Cost-Effectiveness of Finding New HIV Diagnoses Using Rapid HIV Testing in Community-Based Organizations

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1 Reserch Articles Cost-Effectiveness of Finding New HIV Dignoses Using Rpid HIV Testing in Community-Bsed Orgniztions Rm K. Shresth, PhD Hollie A. Clrk, MPH Stephnie L. Snsom, PhD, MPP, MPH Binwei Song, MS Holly Buckendhl, MSW b Cindy B. Clhoun, BS c Angel B. Hutchinson, PhD, MPH Jmes D. Heffelfinger, MD, MPH SYNOPSIS Objective. We ssessed the cost-effectiveness of determining new humn immunodeficiency virus (HIV) dignoses using rpid HIV testing performed by community-bsed orgniztions (CBOs) in Knss City, Missouri, nd Detroit, Michign. Methods. The CBOs performed rpid HIV testing during April 2004 through Mrch In Knss City, testing ws performed in clinic nd in outrech settings. In Detroit, testing ws performed in outrech settings only. Both CBOs used mobile testing vns. Mesures of effectiveness were the number of HIV tests performed nd the number of people notified of new HIV dignoses, bsed on rpid tests. We retrospectively collected progrm costs, including those for personnel, test kits, mobile vns, nd fcility spce. Results. The CBO in Knss City tested men of 855 people yer in its clinic nd 703 people yer in outrech settings. The number of people notified of new HIV dignoses ws 19 (2.2%) in the clinic nd five (0.7%) in outrech settings. The CBO in Detroit tested 976 people yer in outrech settings, nd the number notified of new HIV dignoses ws 15 (1.5%). In Knss City, the cost per person notified of new HIV dignosis ws $3,637 in the clinic nd $16,985 in outrech settings. In the Detroit outrech settings, the cost per notifiction ws $13,448. Conclusions. The cost of providing new HIV dignosis ws considerbly higher in the outrech settings thn in the clinic. The vrition cn be lrgely explined by differences in the number of undignosed infections mong the people tested nd by the costs of purchsing nd operting mobile vn. Division of HIV/AIDS Prevention, Ntionl Center for HIV/AIDS, Virl Heptitis, STD, nd TB Prevention, Centers for Disese Control nd Prevention, Atlnt, GA b Knss City Free Helth Clinic, Knss City, MO c Community Helth Awreness Group, Detroit, MI Address correspondence to: Rm K. Shresth, PhD, Division of HIV/AIDS Prevention, Ntionl Center for HIV/AIDS, Virl Heptitis, STD, nd TB Prevention, Centers for Disese Control nd Prevention, 1600 Clifton Rd. NE, MS E-48, Atlnt, GA 30333; tel ; fx ; e-mil <biu0@cdc.gov>. 94

2 Cost of New HIV Dignoses Using Rpid HIV Tests in Community Settings 95 The Centers for Disese Control nd Prevention (CDC) estimtes tht pproximtely 1.1 million people in the United Sttes re infected with humn immunodeficiency virus (HIV), but tht pproximtely 25% of them re unwre of their infection. 1 Some hve never been tested for HIV. Others do not lern of their infection fter conventionl HIV testing, which requires people to return for their results week or two lter. Between 16% nd 22% of people who tested positive in CDCsupported testing sites from 1999 through 2004 did not return to lern their test results. 2 People who re unwre of their HIV infection re t higher risk of trnsmitting HIV to others nd re unble to benefit from HIV tretment. 3 In 2003, in response to the continuing HIV epidemic in the United Sttes, CDC lunched the Advncing HIV Prevention (AHP) inititive. 4 One key gol ws to reduce brriers to the erly dignosis of HIV infection by offering rpid HIV tests outside medicl settings, including those served by community-bsed orgniztions (CBOs). Offering HIV testing through CBOs, either in CBO-bsed clinics or in outrech settings such s helth firs, public prks, nd homeless shelters, ws expected to increse HIV testing mong people who were t risk for HIV infection nd who hd limited ccess to testing in medicl settings. Offering rpid HIV testing ws lso expected to increse the number of people who received test results. 