FFOOCCUUSSSince 1985, when antibody testing

was licensed in the United States,most publicly funded testing in Calif-ornia has been done anonymously. In1991, for the first time, the number ofconfidential tests performed in thestate exceeded the number of anony-mous tests. Because these testingapproaches coexist and are bothvaluable, it is vital for counselors tounderstand the differences betweenthem and the process through whichclients go to choose the approach thatwill serve them best.

This article presents an overview ofthe advantages of each type of testingand describes techniques counselorscan use with clients to distinguishbetween confidential and anonymoustesting. It then explores programmaticissues related to evaluating the suc-cess of confidential and anonymouscounseling and testing.

Anonymous testing refers to testingand counseling in which clients arenot required to identify themselves inany way to test site staff. A clientreceives a code before testing, andpresents this code—which is linkedwith the blood sample—prior to re-ceiving test results. California policyrequires implied or verbal consent byclients at anonymous test sites.

Confidential testing refers to test-ing and counseling in which clientsidentify themselves—at the very leastto test counselors—by name, andperhaps by address or other personalinformation. At various stages in thetesting process, for instance whenblood is drawn and sent to a laborato-ry, a client may not be identified butin general the test result and theclient’s name are noted together. Cali-fornia policy requires written consentbefore a confidential test is performed.

Confidential TestingIn order to understand the occa-

sions when one type of testing ismore appropriate than another, it isimportant to identify the characteris-tics associated with each type. Forinstance, confidential testing canfacilitate stronger counselor-clientrelationships that allow health careworkers to track clients, work more

closely with them in the process ofnotifying sexual partners, and per-form more extensive research.

Tracking. By knowing a client’sidentity, test site staff can locate aclient who has not returned for a testresult or can monitor a client’s pro-gression through the health caresystem. Such tracking can be used todetermine if the client is receivinghealth care and other services, and canfacilitate case management. Knowing aclient’s identity enables counselors tobe more involved in planning follow-up care, and this knowledge may beespecially important in some settings,for example, prenatal health carefacilities and sexually transmitteddisease (STD) clinics

Partner Notification. While theprocess of partner notification can bebegun in an anonymous setting—because the identity of an infectedpartner is not revealed during actualnotification—some counselors believeit is better initiated in a confidentialsetting. Because confidential counsel-ing and testing can include repeatedvisits that increase rapport withclients, it facilitates the process ofdiscussing the names of a client’ssexual partners and then contactingthese partners, or supporting theclient in doing so.

Documentation. Clients who re-quest documentation of a test result,perhaps in order to access assistancefrom a social service agency, musttest in a confidential setting becausesuch documents cannot be providedin an anonymous setting. It is impor-tant to note, however, that someconfidential test sites do not provideclients with documentation of results.

Research. Some researchers andtesting administrators find that confi-dential testing enables them to gathermore detailed information about thecharacteristics of clients being tested.

Anonymous TestingClients testing at anonymous test

sites may be willing to discuss per-sonal concerns more honestly, main-taining their anonymity while reserv-ing the choice to disclose personalidentity in the future. In addition, an

anonymous counseling and testingprogram is often easier to administer.

Protection of Identity. Clients mayseek to protect their anonymity for avariety of reasons, and some may notknow that HIV infection, unlike AIDS,is not “reportable” to governmentagencies, or they may fear that therewill be a time when this policychanges. Concerns about protectionof identity may be especially preva-lent among undocumented immi-grants, people in rural areas, and gaymen. They may focus on fear ofemployment, housing, or insurancediscrimination. Higher infection ratesamong clients at anonymous com-pared to confidential test sites indi-cate that people who suspect they areinfected seek anonymous testing. In1991, 2.8 percent of clients testing atthe state’s anonymous AlternativeTest Sites were antibody positivecompared to 1.6 percent at sites thatperform primarily confidential testing.

Ease of Administration. Anonymoustesting requires significantly lesspaperwork than confidential testing.Also, because the identity of clients isnot known, fewer administrativemeasures need to be taken to protecta client’s privacy.

Ability to Become Confidential. Aclient who tests at an anonymous sitemay choose at a later point to test at aconfidential one. However, a clientwho tests confidentially once willhave created a record with his or hername on it.

Counseling ImplicationsIt is important for clients to be

aware in the pre-test counselingsession of the availability and value ofboth confidential and anonymoustesting. It is important for counselorsto realize that the testing decisionmay be based less on any of thefactors described above than onwhich form of testing is most avail-able or convenient.

Begin counseling by asking clientsif they are aware of the differencesbetween the types of testing. Explain,if necessary, that the primary differ-ence between anonymous and confi-dential testing relates to what is donewith information regarding the client’sidentity. Help clients understand thepotential implications of their testingchoices. For instance, a client seeking

Anonymous vs. Confidential TestingJohn Tighe

Volume 8 Number 4 March 1993 Supplement to FOCUS: A Guide to AIDS Research and Counseling On HIV Antibody Test Counseling

testing at an anonymous test site in an insularcommunity may find that anonymity isnonetheless sacrificed when client and coun-selor already know each other. And, a clienttesting at a confidential test site, particularly aprimary care clinic, should be aware that thepresence of an antibody test on a medicalrecord may affect his or her chances of receiv-ing life and disability insurance and, despitelaws forbidding the use of results by healthinsurers, even health insurance.

