Abstract

Background: Barriers to Human Immunodeficiency Virus (HIV) and Hepatitis C (HCV) testing and care persist, especially among high-risk populations in medically underserved areas, where limited testing accessibility, stigma, and systemic inequities hinder early diagnosis and treatment. In Southern New Jersey, substance use and mental health treatment facilities serve populations with increased vulnerability to HIV and HCV, yet testing and retention of care remain suboptimal. To address these challenges, we developed a “Group Risk Reduction and Testing” (GRREAT) Model, an interdisciplinary, group-based approach integrating harm reduction counseling, peer support, and rapid testing to enhance screening rates, reduce stigma, and improve patient engagement with care. Unlike traditional individual testing models, the GRREAT Model leverages group therapy principles to create a supportive environment that facilitates knowledge sharing, increases testing uptake, and fosters open conversations surrounding risk behaviors.

Methods: From June 2023 to September 2024, weekly group testing sessions were conducted at residential treatment facilities in medically underserved areas of Southern New Jersey, evaluated using a mixed-methods approach. Participants received educational presentations, rapid HIV and optional HCV antibody testing, and individualized results counseling. Quantitative data included surveys measuring satisfaction, comfort, and perceptions of privacy and confidentiality, which were then interpreted using ender-stratified analyses involving descriptive statistics and chi-square tests. Qualitative feedback was analyzed thematically.

Results: A total of 452 participants completed surveys (348 men, 104 women). Participants were predominantly male (77%) and gender differences were the primary focus of the analysis, as data on other demographic factors such as age and ethnicity were not collected. Participants reported high satisfaction, with 95% of women and 74% of men rating their care as “Excellent.” A statistically significant gender difference was observed in overall care ratings (p=0.007, Cohen’s d=0.303), with women reporting higher levels of overall satisfaction. A smaller but statistically significant difference was noted in preferences for privacy in counseling (p=0.034, Cohen’s h=-0.100), though men and women reported similar levels of comfort and confidence in confidentiality. Thematic analysis of participant comments identified key themes, including “Trust and Emotional Safety,” “Interpersonal dynamics,” “Program Impact and Effectiveness,” and “Value Recognition” of the program.

Conclusions: The GRREAT Model demonstrated strong acceptability among participants and effectiveness in improving perceptions of HIV/HCV testing and harm reduction counseling respective of patient gender. This peer-supported, group-based intervention not only allows for increased testing rates but also fosters open discussions around HIV, harm reduction strategies, and sobriety treatment adherence. Given the high satisfaction ratings and minimal gender differences, this scalable approach holds promise for broader implementation in diverse medical settings. Future research should explore long-term impact, refine strategies for balancing privacy in group settings, and assess how this model can be adapted to different populations to maximize its effectiveness in reducing health disparities.

Keywords

Harm Reduction Counseling; HIV Testing; Hepatitis C Testing; Group Counseling Model; Gender Differences in Care Perception; Rapid Antibody Testing; Barriers to HIV Care; Stigma in Infectious Disease Testing; Interdisciplinary Testing Models

Abbreviations

HIV: Human Immunodeficiency Virus; HCV: Hepatitis C Virus; ID: Infectious Disease; US: United States; LGBTQ+: Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, and others; ART: Antiretroviral Therapy; IDU: Intravenous Drug Use; MSM: Men Who Have Sex With Men; MUA: Medically Underserved Area; TACD: HIV Training and Capacity Development Program; Ab: Antibody; REDCap: Research Electronic Data Capture; CDC: Centers for Disease Control and Prevention; FDA: Food and Drug Administration; IRB: Institutional Review Board; St.Dev: Standard Deviation

Background

Despite significant advancements in Human Immunodeficiency Virus (HIV) prevention and treatment, barriers to testing and care persist, often due to limited testing accessibility and gaps in contemporary Infectious Disease (ID) education [1-3]. These barriers perpetuate harmful stigmas, exacerbating anxiety surrounding ID testing and hindering the diagnosis and management of HIV, especially among vulnerable populations [1-3].

In 2022, approximately 31,800 new HIV infections were reported in the United States (US), disproportionately affecting Black, Hispanic/ Latino, and Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) communities [1-5]. Of the 31,800 newly reported HIV infections, 38% were of Black/African American individuals, 32% were Hispanic, and 67% were associated with male-to-male sexual contact [5]. Intersecting social disadvantages such as race, ethnicity, sexual orientation, gender identity, and socioeconomic status further exacerbates the rate of HIVassociated stigma and discrimination, where varying social identities and systems of oppression can interact to reinforce social inequities [1-4,6,7].

