HIV Testing in 50 Local Jurisdictions Accounting for the Majority of New HIV Diagnoses and Seven States with Disproportionate Occurrence of HIV in Rural Areas, 2016–2017

Marc A. Pitasi, MPH1; Kevin P. Delaney, PhD1; John T. Brooks, MD1; Elizabeth A. DiNenno, PhD1; Shacara D. Johnson, MSPH1; Joseph Prejean, PhD1 (

Summary

What is already known about this topic?

Rates of screening for human immunodeficiency virus (HIV) in the United States are low.

What is added by this report?

This analysis of national survey data found that What are the implications for public health practice?

Novel HIV screening strategies tailored to meet local needs might be needed to reach segments of the population that have never been tested for HIV and achieve national goals to end the HIV epidemic in the United States.

Tables

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Since 2006, CDC has recommended universal screening for human immunodeficiency virus (HIV) infection at least once in health care settings and at least annual rescreening of persons at increased risk for infection (1,2), but data from national surveys and HIV surveillance demonstrate that these recommendations have not been fully implemented (3,4). The national Ending the HIV Epidemic initiative* is intended to reduce the number of new infections by 90% from 2020 to 2030. The initiative focuses first on 50 local jurisdictions (48 counties, the District of Columbia, and San Juan, Puerto Rico) where the majority of new diagnoses of HIV infection in 2016 and 2017 were concentrated and seven states with a disproportionate occurrence of HIV in rural areas relative to other states (i.e., states with at least 75 reported HIV diagnoses in rural areas that accounted for ≥10% of all diagnoses in the state).† This initial geographic focus will be followed by wider implementation of the initiative within the United States. An important goal of the initiative is the timely identification of all persons with HIV infection as soon as possible after infection (5). CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS)§ to assess the percentage of adults tested for HIV in the United States nationwide (38.9%), in the 50 local jurisdictions (46.9%), and in the seven states (35.5%). Testing percentages varied widely by jurisdiction but were suboptimal and generally low in jurisdictions with low rates of diagnosis of HIV infection. To achieve national goals and end the HIV epidemic in the United States, strategies must be tailored to meet local needs. Novel screening approaches might be needed to reach segments of the population that have never been tested for HIV.

BRFSS is an annual cellular and landline telephone survey of the noninstitutionalized U.S. population aged ≥18 years. The median response rate among all participating states and territories was 47.1% (range = 30.7%–65.0%) in 2016¶ and 45.9% (range = 30.6%–64.1%) in 2017.** Respondents were asked whether they had ever been tested for HIV outside of blood donation; those who answered “yes” were asked for the month and year of their most recent test. Respondents were also asked whether any of the following HIV risk–related situations applied to them in the past year: injected drugs that were not prescribed, received treatment for a sexually transmitted disease, exchanged money or drugs for sex, had anal sex without a condom, or had four or more sex partners. Those who answered “yes” to this question were considered to have reported recent HIV risk.

Data collected in 2016 and 2017 were pooled and used to estimate the percentage and corresponding 95% confidence intervals (CIs) of ever testing for HIV and testing for HIV in the past year overall and for each of the 57 jurisdictions. Nationally and within the seven states with disproportionate rural HIV occurrence, counties were grouped as either mostly urban or mostly or completely rural according to designation by the 2010 U.S. Census.†† Rao-Scott chi-square tests were used to compare testing percentages between mostly urban and mostly or completely rural areas in the United States and in the seven states with disproportionate rural HIV occurrence. All estimates were weighted to account for the complex multistage sampling design. HIV diagnosis rates per 100,000 population among persons aged ≥13 years were calculated from HIV diagnoses reported to CDC’s National HIV Surveillance System during 2016–2017 through December 2018; U.S. Census population estimates for 2016 and 2017 were used for the denominators. HIV diagnosis rates and testing percentages were examined together for each of the 50 local jurisdictions as well as urban and rural areas of the seven states to further characterize these areas with respect to their current HIV morbidity and testing coverage; Pearson’s correlation coefficient was used to assess the correlation between these areas’ testing percentages and HIV diagnosis rates. Although BRFSS testing percentages were calculated among those aged ≥18 years, HIV diagnosis rates were calculated among those aged ≥13 years to be consistent with methodology used to identify the jurisdictions accounting for the majority of new HIV diagnoses and because of limited availability of single-year age population estimates at the municipio (county equivalent) level in Puerto Rico. Analyses were performed using SAS (version 9.4; SAS Institute) and SUDAAN (version 11.0; RTI International).

During 2016–2017, 38.9% of adults aged ≥18 years in the United States had ever been tested for HIV (

Testing percentages varied widely by jurisdiction (

Discussion

In this analysis, 1,2). These findings demonstrate missed opportunities to fully implement HIV screening recommendations in the 57 jurisdictions that will serve as the initial geographic focus of the Ending the HIV Epidemic initiative. The observed variability in both ever and past-year testing by jurisdiction highlights the need for screening strategies that are tailored to local needs. BRFSS is likely the only annual survey with a sufficient sample size to provide jurisdiction-level estimates of HIV testing to monitor long-term progress toward increasing screening coverage in the United States.