5 In this study, we ssessed progrm costs nd effectiveness, in terms of the cost per person notified of new HIV dignosis, ssocited with the implementtion of rpid HIV testing t two CBOs. The Knss City Free Helth Clinic in Knss City, Missouri, offered testing t the CBO s clinic nd in outrech settings. The Community Helth Awreness Group in Detroit, Michign, offered testing in outrech settings only. METHODS HIV testing nd outrech The Knss City Free Helth Clinic provides generl medicine, mentl helth, nd dentl services s well s conventionl HIV testing nd HIV primry cre. Under the AHP demonstrtion project, the CBO initited rpid HIV testing in its wlk-in clinic nd, for the first time, offered testing in outrech settings from mobile vn. The clinic provided rpid HIV testing t no chrge to low-income nd uninsured people. Rpid HIV testing ws offered from My 10, 2005, through Mrch 31, 2006, in the clinic nd in outrech settings. The outrech settings were helth firs, public prks, homeless shelters, substnce-buse tretment centers, soup kitchens, motels, brs nd nightclubs, nd res frequented by commercil sex workers. The Community Helth Awreness Group in Detroit, which serves people who re infected with HIV or t risk for infection, previously hd used mobile vn to deliver substnce-buse tretment services. Under the AHP demonstrtion project, the CBO begn new progrm offering free rpid HIV testing from its mobile vn. Rpid HIV testing ws offered from April 24, 2004, through Mrch 28, 2006, t loctions such s street corners, needle-exchnge progrms, substnce-buse nd mentl-helth tretment centers, homeless shelters, soup kitchens, nd bthhouses nd brs frequented by men who hve sex with men (MSM). Stff of both CBOs used vrious methods to recruit clients for testing in outrech settings, including posting signs on the vn, distributing promotionl flyers, nd prtnering with other gencies for referrls. Rpid HIV testing ws performed using n OrQuick Rpid HIV-1 Antibody Test or OrQuick Advnce Rpid HIV- 1/2 Antibody Test (OrSure Technologies, Bethlehem, Pennsylvni) on either orl fluid or whole-blood specimens. To be eligible for rpid testing, people hd to be cpble of providing written informed consent. Using stndrdized forms, CBO stff members collected informtion on demogrphic chrcteristics, risk behviors, nd HIV testing history from ll people tested. They provided pretest counseling nd posttest risk-reduction counseling, regrdless of test results. Orl fluid or whole-blood specimens were collected for confirmtory testing by Western blot from people whose rpid test results were preliminry positive. 6,7 More detils on CBO testing protocols re described elsewhere. 8 Costs nd effectiveness We nlyzed seprte dt on costs nd effectiveness of rpid HIV testing in the Knss City clinic, the Knss City outrech settings, nd the Detroit outrech settings. We obtined nnul totl progrm costs retrospectively for ech intervention from provider s perspective (e.g., we did not mesure prticipnts costs), nd expressed costs in 2005 U.S. dollrs. The key cost-effectiveness mesure ws the men cost per person notified of new HIV dignosis following rpid test. This mesure ws obtined by dividing the nnul totl progrm cost by the number of people notified of new HIV dignoses. To estimte the totl progrm cost, we identified the cost of ech progrm element, such s personnel, fcilities, equipment, nd mterils Fixed costs (i.e., those tht remin constnt during relevnt period regrdless of the number of people served) were those for progrm mngement (plnning, dministrtion, nd supervision), trining, trvel, purchse nd opertion of mobile vns, durble goods, nd equipment.

