Current state and need for improvement of system for antibody testing and counseling for HIV infection at public health centers in Japan

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1 J Med Dent Sci 2005; 52: Original Article Current state and need for improvement of system for antibody testing and counseling for HIV infection at public health centers in Japan Chika Miyazaki 1, Kazuo Kawahara 1, Yoshiki Sakurai 2, Katsumi Nakase 3, Shigeki Shiomi 4 and Mitsunobu Imai 5 1) Department of Health Policy, Graduate School, Tokyo Medical and Dental University 2) Japanese Foundation for AIDS Prevention 3) Okayama City Health Center, Okayama 4) Kennan Health and Welfare Center, Tochigi 5) Department of Virus, Kanagawa Prefectural Institute of Public Health Background: Public Health Centers (PHCs) throughout Japan have been playing a role in preventing HIV in Japan. The number of HIV seropositive persons and AIDS patients is increasing from year to year in Japan. Methods: A survey regarding the HIV antibody test was sent out to 594 PHCs between January 1997 and December The response rate was 73.9%. In order to assess the HIV testing system at PHCs, Pearson s correlation coefficient, an analysis of variance (ANOVA) and multiple regression analysis were used. Results: There was a difference in the demand for HIV antibody tests according to area. The change in number of HIV antibody tests per 100,000 persons was high in metropolitan areas during the 5-year period. It was influenced by two factors; population density and ratio of daytime population to nighttime population. Rate of examinees who did not return to receive their test results was influenced by the area where the PHC was located. Conclusions: PHCs need to establish an HIV Corresponding Author: Chika Miyazaki Department of Health Policy, Graduate School, Tokyo Medical and Dental University , Yushima, Bunkyo-ku, Tokyo , Japan Tel: Fax: kk.hcm@tmd.ac.jp Received March 28; Accepted June 10, 2005 testing system which reflects the characteristics of the area and meets the needs of people who want to get tested. Key words: Public Health Center, HIV antibody testing, HIV counseling, Regional difference Introduction Since the case of a homosexual male was recognized as the first Japanese AIDS patient in 1985, preventive measures for HIV infection have been carried out in Japan. Public Health Centers (PHCs) throughout Japan have been playing a role in preventing diseases, including HIV infection. HIV counseling and HIV antibody testing were started at PHCs in 1985 and 1987, respectively. However, the number of HIV-seropositive persons and AIDS patients has been increasing on a yearly basis and reached 6,560 and 3,277 respectively at the end of Considering above circumstances, we sent questionnaires to PHCs in order to investigate the current state of HIV counseling and antibody testing. This study was to investigate the HIV testing system in question and to specify an effective HIV antibody testing system through analyzing the results of the study.

2 178 C. MIYAZAKI et al. J Med Dent Sci Materials and Methods In order to investigate the current state of the HIV antibody testing system at PHCs, self-administered questionnaires regarding HIV counseling and HIV antibody testing were mailed to 594 PHCs throughout Japan. The period of this study was 5 years between January 1997 and December In addition to question items regarding the number of HIV antibody tests performed during the 5-year period, there were questions on results not received (the number of persons who did not visit again to obtain their test results at the PHC), daily hours HIV antibody tests were available, waiting period (number of days needed before the PHC can notify examinee of results), explanation time (time taken for pre-test explanation), frequency HIV antibody tests were available at the PHC (every week, every other week, irregularly) and whether HIV antibody tests and HCV antibody tests were available at the same time or not. This study was designed to assess the current state of HIV operation management from the 439 PHCs and problems surrounding HIV antibody tests at PHCs and also how to improve the HIV antibody testing system at PHCs. We used Pearson s correlation coefficient to evaluate the relationship between rate of unreceived results (rate of examinees who did not return to receive test results), number of HIV antibody tests during the 5-year period per 100,000 persons, change in number of HIV antibody and variables. In order to investigate regional differences in HIV antibody testing systems at PHCs, we categorized PHCs into the following two groups according to geographical areas specified in the national basic resident population handbook. 2 Geographic area was categorized into metropolitan areas and non-metropolitan areas. Metropolitan areas were defined as the 23 special wards of Tokyo, the 12 ordinance-designated cities (Sapporo, Sendai, Chiba, Yokohama, Kawasaki, Nagoya, Kyoto, Osaka, Kobe, Hiroshima, Kitakyushu and Fukuoka). Non-metropolitan areas were defined as all areas except for the above metropolitan areas. We compared the results of the questionnaires between two geographical groups by an analysis of variance (ANOVA) and used multiple regression analysis to assess related factors with the rate of unreceived results, the number of HIV antibody and year period per 100,000 persons. The independent variables of the multiple regression analysis were: population density, ratio of daytime population to nighttime population, daily hours HIV antibody tests were available, area under PHC jurisdiction, waiting period and explanation time. Dependent variables were: rate of unreceived results, number of HIV antibody and change in number of HIV antibody tests during the 5-year period per 100,000 persons. Statistical analyses were performed using SPSS 10.0J (SPSS Inc., Chicago, IL). P-value less than 0.05 was considered as significant. Ratio of daytime population to nighttime population was calculated by daytime population / nighttime population x Rate of unreceived results was calculated by number of HIV antibody tests performed during the 5-year period at the PHC for which the results were not received / number of HIV antibody tests performed during the 5-year period at the PHC x 100. Change in number of HIV antibody tests performed during the 5-year period at the PHC was calculated by (number of HIV antibody tests performed at the PHC in 2001-number of HIV antibody tests performed at the PHC in 1997) / 4. The number of HIV antibody tests during the 5-year period per 100,000 persons, population density and rate of unreceived results were changed into common logarithms to regularize. There were cases where the rate of unreceived results was zero. As the logarithm of zero was minus infinity, we analyzed it by adding one before transforming in this study. Results Table 1 shows the results of the questionnaire for variables. Out of the 594 PHCs, 541 returned answers with a collection rate of 91.1 %. Of these 541 PHCs, 102 PHCs were excluded because they returned incomplete answers. Responses of 439 PHCs were analyzed, representing 73.9 % of the total of 594 PHCs. Table 2 shows the correlation coefficient between the rate of unreceived results, number of HIV antibody tests during the 5-year period per 100,000 persons and year period per 100,000 persons and variables. Negative correlations were observed between the rate of unreceived results and explanation time (p 0.05). Positive correlations with the rate of unreceived results were observed in the daily hours HIV antibody tests were available (p 0.01) and the area under PHC jurisdiction (p 0.01). The number of HIV antibody tests

