Publicly Funded HIV Counseling and Testing -- United States, 1991

Human immunodeficiency virus (HIV) counseling and testing (CT) services provided by health departments are a major component of the national HIV-prevention program. The purpose of HIV CT is to 1) reinforce perception of risk by those who are unaware or uninformed, 2) help uninfected persons initiate and sustain behavior changes that reduce their risk for becoming infected, and 3) identify HIV-infected persons who can be referred for early medical care and counseled to practice safer behaviors. The use of publicly funded HIV CT has steadily increased; in 1991, nearly 2,091,000 HIV-antibody tests were performed, compared with approximately 79,000 tests in 1985. CT services are provided by health departments in 65 HIV-prevention project areas including the 50 states, the District of Columbia, six cities, and eight territories. * Each calendar quarter, the programs report to CDC data regarding the number of pretest counseling sessions, HIV-antibody tests, positive tests, and posttest counseling sessions. Information is also provided on self-reported risk category, age group, sex, and race/ethnicity. This report summarizes data reported for 1991. **

The data presented here are collected by number of HIV-antibody tests, rather than number of persons tested. Because testing of some clients is repeated, the exact number of persons tested is not known. Serologic Testing Results by Type of HIV CT Site

During 1991, 2,090,635 HIV-antibody tests were performed in the 65 project areas; 57,879 (2.8%) tests were positive (Table 1). Of these, freestanding HIV CT sites (sites that provide HIV CT services exclusively) and sexually transmitted disease (STD) clinics together accounted for 1,289,975 (61.7%) reported tests and 37,485 (64.8%) positive test results. Family-planning and prenatal/obstetric clinics accounted for 14.8% of reported tests and 3.2% of positive tests; drug abuse-treatment centers and prisons accounted for 9.1% of reported tests and 13.5% of positive tests. Risk Category

Of 1,997,415 HIV tests for which self-reported risk information was available, the highest percentage of positive test results was among homosexual/bisexual male injecting-drug users (IDUs) (17.4%); for homosexual/bisexual males who were not IDUs, seroprevalence was 11.8%, and for heterosexual IDUs, 8.3% (Table 2). These three categories accounted for 15.9% of tests and 58.4% of positive results from persons who reported risk category.

"Heterosexual males and females with reported risk" (including heterosexuals whose sex partners are at risk for or are infected with HIV and heterosexuals with multiple sex partners) accounted for 489,014 (24.5%) tests and 9142 (16.2%) positive results. Persons categorized in "other/no acknowledged risk" accounted for 1,161,120 (58.1%) tests. This category is composed predominantly of self-reported heterosexual males and females who indicated no history of risk behavior or no partner(s) at risk for or infected with HIV, or persons for whom risk information is not specified. *** Combined, these persons (heterosexual males and females with reported risk and those with other/no acknowledged risk) had a seropositivity rate of 1.4% but accounted for 40.5% of reported positive results. Demographic Categories

Of 1,993,353 tests for persons for whom demographic information was given, race/ethnicity was specified for 1,956,872 (98.2%). Of HIV tests performed, whites, blacks, and Hispanics accounted for 51.2%, 33.4%, and 11.7%, respectively, compared with their representation in the U.S. population of 75.7%, 11.8%, and 9.0%, respectively (1). The racial/ethnic distribution of those tested was similar to that of new reports of persons with AIDS in 1991, of whom 48.8% were white, 32.0% were black, and 18.0% were Hispanic (Table 3) (2). Whites, blacks, and Hispanics accounted for 34.4%, 43.3%, and 19.5%, respectively, of all positive tests (Table 3). Seropositivity was highest among Hispanics (4.6%), followed by blacks (3.6%).

Males accounted for 1,006,773 (50.5%) of the 1,993,353 tests and 42,527 (76.6%) of the 55,520 positive results. Seropositivity in males and females was 4.2% and 1.3%, respectively. Of persons for whom age was known, persons aged 20-29 years accounted for 42.7% of tests and 34.4% of positive results, and persons aged 30-39 years accounted for 27.3% of tests and 41.8% of positive results. Seropositivity rates for persons aged 20-29 and 30-39 years were 2.2% and 4.3%, respectively. For adolescents aged 13-19 years, 261,942 tests were performed; of these, 1242 (0.5%) were positive. Posttest Counseling

Client record data, representing a 60% subset of the aggregate CT data and providing greater detail about persons receiving CT, indicated that at least 74.0% of persons with HIV-antibody-positive test results and 62.8% of those with negative test results completed posttest counseling (3). Overall, at least 63.1% of persons in the client record database received posttest counseling; however, the proportion of persons receiving posttest counseling was higher for freestanding test sites (81.2%) than for STD clinics (40.6%).