3 96 HIV Testing in Nonclinicl Settings Vrible costs (i.e., those tht vry with the number of people served) were those for recruitment, counseling nd testing, nd nondurble goods nd supplies, such s test kits used for rpid testing, qulity ssurnce, nd confirmtory testing. The cost of rpid test kits ws estimted bsed on bulk purchse price ($8 for ech test kit) pid by CDC. 13 The cost of the confirmtory Western blot testing ($37.91 for the test kit nd processing time) ws bsed on dt from ntionl commercil reference-testing lbortory. 14 We clculted personnel costs bsed on the mount of time the CBO stff spent on ech of the progrm ctivities, including recruitment, counseling, testing, trining, nd trvel, s well s progrm plnning, dministrtion, nd supervision. We multiplied the stff time ssocited with ech ctivity by the compenstion (wges plus benefits) received by the stff who performed these ctivities. We estimted the recruitment cost for the Knss City CBO by collecting dt from six-month recruitment log, which included the mount of time CBO stff spent on outrech, such s distributing promotionl flyers. The recruitment cost included time spent to recruit people who lter declined to be tested (62% of totl). The Detroit site reported ggregte stff time for recruitment, which included the time devoted to the people who were tested nd the people who declined testing. In-kind or nonmonetry incentives (e.g., trnsporttion tokens or grocery vouchers) were provided to people who greed to be tested in outrech settings, regrdless of their HIV sttus. To estimte the overhed (i.e., utilities nd fcility spce) ttributble to HIV testing, we multiplied the totl cost the gency spent on overhed items by the proportion of time the stff spent on the AHP demonstrtion project. Trvel costs included stff trvel time nd vehicle milege to nd from sites. To mortize the costs of office computers, mobile vns, nd other equipment over the expected life of the equipment, we used 3% discount rte. 15 We included the cost of renting fcility spce, but excluded costs relted to progrm evlution. This project ws determined to be public helth progrm ctivity by CDC nd, therefore, review by CDC s Institutionl Review Bord ws not required. RESULTS The CBO in Knss City tested men of 855 people yer in its clinic nd 703 people yer in outrech settings, nd notified 19 (2.2%) people in its clinic nd five (0.7%) people in its outrech settings of new HIV dignoses (Tble 1). The CBO in Detroit tested men of 976 people yer in outrech settings nd notified 15 (1.5%) people of new HIV dignoses. The overll nnul cost of the rpid HIV testing progrm in Knss City ws $148,075: $68,318 yer in the clinic nd $79,757 yer in outrech settings. We estimted the men cost per person notified of new HIV dignosis t $3,637 in the clinic nd $16,985 in the outrech settings. The overll nnul cost of the progrm in the Detroit outrech settings ws $196,461, nd the men cost per person notified of new HIV dignosis ws $13,448. The wide vribility in the cost per person notified of new HIV dignosis in lrge prt reflects differences in the proportions of tested people whose results were positive (Figure). In Knss City, we estimted the men cost of providing rpid HIV testing services to person in the clinic t $80 nd to person in n outrech setting t $113. In Detroit, the estimted men cost of providing rpid HIV testing to person in n outrech setting ws $201. Fixed costs mde up lrge portion of the totl Tble 1. Men nnul rpid HIV testing outcomes nd progrm costs in Knss City, Missouri, nd Detroit, Knss City Detroit Clinic Outrech Outrech People tested (number) People with HIV-positive rpid test result (number) People notified of new HIV dignosis (number) HIV seropositivity (percent) Costs (in 2005 dollrs) Totl progrm $68,318 $79,757 $196,461 Per person tested $80 $113 $201 Per person notified of new HIV dignosis $3,637 $16,985 $13,448 HIV seropositivity (percent) is the proportion of new HIV-positive rpid test results mong people tested. HIV 5 humn immunodeficiency virus

