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CDC Vital Signs: HIV Testing and Diagnosis Among Adults — United States, 2001-2009

Tuesday, November 30, 2010 – 11:30am ET

Operator: Thank you all for standing by. Welcome to the CDC conference call. Your lines have been placed on listen only for today's conference. During the question and answer portion of the call, we ask you announce your name and affiliation by pressing star 1 to ask a question. We do ask you keep your questions to one question and one follow-up to allow all questions to be answered during the call. The conference is being recorded. If you have any objections, you may disconnect at this time. I will now turn the call over to Mr. Tom Skinner. Sir, you may proceed.

Tom Skinner: Thank you, Jill, and thank you for joining us on this telebriefing on CDC's Vital Signs report on HIV testing and diagnosis among adults in the United States in the years 2001 through 2009. Joining us today is the director of the CDC, Dr. Thomas Frieden and the director of the HIV/AIDS prevention program at CDC, Dr. Jonathan Mermin. Both will provide some brief comments about the Vital Signs report, and then we will open it up to your questions. I will now turn the call over to Dr. Tom Frieden.

Thomas Frieden: Thank you very much, and thank you for joining us this morning. This is our monthly first Tuesday of the month Vital Signs release on one of the leading health indicators of the U.S., and today is on HIV. HIV is still a serious problem in this country. More than a million Americans are infected. Many become ill. Many die preventable deaths, and the costs are more than $350,000 per person in medical costs alone. Testing and linking people who are HIV positive to care are key to decreasing the epidemic.

In 2006, CDC issued new recommendations, and today's data shows that following those recommendations there was a significant increase in the number of Americans who were tested for the first time for HIV. In fact, between 2006 and 2009 more than 11 million additional Americans were tested for the first time for HIV. This increased from 40 to 45%. The overall number of people of adults in this country who have ever been tested. And because more people were tested, fewer people were diagnosed late with HIV. The portion of patients diagnosed late decreased from 37% to 32%. Overall, a relative increase of about 10 or 15% in testing, and a relative decrease also by 10% or 15% in a number of people diagnosed late. So this is significant progress in increasing testing and linkage to care.

However, there are still 200,000 or more Americans who have HIV and don't know it. And overall, 55% of adults, and even more concerning, 28% of high-risk adults have never been tested, and those at higher risk are also not testing frequently enough. If you don't know your HIV status, you can't effectively protect yourself and your partners. People who know they're positive cut they're risky behavior in half. People who know they're positive can get treatment, which protects themselves and their partners, greatly reduces the risk of spread of HIV, and also can prevent the development of AIDS.

Virtually all AIDS cases are preventable. Either by preventing infections or progression from HIV infection to clinical illness with AIDS. However, an estimated 37,000 Americans were diagnosed with AIDS in the most recent year for which data are available, 2008. Although many more would have been diagnosed without the expanded testing initiative, that's still far too many AIDS cases. Virtually every one of which could be prevented. There is now a national HIV/AIDS strategy, which will focus on reducing new infections and improving linkage to care, helping those at highest risk and targeting communities at highest risk. The information released today is good news. It shows that progress is possible and is being made. More people are being tested. But it also shows how much more progress is needed. In particular in the health care setting. In-patient units need to routinely offer HIV testing. When that occurs patients are well served. They're diagnosed at an earlier stage of their infection. They can prevent serious illness. And they can avoid spreading HIV to their partners in their communities. As one person who found out too late that they are HIV positive told me, it's hard to find out you're HIV positive, but it's much harder to find out you're HIV positive and you already have AIDS. I now want to turn this over to Dr. Jonathan Mermin, the director of our HIV prevention program here at CDC. Dr. Mermin?

Jonathan Mermin: Thank you, Dr. Frieden. Since everybody on the call already has the press release, I'm going to keep my remarks brief. But I would like to summarize the findings and their significance.

HIV testing is the fundamental link between HIV care and prevention. People cannot take treatment that prolongs their life for decades without knowing they have HIV. And people with HIV who know they are infected are much less likely to transmit the virus. But one in five of the more than one million Americans with HIV don't know they're infected. About 200,000 people. The majority of HIV infections are transmitted by these people who remain unaware of their infection. 3.5 times more infections than those from people who know that they have HIV. Because of this, HIV testing has been one of CDC's central priorities for many years. Together with health departments and organizations around the country we've been working to increase the proportion of HIV-infected individuals who know their status to make sure they're connected to life-extending HIV care and have the support they need to protect others from infection.