This intersectionality is particularly evident in the disproportionate impact of HIV on specific racial/ethnic groups in the US. From 2018 to 2022, Black and Hispanic/Latino people made up approximately 12 and 18% of the US population while representing 37 and 33%, respectively, of new HIV infections [5]. Although there was an 18% decrease in the number of Black individuals diagnosed with HIV from 2018 to 2022, the rate (34.1%) was still nearly 8 times higher than that of White individuals (4.4%) [5]. Despite being disproportionately affected by HIV, members of these groups frequently experience heightened fear of societal stigma surrounding HIV status, creating additional barriers to care [6,8-10]. Fear and shame surrounding HIV are exacerbated by discriminatory attitudes exhibited by peers and healthcare providers, functioning as an additional barrier and obfuscating knowledge and understanding about the role that Antiretroviral Therapy (ART) compliance can have on promoting long and healthy lives [9-11]. Hepatitis C virus (HCV) acquisition shares similar risk factors with HIV, with a particularly strong association with intravenous drug use (IDU), as it significantly increases transmission risk, especially among men who have sex with men (MSM) [12]. Systemic barriers have historically limited testing for the disease [13]. Until the emergence of oral HCV antivirals in 2011, there was little incentive to test for the disease, making its prevalence difficult to assess [13]. However, in 2022, 161,205 new cases of acute and chronic HCV were reported in the US, with the highest burden among those assigned male sex at birth and those in the 24-45 and 55-70 year age groups [13].

The Group Risk REduction and Testing (GRREAT) Model

To address these challenges, we aimed to describe and evaluate a novel approach: the Group Risk REduction and Testing (GRREAT) Model, an interdisciplinary approach to HIV/HCV screening that integrates harm reduction and group therapy principles with peer-supported, group-based education. The GREEAT Model combines structured, interaction education with rapid HIV/HCV testing while leveraging therapeutic approaches such as universality, imparting information, and altruism [14]. This approach helps reduce internalized stigma and fosters an environment where participants can feel comfortable discussing stigmatized topics with recovery coaches/peer counselors, many of whom have lived experience with substance use and recovery, allowing participants to feel understood and supported throughout the process [14-16].

Previous studies, such as the INTEGRATE Joint Action pilots in Europe, have examined the impact of interdisciplinary therapeutic approaches to HIV and HCV testing and care and demonstrated increased testing rates [17]. These initiatives showed that coordinated efforts could significantly increase testing rates and linkages to care among various populations, including those with alcohol dependency and other high-risk groups [17]. Similarly, other studies have shown that a collaborative care model that successfully integrated HCV care with other health services, highlighted by high screening and diagnosis rates, further emphasizes the benefits of interdisciplinary models, particularly among vulnerable populations [17-19].

By embedding HIV/HCV education within a peer-supported, interdisciplinary framework, the GRREAT Model not only has the potential to enhance testing rates but also fosters a sense of community, reducing internalized stigma and improving patient engagement with care. Beyond immediate testing outcomes, the GRREAT Model has the potential to help create long-term systemic changes by providing a scalable framework that can be adapted across various healthcare settings. By integrating harm reduction strategies and peer-based education within the traditional healthcare infrastructure, the GRREAT Model offers a sustainable, evidence-based intervention to reduce disparities in ID care and improve healthcare outcomes, particularly in more vulnerable populations.

Methods

Group Testing Intervention Design

We developed an interprofessional patient education and screening initiative that included peer counselors (recovery coaches), healthcare navigators, social workers, medical students, and physicians. Physicians and medical students collaborated to provide direct care and answer patient questions, with medical students and peer counselors certified as HIV counselors through the HIV Training and Capacity Development Program (TACD). This team encourages patients to offer suggestions and advice and to identify barriers to care within their communities, facilitating personal investment, emotional salience, and a sense of autonomy. This inclusive approach helps build stronger rapport with patients and addresses various barriers to care by providing transportation and direct treatment.

Group Testing Session Procedures

From June 2023 to September 2024, weekly rapid testing for HIV and HCV was conducted at two nonprofit, residential substance use and mental health treatment centers in a Health Resources & Services Administration designated Medically Underserved Area (MUA) in Southern New Jersey. Antibody rapid tests for HIV and HCV (OraSure Technologies, Bethlehem, Pennsylvania) were stored indoors at 70°F and validated against manufacturer control kits before utilization [20,21].