Reported by: HIV-prevention programs of state and local health departments. Program Development and Technical Support Section, Program Operations Br, Div of Sexually Transmitted Diseases and HIV Prevention, and Office of the Director, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Knowledge of HIV-infection status and client-centered counseling can increase self-perception of risk and assist persons in initiating changes in behavior that will reduce their risk for infecting others or for becoming infected (4,5). Successful HIV-prevention counseling involves four essential components: 1) personalized risk assessment to facilitate a realistic self-perception of risk; 2) identification and discussion of barriers to behavior change and reinforcement of positive behavior change already initiated by the client; 3) negotiation between the client and counselor of a realistic and incremental risk reduction plan; and 4) establishment of a specific plan to receive test results and posttest counseling (6). CT services include partner notification and referral for early intervention and other prevention services. Early intervention, including medical evaluation, antiretroviral therapy, and pharmacologic prophylaxis, can enhance and prolong the years of productive life for HIV-positive persons. A substantial proportion of persons infected with HIV have been diagnosed and have received services at publicly funded CT programs (7).

Because data presented in this report are for persons tested at public clinics, the findings are not representative of all persons tested in the United States. Most of these data were collected in service-delivery settings where risk behaviors are self-reported and not validated through epidemiologic or research investigations. An unknown number of persons are tested for HIV antibody in hospitals, outpatient medical facilities, physicians' offices, blood-donation centers, military facilities, and other settings (8). In addition, an unknown number of the tests presented in this report may represent retests; the client record data system began collecting data on repeat tests in January 1992.

One possible explanation for the difference in return rates for freestanding sites and STD clinics relates to the reason for client visit. In particular, persons attend freestanding sites specifically to obtain an HIV-antibody test and, therefore, are motivated to return for results; in comparison, persons attend STD clinics primarily for clinical care of an STD and are offered HIV CT as a supplemental component of that clinical care (9). Therefore, programmatic efforts have been directed toward increasing the proportion of persons who receive posttest counseling, including field follow-up of persons who are HIV-positive or are HIV-negative but at high risk for HIV infection and who do not return for their results.

To ensure that persons with undetected HIV infection receive appropriate CT, public health priorities should focus on increasing testing of persons engaging in risk behaviors and increasing the number who receive the full range of recommended CT, referral, and partner-notification services. HIV-antibody-positive persons who are not tested anonymously and who do not return for posttest counseling should receive timely and effective follow-up to ensure provision of test results, posttest counseling, and appropriate referrals.

HIV CT services should continue to expand within settings such as tuberculosis, STD, and drug abuse-treatment clinics. In addition, recent reports indicate HIV-infected persons may be identified through hospital-based HIV CT programs (10). Public health programs should attempt to maximize the proportion of persons at risk who 1) are offered and receive pretest counseling, including risk assessment; 2) accept and receive HIV-antibody testing; 3) return for HIV-antibody test results; 4) are offered and receive posttest counseling; 5) if infected, participate in partner notification; and 6) if infected, are referred to and receive further medical and prevention services.

References

1. Bureau of the Census. Data tape: state and metropolitan area -- regions, divisions, and states. Washington, DC: US Department of Commerce, Bureau of the Census, 1990.

2. CDC. Update: acquired immunodeficiency syndrome -- United States, 1991. MMWR 1992;41:463-8.

3. CDC. CTS client record database: U.S. total, 1991 annual report. Atlanta: US Department of Health and Human Services, Public Health Service, 1992.

4. Cates W Jr, Handsfield HH. HIV counseling and testing: does it work? Am J Public Health 1988;78:1533-4.

5. Higgins DL, Galavotti C, O'Reilly KR, et al. Evidence for the effects of HIV antibody counseling and testing on risk behaviors. JAMA 1991;266:2419-29.

6. National Center for Prevention Services, CDC. Technical guidance on HIV counseling. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, February 1992.

7. Anderson JE, Hardy AM, Cahill K, Aral SO. HIV counseling and testing in the U.S.: who is being reached and who isn't? (Abstract). Vol 1. VII International Conference on AIDS. Florence, Italy, June 16-21, 1991:383.

8. CDC. Testing for HIV in the public and private sectors -- Oregon, 1988-1991. MMWR 1992:41;581-4.

9. Valdiserri RO, Moore M, Gerber AR, Campbell CH, Dillon B, West GR. Return rates for HIV posttest counseling: implications for program efficacy, United States, 1990 (Poster session). Vol 2. VIII International Conference on AIDS/III STD World Congress. Amsterdam, July 19-24, 1992:C336.

10. Janssen RS, St Louis ME, Satten GA, et al. HIV infection among patients in U.S. acute care hospitals -- strategies for the counseling and testing of hospital patients. N Engl J Med 1992;327:445-52.

• Cities are Chicago, Houston, Los Angeles, New York City, Philadelphia, and San Francisco. Territories are American Samoa, Federated States of Micronesia, Guam, the Marshall Islands, the Northern Mariana Islands, Palau, Puerto Rico, and the Virgin Islands. ** Because several areas do not report all variables on each person tested (i.e., risk factor(s), sex, age, and race/ethnicity), the total number of tests presented in each table may differ. *** In the client record data, representing 60% of aggregate CT data, persons for whom risk information is not specified are 74.9% of the "other/no acknowledged risk" category.

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