One key element of our approach is to make HIV testing a routine part of the care people receive when they visit their doctor. In 2006, CDC issued new recommendations stating that HIV testing should be provided as a routine part of medical care for adults and adolescents in the U.S., and that people at high risk for HIV such as men who have sex with men or people with HIV-infected partners should be tested at least annually. CDC also recommended streamlined consent and counseling procedures to help overcome logistical barriers to HIV testing in the busy medical facilities, barriers that in the past have prevented many people from learning their HIV status.

Since 2006 we've been working with medical associations and other partners to implement the recommendations, while also working to reach people at risk with HIV testing outside of medical settings. Now we have encouraging signs that the nation's HIV testing efforts over the past several years are paying off. But we still have a long way to go. The national testing data we are discussing today are from CDC's National Health Interview Survey. This is a nationally representative annual survey of U.S. adults aged 18 to 64. We looked at survey data on HIV testing from the years 2001 through 2009. The analysis shows in 2009 a record 82.9 million adults in the U.S. reported having ever been tested for HIV infections. That represents an increase of 11.4 million people in 2006. Looked at in other ways, the proportion of Americans who has ever been tested remains stable at 40% from 2001 to 2006, but then rose to 45% in a three-year period from 2006 to 2009. This increase is encouraging, but it also means that 55% of American adults still have not been tested for a deadly infection. And many people at higher risk for HIV infection aren't being tested often enough.

In a recent CDC study among gay and bisexual men in 21 cities, 44% of men with HIV did not know they were infected. Yet almost half had been tested in the past year, underscoring the importance of more frequent testing among those at highest risk. As Dr. Frieden mentioned at the top of the call, today's Vital Signs report also confirms studies finding that many people with HIV are being diagnosed very late in the course of their infection, when treatment is much less likely to be effective and critical prevention opportunities have been lost.

Today's report also includes CDC surveillance data from 37 states with mature HIV reporting systems showing that among people diagnosed with HIV in 2007, 32% progressed to AIDS within a year of their HIV diagnosis. In other words, they had unknowingly been infected with HIV for years before they were diagnosed, as most people with HIV develop AIDS within 10 years of infection. Early diagnosis and linkage to care and prevention services can mean a longer, healthier life for those infected with HIV and a critical opportunity to make end roads to the epidemic.

At CDC we're working hard to increase access to HIV testing. This includes not only providing guidance to physicians and other providers as they continue to adopt CDC's recommendations, but also working with health departments and community organizations to expand community-based HIV testing programs that reach people outside of health care settings. For example, through the use of rapid HIV tests at community centers, churches, and through multiple testing vans and social networks. In 2009, CDC provided $500 million to 65 state and local health departments and 130 community-based organizations for HIV prevention and surveillance activities including testing. Just this year we expanded a successful testing initiative we began in 2007 to support testing efforts in 30 of the hardest hit jurisdictions in the United States. In the first two years of this initiative, more than 1.4 million people were tested and over 10,000 people with HIV were diagnosed.

All these efforts support key goals of the national HIV strategy announced earlier this year. That is to increase the proportion of HIV-infected individuals who know their status from today's 79% to 90% and reduce HIV incidence by 25% by the year 2015. We think these are achievable goals, but it will require commitment from everyone involved. With a new HIV infection every 9 ½ minutes in this country, it's critical we all remember the importance of testing as a life-saving and HIV prevention tool. So now I would like to open up the line for questions.

Tom Skinner: Jill, we're ready for questions.

Operator: Thank you. At this time if you would like to ask a question, please press star 1 and record your name and affiliation. One again, please limit your question to one and one follow-up. Again, press star one at this time and state your name and affiliation. Please stand by. Our first question is from Daniel DeNoon with WebMD.

Daniel DeNoon: Thanks very much. I'm a little confused about the costs of treatment for HIV and AIDS infection. Is there a differential in the cost of what it costs to support a person throughout and HIV infection if there's earlier detection rather than later detection?

Jonathan Mermin: This is Jon Mermin. The current estimate is a lifetime medical cost for a person with HIV infection is $360,000.

Daniel DeNoon: Is there a differential there based on early detection, or is that just overall an average?

Jonathan Mermin: There would be a differential. If diagnosed earlier because of the treatment cost and the number of years you would be taking treatment and the efficacy of the treatment, it would end up costing more over time in total cost than if you diagnose people late in their infection.

Thomas Frieden: So, just to clarify, if you diagnose and treat someone earlier, you also reduce the likelihood they will spread HIV to someone else. And for every – I think the take-home message is for every single infection you prevent, you're preventing at least $350,000 in health care costs.

Jonathan Mermin: Exactly. So the earlier people find out they're infected, the more likely they are to take precautions not to transmit HIV, and the more likely they are to access antiretroviral therapy that reduces their viral load and subsequently reduces the chance they'll transmit to others. So, HIV prevention is a cost-effective activity, and often cost-saving to the health care system.

Daniel Denoon: Thank you.

Tom Skinner: Next question, Jill.

Operator: The next question is from Stephanie Nano with the Associated Press. Your line is open.

Stephanie Nano: Hi. I just wanted to check, is this the first report that we have that measures the impact of the 2006 guidelines?

Jonathan Mermin: This is the first report that comprehensively discusses both national changes in HIV testing among adults in the United States and includes data on late diagnosis among the whole country and separate jurisdictions.

Stephanie Nano: Okay, have we seen these figures before on testing?

Jonathan Mermin: Not like this, no.

Tom Skinner: Next question, please.

Operator: My next question is from Kaitlin Hagen with CNN Medical unit. Your line is open.

Kaitlin Hagen: Thank you. You had said that at least one in three Americans are diagnosed too late to take full advantage of treatment for their HIV. Is the determination that it's too late in their treatment because the infection has progressed to AIDS or because symptoms are starting to develop, and what's the threshold for that?

Thomas Frieden: The definition here is people who are diagnosed with AIDS within a year of first being diagnosed with HIV. Many are diagnosed with AIDS at a same time they're diagnosed with HIV. We know on average it takes ten years for someone to progress from HIV infection to AIDS. So we're talking a long delay. And some of the other data suggests that many of these individuals had been in health care settings in the previous year or years but had not been offered an HIV test. This was Dr. Frieden.

Tom Skinner: Next question, please.

Operator: Our next question comes from Bob Moore with the British Medical Journal.

Bob Moore: I have a couple questions here. While the quantitative data is good and trends in the right direction, what about the – could you give me a better sense of the qualitative picture, of who is getting tested? Is it disproportionately the worried well, or are we reaching the targeted, more at-risk populations? And are any jurisdictions doing better jobs than others?

Jonathan Mermin: This is Jonathan Mermin. We see encouraging signs that not only are more Americans are being tested for HIV, but that those at risk of actually having HIV infection are also more likely to get tested. So the fact that the late diagnosis rate is also going down in the nation means that people who previously have not been tested for HIV but were infected are accessing testing. In addition, other data that we have shows from our expanded testing initiative, which is concentrated in the jurisdictions and among the populations most likely to have HIV, it shows that people at risk for HIV are interested in getting tested, accept testing when offered to them, and are increasingly being diagnosed. However, it's not good enough. And we cannot say which states are doing better and the epidemic varies across states and the burden is greater in some areas than others, but we – but all states should look to their policies and programs to sure they're consistent with CDC's 2006 testing recommendations.

Bob Moore: What are the – the people who are most at risk for infection are those who tend to disproportionately not be in health care. So, if you're making this part of routine care and they're not in routine care, how are you going to be reaching those people?

Thomas Frieden: Well, with the Affordable Care Act, it is projected that a larger portion of Americans will have access to regular sources of care. That will promote a wide variety of preventive health interventions, including HIV testing, which is an important way of getting early diagnosis. We know even among people who have access to health care and, in fact, are going to medical facilities, many are not being offered an HIV test. The fact that within a quarter of people who have a risk factor for HIV—men who have sex with men or injection drug users—have never been tested for HIV, much less are getting annual testing, which would be a reasonable thing to do, indicates how far we would have to go in making voluntary testing a routine part of care.

Jonathan Mermin: This is Jonathan Mermin. Just to add onto Dr. Frieden's comments. In addition to the benefits of having HIV routinely offered in health care settings, CDC is also supporting HIV testing outside of the health care facilities. For many people with HIV, access to the health care system is difficult, and their lives have complexities that often make it difficult to think about and prioritize HIV testing. We have programs that work through community-based organizations in those hardest hit by the epidemic that successfully engage people at risk for HIV infection to be getting tested and finding out they have HIV if they do and accessing important care, treatment, and prevention services.

Operator: My next question is from Steve Sternberg with USA Today.

Steve Sternberg: Thanks very much for taking my question, Dr. Frieden. One of the experts that I've spoken to about these numbers characterized it as a rather painful assessment of how little progress we've made in HIV testing and I was just wondering what you thought of that take on these numbers?

Thomas Frieden: I guess I am more positive than that. These numbers 11 million more Americans being tested in just three years to me sounds like it's a reasonable progress. I think this – the numbers show that progress is possible. They also show how much more progress is needed. If you look at anything in the health care field, we don't expect to see zero to 60 overnight. So to see a steady improvement over just a two or three year period I think is quite encouraging. But it's certainly very far from success. It's progress, but not success.

Steve Sternberg: Thank you very much.

Operator: Our next question is from Betsy McKay with the Wall Street Journal. Your line is open.

Betsy McKay: Hi, thanks. I wanted to ask of the 28% of people who have a risk factor but are not being tested, how much more information do you have on that? How much can we drill down on who these people are? Which risk factors are most at play here? Which age groups – how much can you tell from the data that you have?

Thomas Frieden: What we can say is that there are people who answered yes to a variety of risk factors, including men who have sex with men, even only once, injected drug use, even just once. Traded sex or money for drug use, even just once. We know that it's truly a very high-risk group. We also know from other studies that men who have sex with men who are diagnosed late with HIV often had contacts with the medical field, 70% or so had contact with the medical field in the previous year, and were not offered an HIV test. So it's not as if this is entirely a group of people who are out of care and for whom there would be no way of reaching. They're people who it's possible to reach, but that is one of the reasons CDC has recommended standard routine normalized voluntary testing or screening in health care facilities so that even if the person does not at the time of an interaction indicate if they have a risk factor for HIV they would be routinely tested. And I think routine is a very important concept. If you're trying to say various people that we think you have a risk factor, therefore we're going to test you. You're going to end up testing fewer people with a risk factor than if you say we're testing everyone; therefore we recommend that you get a test. In communities which have lots of HIV, that we think should be standard.

Jonathan Mermin: Just to add on, we would like to see HIV testing as common as cholesterol screening.

Betsy McKay: Okay. Thanks.

Tom Skinner: I have time for maybe two more questions.

Operator: Our next question is Robert Lowe with Medscape Medical News.

Robert Lowe: Good morning. Thanks for taking my call. I'm wondering if you would describe a physician compliance with the 2006 recommendation. Obviously there has been compliance because we've seen it proven in some numbers, but have you identified any places where the – where the recommendations are carried out? Maybe by specialty or by health care setting. I ask all this because I wonder what can you do to increase testing besides just reiterating to physicians what you said in 2006. What can you do in addition to that that?

Jonathan Mermin: This is Jonathan. There's probably three different levels that we can answer that question. The first would be at the policy level. It's important that state policies support routine HIV testing as well as reducing the barriers associated with lengthy counseling and written informed consent. The second is assisting busy health care settings to incorporate ways of overcoming the logistical and staffing barriers that sometimes impede implementing routine HIV testing. So, for example, we have many situations where emergency departments have introduced HIV screening as part of their routine practice. But it took time and thought and effort in terms of the most efficient ways of implementing that practice. And then the third relates to reimbursement, it's important in this economically challenging times that the health care systems that are providing for patients also have a means for getting reimbursed for effective preventive services.

Tom Skinner: Okay, Jill, we'll take one last question.

Robert Lowe: I have a follow up. Are you saying that reimbursement is a serious barrier?

Jonathan Mermin: In certain circumstances reimbursement for the HIV test for the patients can be a barrier. They will either be less likely to think about getting an HIV test or to get tested if they think it could cause them economic hardship.

Tom Skinner: Jill, we'll take one last question.

Operator: That will come from Glenn Reedus with the Chicago Crusader Newspaper. Your line is open, sir.

Glenn Reedus: Thank you very much. The quick question is, are the numbers reflected, the positives, reflected in urban areas as well?

Jonathan Mermin: Yes, definitely, the urban areas of the United States are more likely to have a higher prevalence of HIV and AIDS than rural areas, although that's not universal. There are some rural areas in the southern parts of the United States that are disproportionately impacted by HIV.

Gleen Reedus: I'm sorry. You misunderstood me. The increase in testing. Are we seeing that in urban areas as well?

Jonathan Mermin: You know, we have not done that specific analysis, but we will do that and can get back to you.

Glen Reedus: I appreciate it.

Jonathan Mermin: I want to thank—this is Dr. Frieden—I want to thank everyone for being a part of this briefing. To reiterate, HIV remains a very important health problem in the U.S. It's costing lives. It's costing money. It's continuing to spread. We have some progress today with a significant increase in the number of American who is have ever been tested for HIV. 11 million more Americans that were tested. But despite that we still have 200,000 or more Americans living with HIV who don't know it, and therefore who are at risk of progressing to AIDS, dying and spreading HIV to their partners unless they get tested. There's been progress, but there needs to be much more progress both in the community and health care settings to increase the number of people who are offered and take up voluntary HIV testing, and if positive, are rapidly linked to care. Thank you all very much for your interest. We look forward to continuing to keep you up to date on the leading vital signs of the U.S. Thank you.

Operator: That does conclude today's conference call. We thank you all for participating. You may now disconnect, and have a great rest of your day.

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