4 Cost of New HIV Dignoses Using Rpid HIV Tests in Community Settings 97 Figure. Reltionship between rpid HIV testing costs nd HIV seropositivity mong people tested in Knss City, Missouri, nd Detroit, ,000 Cost per person notified of new HIV dignosis (in 2005 dollrs) 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2, HIV seropositivity mong people tested (percent) HIV 5 humn immundeficiency virus progrm cost in both CBOs, rnging from 51% to 68% (Tble 2). The key components of the fixed costs were progrm mngement, fcility spce, nd the purchse nd opertion of testing vns; the costs relted to the vns incresed the fixed costs in outrech settings. The costs ttributed to fcility spce nd utilities were much higher in Detroit, in prt becuse CBO stff in Detroit, compred with stff in Knss City, devoted greter proportion of their time (13.0% in Detroit vs. 1.9% in Knss City) to the HIV testing project. The costs of test kits, controls, incentives, nd personnel time spent on client recruitment, outrech, counseling, nd testing mde up most of the vrible costs. Across settings, the costs ttributble to stff time spent for counseling nd testing rnged from $8.54 to $13.46 for people whose test results were negtive nd from $12.42 to $18.05 for people whose test results were positive. Vritions in these costs were due to the differences in stff wges in the two cities nd the mount of time spent on counseling nd testing (Tbles 2 nd 3). The Detroit CBO lso incurred higher vrible costs by providing nonmonetry nd in-kind incentives to people who were being recruited for testing. DISCUSSION The CBOs in Knss City nd Detroit provided rpid HIV testing services, which resulted in previously unrecognized HIV infection being identified in 0.7% to 2.2% of the people tested. We estimted the cost of providing rpid HIV testing to people who received new HIV dignoses t $3,637 in the Knss City CBO clinic, $16,985 in the Knss City outrech settings, nd $13,448 in the Detroit outrech settings. The wide vrition in the costs of identifying nd notifying people with new HIV dignoses in the clinic nd in the outrech settings ws primrily due to the vrying proportions of people tested who hd previously undignosed HIV infection. The men overll cost of testing in the clinic nd outrech settings, independent of underlying HIV seropositivity rtes, vried becuse of the cost of purchsing nd operting mobile vn for outrech testing, providing recruitment incentives, renting fcility, nd pying stff (due to differences in wges). The literture on the costs nd the cost-effectiveness of HIV counseling nd testing demonstrtes tht the costs of new HIV dignoses vry ccording to the strtegies used to recruit people for testing (e.g., outrech, prtner notifiction, nd socil networks), testing technologies (e.g., rpid or conventionl HIV testing), nd costs included in the nlysis (e.g., vrible vs. fixed costs) We did not find published cost ssessments of CBO-led HIV testing, either in clinics or outrech settings. However, severl studies specified the costs of identifying new cses of HIV infection by recruitment strtegy. For exmple, Golden nd collegues studied peer-referrl pproch for HIV counseling nd rpid

5 98 HIV Testing in Nonclinicl Settings Tble 2. Vrible nd fixed costs per client of rpid HIV testing services in Knss City, Missouri, nd Detroit, Knss City Detroit Clinic Outrech Outrech Vrible costs (in 2005 dollrs) Client recruitment nd outrech $1.29 $4.35 $13.67 Setup nd brekdown of counseling nd testing session $2.45 $0.69 $2.22 Counseling nd testing time for person with n HIV-negtive result $8.54 $13.46 $12.04 Counseling nd testing time for person with preliminry HIV-positive result $12.42 $17.34 $18.05 Rpid test kits $8.00 $8.00 $8.00 Specimen collection nd delivery for confirmtory testing $9.06 $9.06 $5.40 Confirmtory testing time nd supplies b $37.91 $37.91 $37.91 Provision of confirmtory results c $16.82 $16.82 $7.52 Referrl interviewing nd linking of n HIV-positive person to cre $5.18 $5.18 $4.51 Control kits nd running controls d $0.17 $0.21 $9.51 Incentive for client recruitment e N/A $5.81 $27.04 Office supplies $3.34 $1.58 $1.04 Vrible cost s proportion of totl cost (percent) Fixed costs (in 2005 dollrs) Progrm plnning, dministrtion, nd supervision $28.90 $38.86 $48.03 Stff trining $3.06 $3.93 $1.35 Record keeping nd qulity ssurnce $2.51 $2.67 $12.55 Trvel for progrm strtup nd outrech $3.21 $2.99 $9.19 Utilities $0.79 $0.13 $7.68 Fcility spce $14.59 $6.86 $20.89 Equipment nd durble goods $1.37 $0.05 $2.38 Mobile vn purchse N/A $6.73 $5.71 Mobile vn opertion N/A $16.62 $19.01 Fixed cost s proportion of totl cost (percent) Includes determining eligibility nd witing for client to initite the test. b Preliminry HIV-positive result ws confirmed by Western blot. Dt on test kit cost nd test processing time cme from ntionl commercil reference-testing lbortory. (Source: Frnhm PG, Hutchinson AB, Snsom SL, Brnson BM. Compring the costs of HIV screening strtegies nd technologies in helth-cre settings. Public Helth Rep 2008;123[Suppl 3]:51-62.) c Includes time spent for prevention counseling. d The CBO in Detroit rn controls more frequently for qulity ssurnce. e Both nonmonetry nd in-kind incentives were offered in Detroit outrech settings. HIV 5 humn immunodeficiency virus N/A 5 not pplicble CBO 5 community-bsed orgniztion testing mong MSM in sexully trnsmitted disese clinic in King County, Wshington. 