Group sessions, accommodating up to 15 participants based on room size, included individuals willing to participate at the treatment centers. While the authors acknowledge that gender exists on a spectrum and is not binary, the term ‘male’ refers to those who self-identify as male, and ‘female’ refers to those who self-identify as female. As the rehabilitation facility separates patients by gender, group sessions were also conducted in gender-specific cohorts. This approach was adopted to align with the existing environment and to facilitate discussions relevant to each group’s experiences.

The participants were invited to a round table presentation, given a number identifier, and were instructed not to use their or other participants’ names during the session to preserve confidentiality. Rapid test(s) and surveys were labeled with the identifier to ensure accurate result delivery. If patients did not want to participate, accommodations were made to conduct testing outside of the group by providing individual testing. Testing consists of rapid HIV antibody (Ab) testing with the option of concurrently including HCV Ab rapid testing. Upon completion, test(s) were taken to a private room, and the 20-minute educational presentation allowed adequate time for the tests to develop. The presentation included background information on HIV and HCV, including transmission, common misconceptions, and relevant statistics (such as the percentage of people tested and subpopulation vulnerability), in addition to local resources and interactive (question and answer, true or false) components. The participants were encouraged to ask questions and discuss their own experiences and insights throughout the presentation, encouraging learning through shared experiences.

After the conclusion of the presentation and when the test results had fully developed, the participants were individually called to the results room. Here, counselors delivered results, provided personalized risk reduction counseling, and addressed any additional questions. If individuals received a positive screening result, they were immediately enrolled in care at a clinic of their choice. Case managers assisted with scheduling appointments and coordinating transportation, facilitating follow-up care with ID specialists for confirmatory testing and ongoing management. After receiving the results, participants were directed to return to their individual rooms while avoiding the group testing area to ensure privacy, particularly for those who may have been upset by their results. By structuring this process in this manner, the intervention maintained the benefits of a group testing educational format while protecting the privacy of individual participants' HIV/ HCV test results disclosed during counseling.

Data Collection Methods

Participants completed an anonymous 11-question survey (Appendix I) about their experience and attitudes toward group versus individual screening and education. Data was then digitized and managed via Research Electronic Data Capture (REDCap), an electronic data capture tool hosted at Rowan University [22,23]. Responses that did not select only one answer choice (i.e., a circle around 2 or more answer choices) or provided a circle that did not encompass any of the answer choices were deemed ambiguous and recorded as incomplete.

Quantitative Data Analysis

The data was cleaned in Microsoft Excel (Microsoft, Redmond, Washington) [24]. Data analysis and visualization were conducted in Python (version 3.10.0). The following Python packages were utilized: pandas [25] for data manipulation, seaborn [26] for statistical data visualization, and matplotlib (version 3.10.0rc1) [27] for generating plots.

Descriptive, inferential, and effect size (Cohen’s d/h) statistics were computed to evaluate the participants’ responses. The key metrics included overall satisfaction, perceptions of group versus individual harm-reduction counseling, confidentiality, comfort, and effectiveness of harm-reduction counseling. Question 5 was used to assess participants’ perception of the overall care they received, with responses rated on a 6-point Likert scale (1=“Excellent” to 6=“Very Poor”). The remaining questions were analyzed via descriptive statistics, summarizing answer proportions, central tendency, and variability among all respondents and stratified by gender. For inferential statistics, chi-square tests were used to assess for significant differences in response distributions by gender for binary questions (questions 1 and 6-9). Two items were reverse scored (questions 7 and 9).

Qualitative Data Analysis

A qualitative thematic analysis was conducted based on a final, open-ended question (question 10) soliciting additional feedback from participants at the end of the counseling and testing process. A total of 109 comments were collected, with 100 comments included in the thematic analysis. Nine comments were excluded because they were either single-word responses (e.g., “yes”) or uninterpretable. Thematic analysis followed the systematic six-step thematic analysis framework described by Naeem and Ozuem (2023) [28]:

● Step 1: Data Familiarization and Transcription: Transcripts were reviewed to identify patterns in responses, overarching themes, and relevant quotes that represented diverse perspectives.

● Step 2: Selection of Keywords: Key terms and recurring phrases were identified, grouped, and organized based on the main ideas or opinions expressed in the comments.

● Step 3: Coding: Keywords were converted to codes that captured the core attributes of the data and then grouped into categories reflecting shared characteristics.

● Step 4: Theme Development: Codes were consolidated into broader, meaningful themes that provided insights into the research question.

● Step 5: Conceptualization through Interpretation of Keywords, Codes, and Themes: Themes were interpreted to explore relationships and patterns among responses. A thematic diagram was used to visualize the connections between keywords, codes, and themes.