Learn how information related to a client’sidentity is handled at the confidential testsites to which you might refer clients. In aconfidential setting, for example, only thosewho provide direct test site care to the client,and not ancillary personnel, should be awareof the client’s test results. It is also generallyrecommended—and in some facilities it is anofficial policy—that information related to aclient’s serostatus be kept separate from otherhealth information in a client’s file. Explain toclients that their results may be noted in theirmedical records.

Tell clients that their records may be sharedwith other members of the health care teamlocated at the test site, for instance, if theconfidential test site is also an early interven-tion center or family planning clinic. When acounselor wishes to disclose an antibody testresult to someone who is not a member of thehealth care team providing diagnosis, treat-ment or care to the client, it is necessary toreceive written consent from the client.

After offering basic definitions, focus on theclient’s specific needs. Is he or she concernedabout anonymity? Convenience? Being closelymanaged by a care provider? Having documen-tation of the test result? Knowing these things,begin to describe characteristics of each typeof testing as they relate to these needs.

For example, a client at a confidential sitewho is concerned about losing his or her jobdue to a positive test result may benefit fromlearning that employers and other outsiders donot have access to test results. Despite thissafeguard, it may be useful to state to con-cerned clients that anonymous testing may bea more comfortable alternative.

While the decision of where to test belongsto the client, there are occasions when coun-selors may believe one form of testing mightbe more useful to a particular client. Forinstance, a counselor at an anonymous testsite may suspect that a client will not returnfor a test result or that a client will not be ableto access care without help. For such a client,discuss the difficulty some people have inreturning for results or in seeking neededmedical care. Ask the client if he or she hashad difficulty following up on seeking medicalor personal care in the past. Ask whetherreturning for a test result will be difficult.Describe the availability of confidential testingand the role that a confidential test site coun-selor may play in helping the client. Suggestthat clients ask their friends to remind themabout the return appointment. Through thisdiscussion, counselors give clients a chance tovoice their concerns about receiving test results.

Regardless of whether clients test confiden-

tially or anonymously, it is important to makethem aware that future health or social ser-vices are rarely anonymous. The meaning of“confidentiality” and the handling of clientmedical information may be far differentoutside the HIV test counseling setting.Physicians and other early interventionproviders may record detailed personal andmedical information in client files, and thereare reports that some even photograph HIV-infected patients. While this last practice, inparticular, follows the letter of the law, it maypush ethical boundaries. Help clients under-stand the ethical concerns and complexitiesassociated with the protection of confidentialinformation outside the test counseling session.

Programmatic ConcernsClient return rates and the effect of counsel-

ing and testing on behavior change are oftencarefully scrutinized in order to measure thesuccess of antibody counseling and testing.The extent to which these factors are affectedby whether a test is confidential or anonymouscan determine which type of test programadministrators offer to clients.

Test sites at which 80 percent of clientsreturn to receive their test results are general-ly considered to have acceptable return rates.Acceptable rates are sometimes based onpopulations being served by test sites. Forinstance, acceptable rates might be lower atsites that have large numbers of clients whohave traditionally received poor health care.Anonymous test sites are anecdotally consid-ered to have lower return rates than confiden-tial sites, although this is not true at all sites.When return rates fall below 80 percent, orlevels that are considered acceptable, adminis-trators might ask questions such as: Does thetest site have a reputation for being a trust-worthy place? Are test site staff membersdiscreet in their handling of client identity andconfidentiality? How can administratorsensure the professional, legal, and ethicalhandling of test-related information?

In terms of behavior change success, coun-selors can make use of the unique characteris-tics of confidential and anonymous testing toencourage behavior change. In anonymoussettings, the protection of anonymity may helpclients feel more willing to share their person-al sexual histories; in confidential settings,clients may become detailed in their historiesas they develop a relationship of trust with thecounselor over several sessions. It remainsunclear which type of site is more effective inpromoting behavior change or how to measuresuch efficacy, but researchers may preferconfidential testing because efficacy is easierto study in this setting.

ConclusionThere are clear advantages for health agen-

cies to provide both anonymous and confiden-tial testing and counseling. While client track-ing needs and partner notification programsmay continue to lead to more confidentialtesting, public demand for the privacy ofanonymous testing will likely mean that bothsites should and will continue to be offered.

John Tighe is Staff Writerfor FOCUS, and Writer/Editor of HIV CounselorPERSPECTIVES. Amongthose who provided inputto this article were:Victoria Jauregui; TimQuinn; David Banda;Phyllis Schellenwald, PA.

2 FOCUS March 1993

Executive Editor; Director,AIDS Health ProjectJames W. Dilley, MDEditorRobert MarksStaff WritersJohn TigheClare PotterFounding Editor; AdvisorMichael HelquistMedical AdvisorStephen Follansbee, MDMarketingPaul CauseyRichard McCormackDesignSaul RosenfieldProductionJoseph WilsonStephan PeuraLeslie SamuelsRoger ScroggsCirculationSandra Kriletich

FOCUS On HIV AntibodyTest Counseling is a quar-terly supplement toFOCUS: A Guide to AIDSResearch and Counseling,both published by theAIDS Health Project,which is affiliated with theUniversity of CaliforniaSan Francisco. The Supplement is pub-lished under a grant fromthe California Departmentof Health Services, Officeof AIDS, and is distributedto HIV antibody test sites.Permission to reprint anypart of the Supplement isgranted, provided acknow-ledgement of FOCUS andthe California Departmentof Health Services isincluded. FOCUS itself iscopyrighted by the UCRegents, which reservesall rights.Address correspondenceto: FOCUS, UCSF AIDSHealth Project, Box 0884,San Francisco, CA 94143-0884; (415) 476-6430.

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