Many in the United States Have Not Been Tested for HIV

Ricki Lewis, PhD

June 28, 2019

Fewer than 40% of people in the United States have ever been tested for HIV, according to a report from the Centers for Disease Control and Prevention published June 27 in Morbidity and Mortality Weekly Report.

National HIV Testing Day, on June 27, acknowledges the vital role of testing in preventing, detecting, and treating HIV infection. Early diagnosis is critical to controlling transmission. Those who test negative but are at elevated risk can employ preexposure prophylaxis.

Since 2006, CDC has recommended universal screening for HIV infection at least once in a healthcare setting for people aged 13 to 64 years and at least annual rescreening of individuals at increased risk. However, data from national surveys and HIV surveillance indicate that the recommendations have not been followed.

To accelerate the fight against HIV, the CDC announced in early 2019 the Ending the HIV Epidemic: A Plan for America program, which aims to reduce new HIV infections here by 75% by 2025 and by 90% by 2030. The goal is to tailor prevention strategies to meet local needs, which might require novel screening programs to reach groups whose members haven't been tested.

The plan will initially focus on 50 local jurisdictions (48 counties, the District of Columbia, and San Juan, Puerto Rico) in which nearly half of all new diagnoses in 2016 and 2017 occurred, as well as on seven states that have rural areas in which there is a disproportionate incidence of infection compared with other states (states in which at least 75 reported HIV diagnoses in rural areas accounted for at least 10% of all the HIV diagnoses).

In the new report, Marc A. Pitasi, MPH, of the Division of HIV/AIDS Prevention at CDC, and colleagues analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) covering 2016 and 2017. This telephone survey asked about testing outside of a blood donation setting and about risk factors encountered during the past year, such as intravenous drug use and possible exposure via multiple sex partners.

The researchers discovered that 38.9% of the US population had ever been tested for HIV infection; 46.9% of the testing was in the 50 local jurisdictions; and 35.5% was in the seven states with disproportionate incidence in rural areas.

Of 15,701 individuals (3.2%) who reported elevated HIV risk in the previous year, 64.8% were ever tested, and 29.2% were tested during the past year. Of those tested during the past year, 34.3% were from the 50 local jurisdictions, and 26.2% were from the seven states. The researchers point out that these values are far below the recommended 100% testing within the past year for high-risk individuals.

In the seven states, 32.1% of those who had ever been tested lived in rural areas, and 37.2% lived in urban areas, but among individuals at elevated HIV risk in these states who were tested within the past year, 18.4% were in rural areas, and 29.0% were in urban areas.

The region with the lowest number of ever-tested individuals, 36.5%, was Maricopa County, Arizona. The highest, at 70.7%, was the District of Columbia. For testing during the past year, independent of reported recent HIV risk, values ranged from 8.1% in Alameda County, California, to Bronx County, New York, with 31.3%.

The variability in testing, for both ever and past-year testing, by jurisdiction indicates that screening programs should be tailored to local needs. The BRFSS is the only instrument that provides a large enough sample to accomplish this analysis, the researchers write.

They suggest the following approaches to increase testing:

  • Make HIV screening part of routine healthcare examinations, including sexual health screenings.

  • Increase efforts through the use of social media and mobile apps to identify sexual partners who may have been exposed.

  • Conduct pharmacist-led screenings.

  • Provide screening at urgent care facilities.

  • Implement increased use of HIV self-tests.

"Knowledge is power when it comes to HIV — that is why everyone in America should get an HIV test at least once in our lives," said Jonathan Mermin, MD, MPH, director of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, in a news release. "It is a simple way we can all help end the HIV epidemic in the US."

Limitations of the study include the low number of individuals who reported recent elevated risk for HIV infection and recall bias in self-reporting.

The researchers have disclosed no relevant financial relationships.

Morb Mortal Wkly Rep. Published online June 27, 2019. Full text

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