1/2 3.0 rapid test (Standard
Diagnostics, Inc. Korea). The samples tested positive in the
first method were subjected to tests with two different
rapid tests, that is, PAREEKSHAK HIV 1/2 Triline Card
Test (Bhat Bio‑Tech India (P) Ltd.) and PAREEKSHAK HIV
1/2 Rapid Test Kit (TRISPOT) (Bhat Bio‑Tech India (P) Ltd.)
The samples were considered as positive when found reactive
by all three different methods. All tests were done according to
manufacturer’s instructions.
Statistical analysis
The data were analyzed using the Chi‑square tests. The P values
were calculated using GraphPad QuickCalcs statistical software.
Statistical significance was defined when P value is less than 0.05.
Results
A total of 26,518 clients accessed HCT services during the study
period. Of these, 22,897 (86.3%) accepted HIV testing and rest
3621 (13.7%) clients did not agree for testing. Only 159 (0.7%)
clients did not turn up to receive posttest counseling after HIV
testing. Thus the uptake of HCT services was 85.6% [Table 1]. Out
of total 22,897 clients tested, 1732 were HIV‑seropositive giving a
prevalence of 7.5% [Table 1]. Out of total 22,897 clients received
HIV testing, 15,352 (67%) were males, while females constituted
7545 (33%). From 15,352 males, 1138 (7.4%) were positive, while
594 (7.9%) females out of 7545 were positive (P>0.05).
A majority (88.3%) of those who were HIV‑seropositive were
between the ages of 15 and 49 years. A total of 47.3% females
were positive within the age group of 25‑34 years followed by
174 (29.3%) within 35‑49 years, while 553 (48.6%) of males
were positive within the age group of 35‑49 years followed by
25‑34 years (33%).
Out of total 22,897 ICTC attendees those who received
HIV testing, 11,654 (50.9%) were client‑initiated counseling
and testing (CICT) and among them, 1409 (12.1%) were
HIV‑seropositive. From 11,243 (49.1%) clients who received
provider‑initiated counseling and testing (PICT), only
323 (2.9%) were positive.
Table 1: Year‑wise distribution of ICTC attendees in a tertiary care hospital, Odisha, India for the period 2009-2012
Year No. of clients received
pretest counseling
No. of clients received HIV testing
(% out of no. of pretest counseled)
No. of clients received posttest counseling
(% out of no. of tested)
No. of HIV‑seropositive
(% out of no. of tested)
2009 6688 5119 (76.5) 5062 (98.9) 570 (11.1)
2010 6945 5517 (79.4) 5470 (99.1) 406 (7.4)
2011 7206 6763 (93.8) 6734 (99.6) 461 (6.8)
2012* 5679 5498 (96.8) 5472 (99.5) 295 (5.4)
Total (%) 26,518 22,897 (86.3) 22,738 (99.3) 1732 (7.5)
ICTC – Integrated counseling and testing center; HIV – Human immunodeficiency virus; *Data compiled up to September 2012
Journal of Postgraduate Medicine April 2013 Vol 59 Issue 2 111 

4. Dash, et al.: HIV counseling and testing
Evaluation of the 681 couples showed that 347 (51%) were
concordant and 334 (49%) were discordant. Among discordant
couples, 319 (95.5%) were male partner/husband positive and
female partner/wife negative, while 15 (4.5%) were male partner/
husband negative and female partner/wife positive.
The distribution of cases according to their marital status
showed that 1488 (8.4%) out of all married persons were
HIV‑seropositive. Majority of HIV‑seropositives, that is,
1704 (6.9%) were less educated. Outmigrants showed high
positivity (7.8%) relative to others. Clients who stayed away
from their family were more likely to be HIV positive. The
number of HIV‑seropositivity among ICTC attendees based on
socio‑demographic variables, that is, marital status, occupation,
socioeconomic status, education, and living status were
statistically significant (P<0.0001) [Table 2].
The pattern of risk behavior among HIV‑seropositive males
was heterosexual with multiple sex partners 1021 (58.9%),
followed by unprotected heterosexual route in females
526 (30.4%). The next common route was PTCT 5.8% followed
by unknown routes (3.1%). The least common risk behavior
patterns were infected blood and blood products (0.8%),
homosexual behavior (0.5%), and through infected needles and
syringes (0.5%) [Figure 1].
Discussion
HIV prevention through the process of counseling and testing
is an important tool of intervention and control especially
in the absence of an effective vaccine or curative treatment.