● Step 6: Development of the Conceptual Model: A conceptual model analyzing the identified themes was constructed, allowing for a discussion offering a comprehensive framework for addressing the research question and insights into the study’s impact and reception.

Ethical Considerations

This study was conducted with IRB approval at Rowan University (Pro2020001111). Given the vulnerable nature of the study population, special consideration was taken to ensure anonymity and voluntary participation in each aspect of the study.

Results

Quantitative Data Results

A total of 650 surveys were collected, with only completed surveys utilized in the quantitative analysis. The completion rates were 70.3% for men (n=348) and 67.1% for women (n=104). Across all respondents, only 5.6-7.5% selected the positively biased option for questions 2, 3, 4-1, 4-2, and 4-3. Therefore, ad-hoc grouping of responses into strictly positive or negative sentiments was performed.

The proportion of respondents who reported a positive impression of group risk reduction counseling and testing was similar across genders (Table 1). A statistically significant difference (p<.05) in male and female perceptions was identified for question 5, overall care (p=0.007), and question 9, lack of preference for private counseling (p=0.034). On average, men reported a slightly lower rating of overall care than women (1.35 vs. 1.15, with 1=“Excellent” and 2=“Very Good”). The gender differences for both revealed small to absent effect sizes, with Cohen’s d and h values of 0.303 and -0.100, respectively, for the aforementioned questions. No other statistically significant differences or meaningful effect sizes (0.20 or above) were identified between the male and female responses.

Question/Domain	All Respondents (N=452)	Male (n=348)	Female (n=104)	Test Statistic,P value, Cohen’s d/h
Patient Satisfaction
Q2- Did the medical student or peer recovery coach explain the test results and reasons for any action or treatment you needed in a way that you could understand?* (%)	93.5	92.7	96.0	X2 = 1.689, P=0.905, Cohen’s d/h = 0.006
Q5-  Overall,  how  would  you  rate  the  care  you received at the mobile clinic today? (Mean, St.Dev)	1.303, 0.645	1.348, 0.672	1.154, 0.517	t = 2.709, P= 0.007, Cohen’s d/h= 0.303
Patient Comfort
Q3- Did you have confidence and trust in the medical student and or peer recovery coach you saw today? (%)	91.6	90.5	95.2	X2 = 0.026, P= 0.872, Cohen’s d/h=-0.008
Q6- Do you feel that being tested in a group setting made you feel more comfortable/less anxious? (Yes/No) (%)	68.4	66.4	75.0	X2 = 2.751, P= 0.097, Cohen’s d/h=0.078
Risk Reduction Training
Q8- Did you feel that receiving risk reduction training as a group presentation was helpful/effective? (Yes/ No) (%)	92.5	91.7	95.2	X2 = 1.431, P= 0.232, Cohen’s d/h=0.056
Q9- Would you have preferred to receive risk reduction counseling in the group setting rather than a private room? (Yes/No)*** (%)	74.8	72.4	82.7	X2 = 4.485, P= 0.034, Cohen’s d/h=-0.100
Privacy/Confidentiality
Q1- Did you feel the peer recovery coaches were discreet Yes enough when they called you in for the group and No results? (%)	93.8	93.1	96.2	X2 = 1.282, P= 0.257, Cohen’s d/h=0.053
Q4-1- Did you feel that your personal information was kept confidential in the treatment facility? (%)	91.6	91.1	93.3	X2 = 1.203, P= 0.272, Cohen’s d/h=-0.052
Q4-2- Did you feel that your personal information was kept confidential in the group harm reduction counseling? (%)	89.8	88.2	95.2	X2 = 2.053, P= 0.152, Cohen’s d/h=-0.067
Q4-3- Did you feel that your personal information was kept confidential in the consulting room? (%)	91.4	89.9	96.2	X2 = 0.138, P= 0.710, Cohen’s d/h=-0.017
Q7- Did being tested in a group setting make you feel that your privacy and personal information were well-protected? (Yes/No) ***(%)	75.4	73.9	80.8	X2 = 2.069, P=0.150, Cohen’s d/h=-0.068

Table 1: Gender differences of respondents with ‘positive impressions’* surrounding testing.
*The ‘positive impressions’ were dummy-coded such that responses indicating “yes” or those ranked as "Excellent," “Very Good,” or “Good” were categorized as positive impressions for analysis.
**Eight participants (4 women, 4 men) were removed for analysis because they responded “I did not need an explanation” or “I did not need treatment.”
***Questions 7 and 9 originally had differing directionality and were recoded to align with the positive directionality of the other questions. Q7 was originally “Did being tested in a group setting make you feel that you had less privacy/your personal information was less confidential?”, and Q9 was “Would you have preferred to receive risk reduction counseling in the private room rather than in a group setting?”.