HIV screening strategies will likely need to be locally tailored and novel to reach segments of the population that have not been reached by previous efforts. Examples of novel or promising approaches to increase access to HIV testing include routinizing HIV screening in health care settings, integrating HIV screening with sexual health screenings, scaling up partner notification and other strategies (using social network strategy§§ or mobile applications) that offer screening of the social and sexual networks of persons seeking HIV screening, promoting pharmacist-led screening¶¶ as well as screening in other alternative clinical settings such as urgent care, and mass distribution of HIV self-tests*** (6–10). Further efforts will be needed to identify which approaches are most effective in increasing access to HIV testing in various settings and jurisdictions with different baseline needs. Early diagnosis and effective treatment that suppresses HIV replication not only minimize immune system damage and reduce individual morbidity and mortality but also reduce the risk for transmission to others.††† Delayed diagnosis limits these benefits. HIV screening is a critical entry point to a range of HIV prevention and treatment options. For persons at ongoing risk for HIV infection exposure, annual screening also offers the opportunity to discuss options to reduce risk, including HIV preexposure prophylaxis.§§§

The findings in this report are subject to at least six limitations. First, because the proportion of respondents reporting recent HIV risk was small, testing percentages for this group could not be reported separately in the 57 jurisdictions. Second, self-reported data might be subject to social desirability and recall biases, which might have led to over- or underestimation of testing. Third, BRFSS response rates were low; however, the response rates are comparable with those of other national landline and cellular telephone surveys, and survey weights were designed to ensure generalizable findings. Fourth, the measure of HIV-related risk did not include every behavior that might increase risk for HIV infection, such as unprotected sex with a partner who is known to have HIV or whose HIV status is unknown. Fifth, the assessment of HIV diagnosis rates and HIV testing percentages relied on disparate age ranges (≥13 years and ≥18 years, respectively). Finally, this analysis included data from surveys conducted during 2016–2017 and HIV diagnoses that occurred during the same period. These are the most current data available for these measures but represent a delayed cross-section of the current state of HIV testing and diagnoses for 2019. To monitor progress toward national goals, closer to real-time reporting of select HIV testing activities might be needed.

HIV screening remains suboptimal for persons residing in the 57 jurisdictions that will constitute the initial geographic focus of the Ending the HIV Epidemic initiative. These data provide a baseline from which to measure changes in screening in these jurisdictions and other parts of the United States over time. To achieve national goals and end the HIV epidemic in the United States, innovative and novel screening approaches might be needed to reach segments of the population that have never been tested for HIV.

Acknowledgment

Kim Elmore, PhD, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.

Corresponding author: Marc A. Pitasi, mpitasi@cdc.gov, 404-639-6361.

1Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.

All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

• https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview.

† The 50 local jurisdictions and seven states were identified from diagnoses made during 2016–2017 reported to CDC’s National HIV Surveillance System through June 2018. Diagnosis data from 2017 were considered preliminary (https://files.hiv.gov/s3fs-public/ending-the-hiv-epidemic-flyer.pdf). A list of the 50 local jurisdictions and seven states is available in Table 2 of this report and at https://files.hiv.gov/s3fs-public/Ending-the-HIV-Epidemic-Counties-and-Territories.pdf.

§ https://www.cdc.gov/brfss/index.html.

¶ https://www.cdc.gov/brfss/annual_data/2016/pdf/2016-sdqr.pdf.

** https://www.cdc.gov/brfss/annual_data/2017/pdf/2017-sdqr-508.pdf.

†† https://www.census.gov/programs-surveys/geography/guidance/geo-areas/urban-rural.html.

§§ https://effectiveinterventions.cdc.gov/en/care-medication-adherence/group-4/social-network-strategy-for-hiv-testing-recruitment.

¶¶ https://effectiveinterventions.cdc.gov/en/hiv-testing/group-1/hiv-testing-in-retail-pharmacies.

*** https://www.cdc.gov/hiv/testing/hometests.html.

††† https://www.cdc.gov/hiv/risk/art/index.html.

§§§ https://www.cdc.gov/hiv/risk/prep/index.html.

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• Urban and rural classifications were derived from 2010 U.S. Census. Counties with † The 50 local jurisdictions (48 counties, the District of Columbia, and San Juan, Puerto Rico) accounted for the majority of new HIV diagnoses, and the seven states (Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma, and South Carolina) experienced disproportionate occurrence of HIV in rural areas, as identified from HIV diagnoses made during 2016–2017 and reported to the National HIV Surveillance System through June 2018. Diagnosis data from 2017 were considered preliminary.
  § Rao-Scott chi-square p-values compare testing estimates between mostly urban counties and mostly or completely rural counties.

• Urban and rural classifications were derived from 2010 U.S. Census. Counties with †**** Number of respondents with “yes” or “no” response to question about ever testing for HIV.

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• HIV diagnosis rates per 100,000 population among persons aged ≥13 years during 2016–2017 were calculated from HIV diagnoses reported to NHSS through December 2018 and Census population estimates for 2016 and 2017.

† The 50 local jurisdictions (48 counties, the District of Columbia, and San Juan, Puerto Rico) accounted for the majority of new HIV diagnoses, and the seven states (Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma, and South Carolina) experienced disproportionate occurrence of HIV in rural areas, as identified from HIV diagnoses made during 2016–2017 and reported to NHSS through June 2018. Diagnosis data from 2017 were considered preliminary.

§ Pearson’s correlation coefficient = 0.71; p

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