Missed Chances for HIV Testing: Provider Offers to At-Risk Adults, Virginia, 2016

Since 2006, CDC has recommended routine, provider-initiated HIV screening — at least once in a lifetime — for all patients aged 13–64 in all health care settings. How often people are tested is fairly well known; how often providers actually offer a test is not. This study used National HIV Behavioral Surveillance (NHBS) data from Virginia to find out, for heterosexual adults at increased risk of HIV.

Who was studied

• Where and when: the Norfolk–Newport News–Virginia Beach metropolitan area, September–December 2016, through anonymous HIV testing and face-to-face interviews.
• Who: heterosexual, cisgender adults 18–60 at increased risk through heterosexual sex — no injection drug use or male-to-male sex in the past year, and low socioeconomic status (at most a high school education, or income at or below the federal poverty guidelines), recruited by respondent-driven sampling.
• The sample: of 548 people interviewed, 333 remained after excluding those who did not meet the risk definition, reported being HIV-positive, had not seen a provider in the past year, had been tested more than a year earlier with no recent risk or STD diagnosis, or did not know whether they had been offered a test.

What they found

• 139 (42%) had been offered an HIV test by a provider in the past year; 194 (58%) had not.
• Of those not offered a test, 156 (80%) reported high-risk sexual activity and 71 (37%) had never been tested in their lives.
• Offers work: 71% of those offered a test had been tested in the past year, against 16% of those not offered — more than three times as many.
• Men were offered a test less often than women: 32% versus 48%. This was the only factor that stayed significant after adjustment (adjusted prevalence ratio 0.72), and it held when other factors were accounted for (0.69).
• Lacking health insurance and being older (51–60) were linked to fewer offers in initial analyses, but not significantly after adjustment. High-risk sexual activity did not predict an offer.

Why it matters

• Testing has risen — the share of adults ever tested went from 40% in 2006 to 45% in 2009, and has risen among at-risk heterosexuals — yet an estimated 15% of HIV infections are undiagnosed. Provider offers are needed to find them.
• Why women were offered more: in a side analysis, a quarter of women who were both offered and tested had their recent test at a family planning or obstetrics clinic. But heterosexual men report more sex partners than women, and are less likely to seek care and routine screening — so screening the men who do come in is essential.
• Risk talk is not required for testing. CDC's 2006 guidance dropped risk-based screening to reduce barriers and stigma, so it is not surprising that risk did not predict an offer. But repeat screening is recommended for people at high risk, and finding them still needs providers and patients to talk about sexual health. Among those not offered a test, sexual risk was common, so screening should come with discussion of pre-exposure prophylaxis and other prevention as appropriate.

Limitations

1. Cross-sectional data cannot show cause.
2. Answers were self-reported face to face, open to social desirability bias — though probably not differently by offer status.
3. The sample was low-income, from eastern Virginia, and mostly Black or African American, so results may not apply to other groups. Future work should look at racial, regional and socioeconomic differences in test offers.

Bottom line: provider-initiated test offers are a key way to raise HIV testing among heterosexual adults — and more are needed for those at increased risk, especially men.

How the study sample was selected. Image from the Centers for Disease Control and Prevention

Sources

Based on "Prevalence and Predictors of Provider-Initiated HIV Test Offers Among Heterosexual Persons at Increased Risk for Acquiring HIV Infection — Virginia, 2016," by Karen L. Diepstra, Tina Cunningham, Anne G. Rhodes, Lauren E. Yerkes and Celestine A. Buyu, Morbidity and Mortality Weekly Report 67(25), Centers for Disease Control and Prevention; a work of the United States government in the public domain.