Counseling for HIV consists of pretest, posttest, and follow‑up
counseling. Pretest counseling plays an important role in
improving the acceptability for HIV testing. ‘‘Opt‑in’’ or
‘‘opt‑out’’ approaches have been used while offering HIV
testing. In the ‘‘opt‑in’’ approach, clients are given pretest
counseling and offered an HIV test. If they choose to get a
test done, consent is taken usually in writing. In the ‘‘opt‑out’’
approach, the clients are told about the HIV tests and they
must explicitly refuse the test. Centers for disease control and
prevention (CDC) recommends an ‘‘opt‑out’’ approach, as
the testing rate with it is 85%‑98% but with an ‘‘opt‑in’’ the
testing rate ranges from 25% to 83%.[9] In the present study, the
overall acceptance for the HIV testing with ‘‘opt‑out’’ approach
was 86.3% (22,897/26,518). The studies conducted by Joshi
et al., and Kawatra et al., the acceptance for HIV testing in
‘‘opt‑out’’ approach were 83% and 82.4%, respectively, similar
to our study.[10,11] But Solomon et al.,[6] reported high uptake
of HCT was 99.9% in Nigeria. This emphasizes there is need
for good counseling and proper communication skills by the
counselor to achieve both counseling and testing close to
100%. As the rapid HIV tests provide results within few hours,
clients are expected to collect the report on the same day
and undergo posttest counseling. In this present study, it was
observed that only 0.7% (159/22,897) of ICTC attendees did
not receive either HIV test report or posttest counseling. There
are many reasons for this noncompliance. There is always an
element of fear of the test result being positive. Inadequate
emphasis regarding the importance of posttest counseling
Table 2: HIV‑seropositivity (%) of ICTC attendees based
on sociodemographic variables (n=26,518)
Variables Attendee
(n=26,518)
HIV‑positive
(%) (n=1732)
Chi square P value
Marital status
Married 17,608 1488 (8.4) 281.702 <0.0001
Others (unmarried/
8910 244 (2.7) (HS)
separated/widowed)
Level of education
Undermatric 24,816 1704 (6.9) 64.371 <0.0001
College and above 1702 28 (1.6) (HS)
Occupation
Migrants 9118 713 (7.8) 32.660 <0.0001
Others 17,400 1019 (5.8) (HS)
Socio‑economic
status
Low 25,232 1693 (6.7) 23.966 <0.0001
High 1286 39 (3) (HS)
As per living status
With family 15,884 839 (5.3) 87.891 <0.0001
Others (Alone,
10,634 893 (8.4) (HS)
hostel, hotels)
Sex
Male 15,352 1138 (7.4) 1.254 0.2628
Female 7545 594 (7.9) (NS)
HIV – Human immunodeficiency virus; ICTC – Integrated counseling and
testing center; HS – Highly significant; NS – Not significant; (Highly
significant when P is less than 0.001)
1200
1000
Number of seropositives 600
800
400
200
0
HTP HMP PTCT
Males
Females
NS IBT INS
Risk behavior
Figure 1: Distribution of seropositive clients on the basis of their risk
behavior. HTP‑heterosexual promiscuous; HMP‑homosexual promiscuous,
PTCT‑parent‑to‑child transmission, NS‑nonspecific, IBT‑infected blood
transfusion, INS‑infected needles and syringes
during pretest could be the another reason for nonattendance
at posttest counseling.
CICT are the clients who present themselves at the ICTC
of their own will. The advantages of CICT are client is
emotionally ready to do the test, more time can be given to the
client, and more importantly couple counseling and testing is
usually available. It remains as the dominant form of testing
in many sub‑Saharan countries.[12] But the global coverage of
HCT remains low. In PICT, clients are referred from medical
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5. Dash, et al.: HIV counseling and testing
providers such as those associated with tuberculosis, sexually
transmitted infections as well as pregnant women for active
screening of HIV irrespective of their risk behaviors. The WHO,
UNAIDS, and CDC recommend PICT as a cost‑effective and
ethical way of improving access to HIV testing during general
epidemics.[13] The introduction of routine ‘‘opt‑out’’ PICT
would offer additional point of entry to HIV care and treatment
for affected individuals. In our study, 11,654 (50.9%) of ICTC
attendees were CICT and from these 1409 (12.1%) were
HIV‑seropositive. PICT constituted 11,243 (49.1%) clients,
but only 323 (2.9%) was positive. The study conducted by
Langare et al.,[14] at Sangli district of Maharashtra revealed
85.8% of clients were PICT and only 14.2% were CICT. This
may be attributed to stigma, fear, and ignorance associated
with HIV/AIDS among general population. Similar to our study,
Langare et al.,[14] observed HIV‑seropositivity was more among
CICT (17.1%) when compared with PICT (8.3%). CICT group
presents voluntarily themselves to ICTC and is more likely to
practice high‑risk behavior.