20 They found tht the cost per new HIV dignosis rnged from $5,600 to $12,000 (djusted to 2005 U.S. dollrs) when the HIV seroprevlence rtes were 4.4% nd 1.3%, respectively. In two studies tht used prtner notifiction, the cost of new HIV dignosis ws $3,800 (seroprevlence, 15%) in Colordo 22 nd $6,400 (seroprevlence, 14%) in Uth. 23 In both of these studies, people with newly dignosed HIV infection provided the nmes of sexul or needle-shring prtners to stte helth deprtment stff, who then offered HIV testing to the prtners. In Knss City, the proportion of people tested who received new HIV dignosis ws lrger in the clinic thn in the outrech settings. This unexpected result led to lower cost per person notified of new HIV dignosis for the clinic. Becuse outrech testing sites were in reltively close proximity to the clinic most of the sites were within 15-minute drive people who were wre of recent HIV exposure or who frequently engged in high-risk behviors my hve gone to the clinic for testing before they could be pproched for testing in n outrech setting. Our nlysis suggests tht in communities such s the one served by the Knss City CBO, where t-risk groups cn nd do go to nerby clinic for HIV testing, the ddition of outrech

6 Cost of New HIV Dignoses Using Rpid HIV Tests in Community Settings 99 services my not hve yielded mny dditionl new HIV dignoses. On the other hnd, in Detroit, where the high-risk community ws not served by such clinic, the use of mobile vn in outrech settings provided unique opportunity for testing. The CBOs included in our nlysis did not hve prior experience in rpid HIV testing using mobile vns, lthough both CBOs hd some experience in performing street outrech, offering HIV prevention, or delivering cre nd tretment for substnce buse in community settings. It is possible tht progrms become more successful over time in identifying loctions where high-risk people congregte, nd the HIV prevlence mong individuls tested initilly will be lower thn when the progrm is more estblished. On the other hnd, HIV prevlence mong those tested my decline over time if the progrm is successful initilly t trgeting high-risk groups. To ccount for potentil vribility in HIV testing outcomes, we clculted the men nnul number of individuls notified of new HIV dignoses during the entire two-yer project period. To more ccurtely estimte costs, we collected cost dt during the second yer of progrm opertions, when we expected the progrms to be running more efficiently. Limittions The limittions of our study included the retrospective collection of cost dt, rising the possibility of recll bis. Despite our efforts to trck ll progrm costs, we my hve unintentionlly excluded some costs. Also, we ssigned the cost of the OrQuick test kit on the bsis of bulk-purchse price ($8 per kit) vilble to CDC t the time. Current retil cost per test kit my rnge from $8 to $ Other progrms my hve to py different price for rpid test kits; new testing technologies t vrying prices my become vilble in the future. In ddition, we nlyzed the costs nd effectiveness of the rpid HIV testing progrms in only two CBOs, limiting our bility to generlize our results. CONCLUSIONS For these two CBOs, the vrition in cost per person notified of new HIV dignosis ws due primrily to differences in HIV seropositivity mong people tested nd in progrmmtic costs of providing testing in clinic vs. outrech settings. On the bsis of our results, CBOs tht lredy offer HIV testing through clinic my wnt to pilot HIV testing in outrech settings before investing in mobile vn to determine whether the number of new HIV dignoses identified in outrech settings justifies the lrge investment. The uthors thnk the following people for their ssistnce in dt collection: Leleh Emmi, Crl Gibson, Mrquit Leverette, Etienne Orozzo, Rchel Pope, nd Sndr Springer of the Knss City Free Helth Clinic in Knss City, Missouri, nd Adrin Grz, Lydi Meyers, Dr. Lis Rndll, nd Donell Welton of the Community Helth Awreness Group in Detroit. The findings nd conclusions in this rticle re those of the uthors nd do not necessrily represent the views of the Centers for Disese Control nd Prevention. REFERENCES 1. Glynn M, Rhodes P. Estimted HIV prevlence in the United Sttes t the end of 2003 (bstrct T1-B1101). Progrms nd bstrcts of the 2005 Ntionl HIV Prevention Conference; 2005 Jun 12 15; Atlnt. Also vilble from: URL: nhivpc/2005/t1-b1101.html [cited 2008 Aug 26]. 