3 CURRENT STATE OF HIV ANTIBODY TESTING SYSTEM AT PHCS IN JAPAN 179 Table 1. Characteristics of study subjects (439 Public Health Centers). Table 2. Pearson s correlation coefficient of rate of unreceived results (I), number of HIV antibody tests during the 5-year period per 100,000 persons (II), and change in number of HIV antibody tests during the 5-year period per 100,000 persons (III) with variables. during the 5-year period per 100,000 persons was negatively correlated with the daily hours HIV antibody tests were available (p 0.01) and the area under PHC jurisdiction (p 0.01). Positive correlation was observed between the number of HIV antibody tests during the 5-year period per 100,000 persons and population density (p 0.01). Negative correlations were observed between the change in number of HIV antibody and the area under PHC jurisdiction (p 0.01). Positive correlations with the change in number of HIV antibody tests during the 5-year period per 100,000 persons were observed in population density (p 0.01) and waiting period (p 0.05). Table 3 shows the results of ANOVA for the comparison of variables between the two geographical groups. There were statistically significant differences in all the variables except for waiting period. Table 4 shows the relationship of variables to the rate of unreceived results, the number of HIV antibody tests during the 5-year period per 100,000 persons and the year period per 100,000 persons. The rate of unreceived results was positively correlated with daily hours HIV antibody tests were available and the area under PHC jurisdiction. Negative correlations were observed between the rate of unreceived results and population density. The number of HIV antibody tests during the 5-year period per 100,000 persons and year period per 100,000 persons were positively correlated with population density. Table 5 shows the comparison of variables for the PHC in the two groups on whether HIV antibody tests and HCV antibody tests were available at the same time or not. There were significant differences in population density and number of HIV antibody tests during the 5-year period per 100,000 persons.

4 180 C. MIYAZAKI et al. J Med Dent Sci Table 3. Comparison of variables between two geographical groups. Table 4. The results of multiple regression analysis for rate of unreceived results (I), number of HIV antibody tests during the 5-year period per 100,000 persons (II), and change in number of HIV antibody (III). Table 5. Comparison of variables between two groups of Public Health Ceters (PHCs) on whether HIV antibody tests and HCV antibody tests were available at the same time or not.