Among the female participants, 95.2% felt that the care received at the facility was “Excellent” or “Very Good”, with no person reporting the care received below “Fair” (Figure 1). Among the male participants, 74.4% rated the delivery of care as “Excellent,” and 18.4% thought it was “Very Good.” When considering the effectiveness of harm reduction counseling, 92.5% of all participants felt that the educational component was effective (Table 1, Figure 2).

Figure 1: Distribution of ratings for Q5- assessing the overall rating of care received at testing events in men, women, and cohorts combined.

Figure 2: Participant responses to Questions 6 to 9 for males, females, and cohorts combined.

Qualitative Data Results

For the 100 included comments, keywords were identified and assigned to each comment. Keywords included “Lecture” or “Presentation” (n=7); “Process” or “Experience” (n=6); “Group” (n=2); “Staff,” “Peers,” “Team,” or names of counselors (n=15); “Privacy,” “Private,” or “Discrete” (n=3); “Confidentiality” (n=2); “Comfortable” (n=2); “Informative” or “Informational” (n=6); “Results” (n=2); “Good,” “Great,” “Awesome,” “Excellent,” or “Perfect” (n=23); “Thank(s),” “Grateful,” or “Appreciate” (n=20); “Professional” (n=3); “Helpful” (n=4); “Keep” (n=2), and a miscellaneous category (n=3) for comments that did not contain other identified keywords.

Keywords were then grouped into codes that captured broader patterns in the data, including “Confidentiality and Privacy Concerns,” “Environment Perception,” “Positive Staff Feedback,” “Process Satisfaction,” “Educational Content,” and “Appreciation and Endorsement.” Through thematic analysis, four overarching themes that reflected participants’ feedback on the group harm reduction counseling and testing experience (Figure 3) were identified.

Figure 3: Inductive Thematic Analysis Process to Develop a Conceptual Framework on Participants’ Optional Comments.

Overall, the participants indicated a preference for group education, with few expressing concerns about the privacy of their test results. Additionally, throughout testing, several participants expressed a greater sense of autonomy and control in a group setting where they could volunteer answers relative to a typical visit with a physician where information is typically imparted to the patient.

Discussion

This study's findings offer insights into the reception and effectiveness of group harm reduction counseling, emphasizing a collaborative setting where participants can share experiences, especially when paired with HIV/HCV testing. Gender-based analyses revealed minimal differences in participant responses (Table 1), with similar levels of comfort, satisfaction, and confidence in the confidentiality of the group testing environment. Among participants, 95% of female participants felt the care they received was “Excellent”, whereas 74% of male participants rated the delivery of care as “Excellent”, with no individuals rating the level of care received as below “Fair” and the majority rating care as “Excellent,” “Very Good,” or “Good,” highlighting the positive perception of participants experiences (Figure 1).

A statistically significant difference was observed between genders in overall care ratings (Q5), with women reporting higher levels of satisfaction (p=0.007), which met classification for a small effect size (Cohen’s d= 0.303), indicating a potentially meaningful difference in care perception between genders. The gender-specific differences revealed may be related to underlying social and cultural norms that shape comfort in group settings, particularly topics that may be perceived as sensitive. Previous research has shown that women in gender-specific groups report enhanced intimacy, support, empathy, and a greater ability to be open to their addiction and life circumstances [29]. Women also express increased comfort and a sense of kinship, underscoring the value of gender-specific spaces for sensitive discussion, particularly for women [29].

A statistically significant difference was observed between genders in overall care ratings (Q5), with women reporting higher levels of satisfaction (p=0.007). This met the classification for small effect size (Cohen’s d= 0.303), utilizing Cohen's d values of 0.2, 0.5, and 0.8 as the cutoff values for small, medium, and large effect sizes, respectively. While a Cohen’s d of 0.303 indicates a small effect size, even modest differences may have practical implications in the setting of healthcare satisfaction. Given the vulnerability of the population targeted with this intervention, these findings highlight the importance of understanding gender-based perceptions of care, which can help inform targeted interventions to enhance patient experience and improve retention in care [30].

The differences seen in care satisfaction between genders may be influenced by broader social and cultural factors, such as discussing sensitive topics in group settings. Prior research suggests that women in gender-specific spaces often report feeling more supported and open in discussions related to personal experiences [29,30]. While this study did not specifically assess the impact of gender-based support models, these findings do highlight the need for further exploration of gender-informed approaches to care, specifically in the setting of addiction medicine, HIV education, and treatment.