2. Centers for Disese Control nd Prevention (US). HIV counseling nd testing t CDC-supported sites United Sttes, [cited 2008 Jun 9]. Avilble from: URL: 3. Mrks G, Crepz N, Jnssen RS. Estimting sexul trnsmission of Tble 3. Counseling nd testing time in hours per person for rpid HIV testing services in Knss City, Missouri, nd Detroit, Knss City Detroit Clinic Outrech Outrech Counseling nd testing person with: HIV-negtive results Preliminry HIV-positive results Specimen collection nd delivery for confirmtory testing Provision of confirmtory results b Referrl interview nd linkge to cre Includes eligibility determintion, specimen collection, pperwork, test processing, nd provision of results. b Includes time spent for prevention counseling. HIV 5 humn immunodeficiency virus

7 100 HIV Testing in Nonclinicl Settings HIV from persons wre nd unwre tht they re infected with the virus in the USA. AIDS 2006;20: Advncing HIV prevention: new strtegies for chnging epidemic United Sttes, MMWR Morb Mortl Wkly Rep 2003; 52(15): Hutchinson AB, Brnson BM, Kim A, Frnhm PG. A met-nlysis of the effectiveness of lterntive HIV counseling nd testing methods to increse knowledge of HIV sttus. AIDS 2006;20: Notice to reders: protocols for confirmtion of rective rpid HIV tests. MMWR Morb Mortl Wkly Rep 2004;53(10): Greenwld JL, Burstein GR, Pincus J, Brnson B. A rpid review of rpid HIV ntibody tests. Curr Infect Dis Rep 2006;8: Rpid HIV testing in outrech nd other community settings United Sttes, MMWR Morb Mortl Wkly Rep 2007; 56(47): Levin HM, McEwn PJ. Cost-effectiveness nlysis: methods nd pplictions. 2nd ed. Thousnd Oks (CA): Sge Publictions, Inc.; Drummond MF, O Brien B, Stoddrt GL, Torrnce GW. Methods for the economic evlution of helth cre progrmmes. 2nd ed. New York: Oxford University Press; Gorsky RD. A method to mesure the costs of counseling for HIV prevention. Public Helth Rep 1996;111(Suppl 1): Hddix AC, Teutsch SM, Corso PS, editors. Prevention effectiveness: guide to decision nlysis nd economic evlution. New York: Oxford University Press; Rpid HIV test distribution United Sttes, MMWR Morb Mortl Wkly Rep 2006;55(24): Frnhm PG, Hutchinson AB, Snsom SL, Brnson BM. Compring the costs of HIV screening strtegies nd technologies in helth-cre settings. Public Helth Rep 2008;123(Suppl 3): Gold MR, Siegel JE, Russell LB, Weinstein MC, editors. Costeffectiveness in helth nd medicine. New York: Oxford University Press; Ekwueme DU, Pinkerton SD, Holtgrve DR, Brnson BM. Cost comprison of three HIV counseling nd testing technologies. Am J Prev Med 2003;25: Frnhm PG, Gorsky RD, Holtgrve DR, Jones WK, Guinn ME. Counseling nd testing for HIV prevention: costs, effects, nd cost-effectiveness of more rpid screening tests. Public Helth Rep 1996;111: Toomey KE, Petermn TA, Dicker LW, Zidi AA, Wroten JE, Crolin J. Humn immunodeficiency virus prtner notifiction: cost nd effectiveness dt from n ttempted rndomized controlled tril. Sex Trnsm Dis 1998;25: Gorsky RD, McGown RJ, Swnson NM, DelGdo BP. Prevention of HIV infection in drug busers: cost nlysis. Prev Med 1995;24: Golden MR, Gift TL, Brewer DD, Fleming M, Hogben M, St. Lwrence JS, et l. Peer referrl for HIV cse-finding mong men who hve sex with men. AIDS 2006;20: Shresth RK, Snsom SL, Richrdson-Moore A, French PT, Sclco B, Llot M, et l. Costs of voluntry rpid HIV testing nd counseling in jils in 4 sttes Advncing HIV Prevention demonstrtion project, [published online hed of publiction]. Sex Trnsm Dis Spencer NE, Hoffmn RE, Revsky CA, Wolf FC, Vernon TM. Prtner notifiction for humn immunodeficiency virus infection in Colordo: results cross index cse groups nd costs. Int J STD AIDS 1993;4: Pvi AT, Benyo M, Niler L, Risk I. Prtner notifiction for control of HIV: results fter 2 yers of sttewide progrm in Uth. Am J Public Helth 1993;83:

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