The HIV seroprevalence among ICTC attendees in our study
was 7.5% (1732/22,897), higher than the overall adult prevalence
among general population for the state of Odisha (0.29%).[4]
In comparison, lower prevalence of 1.44% were observed by
Biswas et al., at Rajasthan, India, 4.8% by Sharma et al., at
Ahmadabad, India, 5.1% by Kommula et al., at Andhra Pradesh,
India, and 5.6% by Akhigbe et al., at Kwara, Nigeria.[15‑18] The
studies conducted by Langare et al., at Maharashtra, India,
Gupta et al., at Udupi, Karnataka, India and Mallick et al., at
Surat, Gujarat, India showed higher prevalence of 9.5%, 9.6%,
and 20.5% respectively.[14,19,20] A very high prevalence of 50.2%
and 38% were noted by Solomon et al., at Lafia, Nigeria, and
Wanyenze et al., at Uganda, respectively.[6,21] The difference in
HIV seroprevalence in these studies may be attributed to the
difference in health‑seeking and risk behaviors in different parts
within and outside India, which mostly depends on sociocultural
milieu of the community.
Our study revealed that males contributed to 67% of the total
case load in ICTC with 33% being females. Similar findings were
observed by Gupta et al., and Langare et al., where more number
of males attended ICTC.[14,19] In comparison, Solomon et al.,[6]
found 57.7% were females, while males constituted 42.3%.
According to the present study, 88.3% of HIV‑seropositive clients
belonged to the age group of 15‑49 years, the most sexually
active group. Similar results were obtained by Gupta et al., and
Langare et al., that is, 88.7% and 86.6%, respectively.[14,19] These
values are slightly lower than the study (92.4%) conducted
at ICTC, Darjeeling, India.[22] HIV/AIDS threatens the most
productive segment of the society in the prime of their working
life. This emphasizes the need of youth specific interventions
or some high school and college‑based sex education, whereby
these young adults can be prepared beforehand.
Couple counseling and testing and partner notification is an
important tool in prevention and transmission of HIV/AIDS.
Once the couple status is known, spouse can decide to access
available HIV prevention, counseling, and testing services.
This present study showed 347 (51%) were concordant couples
and 334 (49%) were discordant couples. Among discordant
couples, majority 319 (95.5%) were male partner/husband
positive, female partner/wife negative, while only 15 (4.5%)
were male partner/husband negative, female partner/wife
positive. Langare et al., observed that from total 21 discordant
couples, 16 (76.2%) were male partner/husband positive,
female partner/wife negative, and 5 (23.8%) were male partner/
husband negative, female partner/wife positive.[14] Early
diagnosis of HIV cases is key to prevention of HIV transmission,
especially when issues of HIV serodiscordance in relationships
are considered.[23]
Our study revealed majority of seropositives were married,
males, less educated, lower socioeconomic status, mostly
stayed away from their family or single and outmigrants.
Greater access to higher education could facilitate the
spread of HIV awareness and increase the use of barrier
contraceptives.[24] In our study, majority of married men
were outmigrants to Surat in Gujarat, Mumbai, and
Thane in Maharashtra and work in the unorganized sector
in the power loom, diamond polishing, and construction
industries. Migration into the other cities enhances casual
and commercial contacts, because of spousal separation
and weaker social control.[25] Moreover, migration increases
the size of sexual networks by linking networks from
different locations.[26] Although migrant men are believed
to acquire HIV infection in destination areas and transmit
the virus to their sexual partners upon returning to their
home towns.[27,28] The high volume of returned migrants
and their spouses in their hometown reflect the urgent
need to provide HIV prevention and treatment services in
these areas.[29]
The pattern of risk behavior showed that majority of
heterosexual transmission (58.9%) in males had multiple
sex partners and unprotected heterosexual contacts among
females (30.4%). This was followed by PTCT (5.8%),
nonspecific/unknown (3.1%), infected blood and blood
products (0.8%), homosexual (0.5%), and through infected
needles and syringes (0.5%). Similar findings to our study were
noted by Langare et al.,[14] and study from Eastern India.[30]
This present study was limited by incomplete documentation
as also missing information. The results are based on reporting
and data collection by personnel employed in the ICTC; thus
bias. The data used are from a tertiary care facility and would
not be a true representation of the community. The study
however can help local planning and contribute data for policy
makers to improve the existing national HIV/AIDS intervention
strategies.
Acknowledgments
The authors gratefully acknowledge the National AIDS Control
Organization (NACO) for providing HIV test kits and the guidelines
laid down to conduct such tests.The authors also wish to thank all
the staff of ICTC, Department of Microbiology for their support and
contribution.
Journal of Postgraduate Medicine April 2013 Vol 59 Issue 2 113 

6. Dash, et al.: HIV counseling and testing
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How to cite this article: Dash M, Padhi S, Sahu S, Mohanty I, Panda P,
Parida B, et al. HIV counseling and testing in a tertiary care hospital in Ganjam
district, Odisha, India. J Postgrad Med 2013;59:110-4.
Source of Support: Nil, Conflict of Interest: None declared.
 114 Journal of Postgraduate Medicine April 2013 Vol 59 Issue 2