5 CURRENT STATE OF HIV ANTIBODY TESTING SYSTEM AT PHCS IN JAPAN 181 Discussion Globally, 4.9 million people were reported newly infected with HIV in the year HIV infection in Japan is reported to be less than 1/5 to 1/10 of that in Europe and the United States of America, and Japan is categorized as a country with a low infection rate. But the number of HIV-seropositive persons is increasing year by year in Japan. The number of people who tested HIV-seropositive in 2004 was reported to be 780 and this is the highest number since 1985, when statistics were first taken. 1 PHCs throughout Japan have played a central part in promoting public health and hygiene in the area under their jurisdiction for a long time. HIV counseling and HIV antibody testing were started at PHCs in 1985 and 1987, respectively, as AIDS countermeasures. Shiomi conducted surveys on the HIV testing system at PHCs in Japan in 1993 and ,6 He pointed out that it was necessary to take the regional differences in demand for HIV antibody tests at PHCs into consideration for the HIV antibody testing system. PHCs have reformed the HIV antibody testing system since then. On the other hand, the number of HIV-seropositive persons discovered by blood donation is increasing from year to year. 1 Studies by Inoue et al. on blood donors and HIV antibody testing showed that when asked why they chose blood donation as a means to have HIV testing, 30% answered that it was difficult and inconvenient to get tested at PHCs and over 80% answered that it was easier and more comfortable to find out their HIV status by examination at the same time as they made a blood donation. 7 Watanabe et al. reported that repeaters existed among those who took HIV antibody tests at PHCs. 8 It is therefore possible that PHCs do not play an important part in the HIV testing system in Japan and do not meet the needs of people who want to get tested and counseling. PHCs need to change the HIV testing system in order to meet the needs of examinees and residents in the future according to the findings of this study. Taking regional differences into consideration for the HIV antibody testing system The number of HIV antibody tests performed during the 5-year period per 100,000 persons and change in number of HIV antibody tests during the 5-year period per 100,000 persons showed a statistically significant difference between the two geographical groups by ANOVA. In order to investigate regional difference, we compared population density and ratio of daytime population to nighttime population between the two groups. Ratio of daytime population to nighttime population is an index of regional characteristics. The daytime population includes the number of people who commute into the area for work and school, in addition to those people who live in the area. A high ratio suggests that the area has more in-coming population than out-going population in the daytime. 3 The number of HIV antibody tests during the 5-year period per 100,000 persons and change in number of HIV antibody increased in proportion to population density and ratio of daytime population to nighttime population. Kawahara et al. reported that the areas with a high rate of daytime population to nighttime population are highly urbanized and it is possible that people who received HIV antibody tests at PHCs included those people who come into the area from the surrounding areas only during the day, in addition to the residents of the area. 9 The report by Barrios et al. which emphasized that the number of people who had undergone HIV testing was greater in metropolitan areas indicates there is a need for a HIV testing system in this area. 10 We suggest it is necessary to establish an effective HIV testing system which considers population density and ratio of daytime population to nighttime population at PHCs according to these data. Taking the needs of people who want to get an HIV antibody test at PHCs into consideration for the HIV antibody testing system There was a statistically significant difference in the rate of unreceived results between the two geographical groups by ANOVA. Comparing three groups categorized by the frequency of HIV antibody tests at the PHC, there was not significantly different by ANOVA. But the rate of unreceived results was positively correlated with the area under PHC jurisdiction by multiple regression analysis. This indicated that the more extensive the area under PHC jurisdiction, the higher the rate of unreceived results was. We think it is necessary to investigate the area under the jurisdiction of the PHC where the rate of unreceived results was high and location of the PHC. It is necessary to create an environment that is convenient for people who want to get an HIV antibody test at PHCs in the future. There was a statistically significant difference in the number of HIV antibody tests during the 5-year period per 100,000 persons between two groups on whether HIV antibody tests and HCV antibody tests were available at the same time at the PHC or not. We think

6 182 C. MIYAZAKI et al. J Med Dent Sci it possible that the number of HIV antibody tests will lead to an increase in performing HIV antibody tests and HCV antibody tests at the same time. Regional responsibility of PHCs to make countermeasures against HIV infection Dissemination of information about AIDS which is suitable for residents of the area, in addition to examinees, is the responsibility of the PHC from the position of its central part in promoting public health and hygiene in the area under its jurisdiction and this is also important to prevent HIV infection. As a result of analyzing the HIV antibody testing system at PHCs in Japan, we found that there were regional differences in the demand at PHCs. In the future, it will be necessary to establish an HIV testing system to reflect the characteristics of the area and meet the needs of people who want to get tested. Acknowledgements This study was supported by a Health Science Research Grant, Research project on measures against AIDS, by the Ministry of Health, Labour and Welfare. [Grant No. H12-AIDS-010] References 1. AIDS trend committee, Ministry of Health, Labour and Welfare. An AIDS outbreak trend annual report in (in Japanese). Tokyo:Ministry of Health, Labour and Welfare, Japan Geographic Data Center. The national basic resident register population handbook. (in Japanese). Tokyo:Japan Geographic Data Center, Statistics Bureau, Management and Coordination Agency. Population statistics of Japan. Summary of National Censuses and Other Surveys, (in Japanese). Tokyo:Ministry of Internal Affairs and Communications, Joint United Nations Programme on HIV/AIDS (UNAIDS) Report on the Global HIV/AIDS epidemic update. Geneva:United Nations, Shiomi S. Investigation of measures against AIDS in Public Health Centers. (in Japanese). Tokyo:Ministry of Health, Labour and Welfare, Shiomi S. Investigation of measures against AIDS in Public Health Centers. (in Japanese). Tokyo:Ministry of Health, Labour and Welfare, Inoue C, Kamiya T, Ozawa K. Survey of blood donor awareness of HIV. (in Japanese). Japanese Journal of Transfusion Medicine 2001;47: Watanabe T, Nakamura Y, Kidokoro T, et al. The characteristic of people requesting HIV antibody tests at Public Health Centers in Japan. J Epidemiol 2004;14: Kawahara K, Sakurai K. Research on HIV testing system as a measure against AIDS in public administration. (in Japanese). Tokyo:Ministry of Health, Labour and Welfare, Barrios DC, Hearst N, Coates TJ, et al. HIV antibody testing among those at risk for infection. JAMA 1993;270: