Testing for HIV in the Public and Private Sectors -- Oregon, 1988-1991

Counseling and testing persons for human immunodeficiency virus (HIV) infection is a key component of the public health strategy for reducing transmission of HIV in the United States (1,2). In 1991, the federal government allocated $100 million to state and local health agencies to provide counseling and testing programs in public clinics for at-risk persons, including persons who may not otherwise use public health services. However, the relative contribution of HIV testing in public clinics to HIV testing in the private sector is unknown. To compare HIV testing in Oregon public clinics to overall HIV testing, the Health Division (HD) of the Oregon Department of Human Resources, in cooperation with CDC, reviewed data collected from September 1, 1988, through August 31, 1991, on public and private HIV testing in Oregon. This report summarizes findings for HIV testing rates and assesses the importance of publicly funded testing in identifying HIV-seropositive persons.

Oregon law requires that all blood samples to be tested for HIV antibody be accompanied by certification that informed consent was obtained from the person being tested. The certification form, completed by the health-care provider, includes general demographic information about the person tested, reason for testing, previous HIV test results (if any), and the specimen collection date; the patient's name is not reported. Because HIV testing certificates do not include names, the data represent tests and not individual persons. Licensed laboratories (both public and private sector) are required to forward this information, along with test results, to the Oregon HD. For a specimen to be considered positive for HIV, enzyme immunoassay (EIA)-positive results must be confirmed by Western blot or immunofluorescent assay.

During the 3-year period, 125,159 HIV tests were reported to the Oregon HD. The annual number of reported tests increased steadily from 34,525 in 1989 (12 per 1000 residents) to 50,351 in 1991 (18 per 1000) (Table 1). Testing rates varied by persons' age, race/ethnicity, and place of residence. The highest testing rate was for persons aged 20-29 years (31 per 1000 state residents); testing rates were higher for blacks (40 per 1000) and Hispanics (28 per 1000) than for whites (13 per 1000). Testing was more common for residents of Oregon's Portland metropolitan area counties (17 per 1000) than for residents of other urban (12 per 1000) or rural (9 per 1000) counties.

In Oregon, publicly funded testing is done at 57 sites, primarily in county health departments. During the study period, 46,259 (37%) tests were publicly funded, and 78,900 (63%) were privately funded (Table 1). The proportion of all tests that were publicly funded increased from 32% in 1989 to 40% in 1991. Of persons tested, those aged 13-39 years were more likely to be tested at publicly funded test sites (43%) than were those aged less than 13 years or greater than or equal to 40 years (28%). Blacks were more likely to be tested at publicly funded sites (56%) than were whites (39%) or Hispanics (25%).

Test providers classified persons being tested as 1) symptomatic; 2) asymptomatic and initiating testing of their own accord, or 3) asymptomatic and being referred by a third party (e.g., an insurance company). A minority of tests from symptomatic persons (10%) and third-party referred (3%) were performed at public sites. However, nearly half (46%) of tests from asymptomatic persons were performed at public sites.

Overall, 2667 (2%) tests were positive for HIV antibody. Newly diagnosed HIV infections were defined as positive tests for persons who had no history of a positive HIV-antibody test (i.e., persons who were tested for the first time or who had a previously negative test, or those for whom no previous testing history was available). Of positive HIV tests, 2060 (77%) represented newly diagnosed infections. Of tests for which age, sex, race/ethnicity, and place of residence of the person were reported, most newly diagnosed infections were among persons aged 20-49 years (91%), men (91%), whites (87%), and persons from the Portland metropolitan area (72%).

Rates of newly diagnosed infections varied by demographic characteristics: 1769 (3.0%) tests among males were newly positive, compared with 167 (0.3%) among females. The highest rate by age group was among persons aged 30-49 years (2.1%), followed by those aged 20-29 years (1.6%), and those aged greater than or equal to 50 years (1.2%). Rates also varied by race/ethnicity: 2.2% of tests among blacks were newly positive, 1.7% among whites, and 0.9% among Hispanics. Tests from the Portland metropolitan area were more likely to be newly positive (2.3%) than were those from other urban (0.9%) or rural areas (0.8%).

Samples submitted by the public and private sectors each accounted for approximately half of the newly diagnosed HIV infections (Table 1). The overall rate of newly diagnosed HIV infections was greater for the public (2.0%) than private (1.4%) sector. Of all tests for which reason for testing was known, most (69%) newly diagnosed HIV infections were among asymptomatic persons who self-initiated testing, 29% of new diagnoses were among symptomatic persons, and 2% were among third-party referrals. Of all tests representing newly diagnosed HIV infections among asymptomatic persons who self-initiated testing, 65% were performed in the public sector. Fewer newly diagnosed HIV infections among symptomatic persons and third-party referrals were diagnosed through public-sector testing (15% and 3%, respectively).

Reported by: K Hedberg, MD, R Klockner, D Fleming, MD, State Epidemiologist, State Health Div, Oregon Dept of Human Resources. Div of Field Epidemiology, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that from 1988 through 1991, nearly half of newly diagnosed HIV infections in Oregon were diagnosed through public-sector testing. In addition, the overall rate of HIV testing and the proportion of tests conducted in the public sector increased during this time.

Asymptomatic persons who are unaware of their HIV infection are an important target group for prevention programs aimed at reducing transmission of HIV through counseling and testing; however, unlike symptomatic persons, asymptomatic persons may need to be convinced through various education efforts to seek testing. In Oregon, public clinics performed only 37% of all tests but diagnosed nearly two thirds (65%) of new HIV infections among asymptomatic persons who self-initiated testing. Asymptomatic persons seeking testing at public clinics were twice as likely to have a newly diagnosed HIV infection as asymptomatic persons seeking testing in private clinics. These findings suggest that the cumulative impact of community education, case-finding, and outreach programs have been effective in encouraging high-risk, asymptomatic persons to be counseled and tested at public clinics. These findings also suggest that, in Oregon, publicly funded HIV counseling and testing is increasingly important in identifying persons with undetected HIV infection.

References

1. CDC. Publicly funded HIV counseling and testing -- United States, 1990. MMWR 1991;40:666-9,675.

2. Francis DP, Anderson RE, Gorman ME, et al. Targeting AIDS prevention and treatment toward HIV-1 infected persons. JAMA 1989;262:2572-6.

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