Despite differences in satisfaction, men and women showed no significant differences in reported comfort or privacy/confidentiality ratings. While a statistically significant difference in preferences for privacy during risk reduction counseling was observed between genders (Table 1), the effect size (Cohen’s d=-0.100) was below the threshold of a small effect size, which suggests that gender differences did not have a substantial impact on the group-testing experience. However, social and cultural norms may still play a role in shaping how men and women perceive privacy and comfort when receiving care in a group setting. Research has indicated that men are less likely to seek psychological help as it conflicts with traditional masculine norms and societal expectations of male behavior [31]. Studies have also shown that men are more often socialized to value emotional independence and may feel less inclined to share personal health concerns in a group setting, whereas women are more likely to exhibit greater levels of emotional disclosure and support-seeking in a social setting [31,32]. These differences in gendered communication patterns have the potential to impact participants’ comfort levels and perceptions of privacy, even if not translated significantly into quantitative differences in survey responses.

Considering this, while men and women may hold different views on group counseling and the benefits of testing, they generally share similar levels of comfort and confidence in the confidentiality provided within the group counseling environment. This may indicate that the staff fostered a secure and supportive atmosphere, helping participants feel comfortable and assured of their privacy, regardless of gender or preference for group versus individual counseling and testing. Given the sensitive nature of the topic, it is vital for staff to have an appropriate level of training and lived experience to help counsel clients appropriately.

Analysis of written participant comments revealed several themes. Most of the comments concerned staff interactions, privacy and confidentiality concerns, and educational value, indicating that these topics may be more important to participant satisfaction. Most of the comments on staff interactions praised the staff for their professionalism, knowledge, and concerns expressed by the participants. This positive rapport and confidence in staff ability was one of the most important factors in driving participant comfort, a finding that was also echoed in one Canadian study [33]. Comments commonly cited professionalism, kindness, and confidence in staff knowledge as necessary for improving their testing experience. Additionally, the participants highlighted the supportive and welcoming environment fostered by the staff, reinforcing the role of interpersonal dynamics in ensuring a positive experience, aligning with the theme of “Interpersonal Dynamics” identified in the thematic analysis.

Another factor that heavily influences patient comfort levels, especially when testing for highly stigmatized diseases such as HIV, is privacy and confidentiality. It is a challenge to eliminate privacy concerns altogether. A well-documented phenomenon in HIV testing is a sense of anxiety surrounding being seen at a known testing center [34]. Many individuals have expressed this hesitation, as they fear that someone they know will see them at a testing center and assume that they are HIV positive [34], making the attendance and consistency of HIV testing more difficult. However, in this setting, many patients were already accustomed to discussing sensitive topics such as substance use or adverse childhood experiences with each other in a group therapy environment. As a result, patients often expressed feelings of solidarity, companionship, and self-efficacy. Regardless of their own risk profile, they valued the opportunity to support their peers in recovery and often gained insight into their own risk factors and strategies for risk reduction.

Fostering this sense of mutual support required a group environment that prioritized emotional safety, enabling participants to be more open about their experiences. This was achieved not only through the involvement of peer counselors, each of whom was an individual with lived experience of substance use and recovery but also by ensuring that all staff members, including medical students, were trained in trauma-informed approaches. These approaches helped facilitate sensitive and nonjudgmental discussions, particularly for individuals with histories of stigma, discrimination, or prior negative healthcare experiences.

While the intention of implementing a group setting was to surround the patient with other individuals who were also being tested to alleviate this fear, it was not wholly effective in doing so.

In one negative comment regarding privacy and confidentiality received, the participant commented that they would “feel nervous like if tested positive for HIV, I would feel terrified if the group would determine and shun me.” This finding indicates room for improvement in alleviating this barrier to testing. While test results are disclosed privately, the inpatient setting means that participants are still in close proximity to one another, making it challenging for individuals with unexpected positive results to fully conceal their reactions. Despite this, most comments mentioning the group setting stated that it provided an additional measure of comfort to the participants, with one noting that they would “test like this every 6 months vs the years I was going without testing.” Several individuals verbally expressed that it was helpful to have the support of their peers after receiving an unexpected result. Although the comments suggest a somewhat mixed reception, most participants noted improved comfort and a reduced sense of isolation from the group setting, aligning with the themes of “Trust and Emotional Safety” and “Program Impact and Effectiveness.” Several participants additionally pointed out that other participants asked questions they were too shy to ask or had not thought of. Several such questions from the pilot event were incorporated into the didactic portion of the presentation.

Overall, the participants frequently expressed gratitude and appreciation for the program, with some even highlighting the perceived importance in their lives. Comments such as “Keep doing this” and “It should be mandatory” emphasize the value participants placed on the program and their desire for its continuation. This recognition not only underscores the program’s effectiveness but also reflects its role in fostering a sense of community and support among participants, aligning with the identified theme of “value recognition.” These comments demonstrate the program’s impact beyond immediate outcomes, resonating as a meaningful resource within the community.

Importantly, while improvements can be made to the testing process, there is no “one size fits all” approach to HIV testing. Even within narrow demographic groups, individual preferences and priorities can vary widely [35]. While some participants cited privacy concerns as their reason for disliking the group setting, others simply preferred the interaction of a one-on-one encounter, with one participant stating that “I do not feel my confidentiality was at risk, but I prefer one-onone instead of a group setting.” This emphasizes the importance of utilizing a diverse range of testing methodologies to fulfill the many different needs of the community.

The results of this study provide several opportunities for the expansion of HIV/HCV research. For example, an anthropological lens can be applied to patients. Cultural background may influence the reception and processing of results, and further analysis can be conducted to explore this relationship. Research suggests that it is imperative to understand the factors that contribute to discriminatory stigmas in various ethnic populations. Culture may influence stigma and disclosure concerns among individuals with HIV, so correcting for this factor may lead to increased efficacy in patients [36]. Additionally, this research may provide momentum for incorporating culturally sensitive education initiatives into HIV/HCV outreach.

An additional avenue of research based on this project can explore whether any difference is made in the results if the gender of the counselor or peer recovery coach matches that of the patients. Considering that there were statistically significant differences in the survey responses of women versus men, this path may yield higher levels of patient satisfaction. This may provide both more comfort and a way of identifying with team members and therefore can improve outcomes.

An opportunity to improve the survey may include further exploration of psychosocial factors. For example, measuring a participant’s readiness to engage in group counseling may provide more context for their answers to survey questions. This may vary based on withdrawal status or motivation level. Moreover, including emotional safety questions offers another metric for the efficacy of a group setting. “I felt emotionally safe during the group sessions” or “I felt supported by other participants” are some of the questions that can gauge participant comfortability.

For accessibility and administration, the survey can be offered in multiple languages relevant to the population. Patients may also face literacy barriers, which can be overcome with visual aids such as diagrams, images, or simpler language.

If participants are explicitly asked to qualify their confidence level after the session, this may point toward better longitudinal outcomes. Self-efficacy assessment questions can also be added to the survey. This may be written as “I feel confident in my ability to implement the strategies I learned today.” Question items can be included to assess how a patient’s perspective on content matter may change over time. For example, an additional survey regarding the patient’s ability to manage care may be administered one month after the initial survey. Items can include topics from the presentation given to patients while their results are being processed. These topics include disease transmission, common myths, and treatment modalities of HIV/ HCV. Behavioral outcomes can also be measured in this way, such as patients’ understanding of safer practices or increased testing frequency.

Limitations and Directions for Future Research

Limitations of this study primarily concern participant response quality and the survey structure. The open-ended final survey question may have led some participants to omit true opinions because of perceived futility or a lack of incentive to record neutral views. Open-ended probes in surveys may also result in participants changing answers to previous close-ended questions [37]. Additionally, questions 7 and 9 reserved response directionality, where “Yes” implies a negative response compared with the other questions. This inconsistency may have caused participants to assume consistent directionality, potentially skewing accuracy. Language and reading comprehension could also have impacted the accuracy of the survey responses. Another limitation is the gender imbalance, with substantially more men tested and surveyed than women, potentially limiting generalizability. Despite the proportion of men and women responding, there was a sufficient sample size of women to power a comparison of male and female responses. However, this imbalance should be considered when evaluating the specifics of the combined dataset (Table 1, “All Respondents”). Due to sample size differences, the “All Respondents” data is skewed toward the sentiment of the male respondents and may be less generalizable to females as a result. Of note is the broad trend of acceptance and support of the GRREAT Model by both males and females is still represented in the combined dataset, albeit with some attenuation due to subtle differences in gender preference. The survey items used in this study were also not validated for their psychometric properties, which may limit the reliability and accurate interpretation of the results.

Another limitation is the gender imbalance, with substantially more men tested and surveyed than women, impacting the generalizability of our findings. This imbalance largely stems from the study’s initial design, as the grant originally only included men, with women being added to the program at a later time. In addition, the testing of the facilities contributed to the gender disparities, as one facility was maleonly, while the other facility housed both men and women. As a result, there were naturally more male inpatients available for participation, leading to a larger population of male responses.

While the study included a sufficient sample size of women to conduct statistical comparisons between genders, the disproportionate number of male participants in the study means that the overall trends in combined datasets reflect more male perspectives. This is particularly important when interpreting findings related to comfort within a group setting, privacy concerns, and overall satisfaction, as these measures will be more heavily influenced by the number of male participants when looking at the combined data. In addition, given that women reported statistically higher satisfaction than men with a significantly smaller sample size, it is possible that if more women were surveyed, different trends might have been observed in gendered perceptions of care and group testing comfort.

While differences in men’s versus women’s perspectives on group harm-reduction counseling and group HIV/HCV testing may partly reflect gender-based comfort levels with sharing or opening up in a group setting, it is also important to consider other factors, such as ethnicity, race, and age, when interpreting these differences. In the absence of data on participants’ race, ethnicity, age, and education, insights into how these factors might affect trust, comfort, and interactions with peer coaches and medical students are limited. These intersecting factors are likely to impact how a person self-identifies within a group, influencing their experiences and willingness to engage openly in group harm-reduction counseling. A study published in 2011 on sex, race, and group behavior in group drug rehabilitation treatment revealed that race and race by gender, but not gender alone, were the most significant predictors of group behavior [38]. Similarly, we could not account for the duration of participants’ sobriety before enrollment. Varying admission circumstances (voluntary vs. involuntary) and the recentness of sobriety, especially among those experiencing withdrawal, are likely to affect participants’ experiences.

Future studies should aim to collect follow-up data with testing recipients to see how their satisfaction relates to their future ID decision-making behaviors and longitudinal continuity of care. Future studies may also consider exploring the replicability and scalability of the group harm reduction counseling model in other clinical settings and among diverse patient demographics. The high levels of satisfaction reported, coupled with minimal differences in responses between genders, suggest this approach has the potential for broader implementation. This scalability is particularly promising for medically underserved areas where similar testing barriers exist, offering opportunities to address gaps in care and improve health outcomes.

Conclusion

Harm reduction counseling paired with HIV/HCV testing was well received by both the male and female cohorts. While women tended to favor group testing and perceived more significant levels of privacy, both men and women ultimately showed positive results, indicating acceptance of the program. The Group Risk REduction and Testing" (GRREAT) Model aims not only to increase HIV and HCV testing rates among vulnerable populations but also to foster conversations and education about HIV, safe sex practices, and sobriety treatment compliance. This approach empowers participants to stay safe in their communities and advocate for their health.

List of Declarations

Ethics approval and consent to participate: Study procedures were approved by the Rowan Institutional Review Board, Protocol Number Pro2020001111 (PI RJ).

Consent for Publication

The authors provide consent for publication.

Availability of Data and Materials

To comply with research ethics, the data underlying this study will not be made available to persons outside of the research team, as approved by the Rowan University Institutional Review Board. Please contact Jaimy Jabon for any data inquiries.

Competing Interests

None reported.

Funding

This study was funded by a discretionary grant from the Substance Abuse and Mental Health Services Administration (SAMHSA, #6H79TI082453 to RJ).

Authors’ Contributions

All authors contributed to the conceptualization and development of the methodology. GA, DJ, VWM, AS, RS, JJ, SF, and MA were involved in data collection and manuscript writing. JL contributed to the interpretation of data, provided edits to the writing, and critical review of the manuscript. RJ provided oversight and critical review of the manuscript. All authors read and approved the final version of the manuscript. Abbreviations: Gabrianna Andrews (GA), Dale Johnson (DJ), Victoria Wong Murray (VWM), Aria Sen (AS), Ryan Salerno (RS), Jaimy Jabon (JJ), Sydney Fulton (SF), Michael Acevedo (MA), Jamey J. Lister (JL), Richard Jermyn (RJ).

Acknowledgments

We would like to acknowledge and thank the peer counselors and treatment center employees for their dedication and support in working with the community. We also thank the medical student volunteers for their invaluable help with data collection.

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Article Information

Article Type: RESEARCH ARTICLE

Citation: Andrews G, Johnson D, Murray VW, Sen A, Salerno R, et al. (2025) A Mixed-Methods Evaluation of Group Harm Reduction Counseling and Testing for HIV and Hepatitis C in High-Risk Individuals. J HIV AIDS 9(1): dx.doi.org/10.16966/2380-5536.193

Copyright: ©2025 Andrews G, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Publication history: 

Received date: 22 Jan, 2025

Accepted date: 10 Feb, 2025

Published date: 17 Feb, 2025