HIV Testing Among Women Aged 18-44 Years -- United States, 1991 and 1993

Human immunodeficiency virus (HIV) infection is a major cause of morbidity and mortality among women and children in the United States. In 1995, of the 73,380 acquired immunodeficiency syndrome (AIDS) cases reported, women accounted for 13,764 (19%) (1). HIV infection is the third leading cause of death among all U.S. women aged 25-44 years and the leading cause of death among black women in this age group (2). Moreover, an estimated 7000 infants are born to HIV-infected women in the United States each year (3); without intervention, approximately 15%-30% of these infants would be infected (4). HIV counseling and testing services are important for women to reduce their risk for becoming infected or, if already infected, to initiate early treatment and prevent HIV transmission to others, including their infants. This report summarizes findings about HIV-testing practices for women aged 18-44 years based on data obtained from CDC's 1991 and 1993 AIDS Knowledge and Attitudes Supplements to the National Health Interview Survey (NHIS-AIDS), which indicate that approximately one third of women aged 18-44 years have been tested for HIV.

The NHIS is an annual national probability sample of the civilian household population of the United States. Data about HIV testing have been collected annually as part of the NHIS-AIDS Supplement since 1987. Information about a broad range of issues related to HIV infection and AIDS was collected through personal interview with one randomly selected adult (aged greater than or equal to 18 years) per household. Response rates for the 1991 and 1993 NHIS-AIDS were 86% and 80%, respectively. Information about voluntary HIV-testing practices was analyzed for women aged 18-44 years who responded to the survey; women who had HIV tests at the time of blood donation were excluded. Because interviews for the 1993 NHIS-AIDS were conducted only for 6 months, the number of responses from women in this age group is smaller (n=6267) than in 1991 (n=13,411). All data were analyzed using SUDAAN and weighted to produce national estimates.

Although the 1993 NHIS-AIDS provides the most recent national data available about HIV testing, * information about current or past pregnancies was collected only during 1991. However, because the number of pregnant women responding to the 1991 survey was too small for meaningful estimates of HIV testing, 1991 data were analyzed for the 30% of women (n=3996) who reported having had a live-born infant during the preceding 5 years. Trends

In 1991, 18.8% of women aged 18-44 years reported having been tested for HIV antibody (Table_1). The proportion of black (25.7%) and Hispanic (27.5%) women who reported having been tested was substantially greater than that for white women (16.2%). ** In addition, women with less than 12 years of education were more likely to report having ever been tested for HIV (25.1%) compared with high school graduates (17.2%) or those who had completed college (18.9%). A greater percentage of women living in poverty *** reported having been tested for HIV (25.9%) compared with those at or above the poverty level (17.5%). Women who had been previously married were more likely to report having been tested (24.0%) than were those who were currently (18.4%) or never (17.4%) married. Nearly 40% of women who perceived a high or medium risk for becoming or being HIV-infected and 33.1% of those who reported any HIV risk behavior had been tested. **** Compared with women residing in non-metropolitan statistical areas (MSAs), women residing in central cities of MSAs were more likely to have been tested (18.1% and 20.5%, respectively); regionally, the highest rates of testing were for women residing in the South (20.6%) and West (22.2%).

From 1991 to 1993, the proportion of women aged 18-44 years who had ever been tested for HIV increased 60% (from 18.8% to 31.8%) (Table_1). Increases were similar across all sociodemographic groups. As in 1991, in the 1993 survey, higher percentages of black and Hispanic women (46.1% and 39.7%, respectively) compared with white women (27.9%) reported having been tested for HIV. Similarly, a higher proportion of women with less than 12 years of education reported having been tested for HIV (36.9%) compared with high school graduates (31.5%) or those with college education (30.4%). In addition, more women living in poverty reported having been tested for HIV (40.2%) than did women living at or above the poverty level (30.3%). HIV-testing trends among women aged 18-44 years were similar to those in 1991 with respect to marital status, risk perception, and region of residence; however, the proportions of women tested in all three groups increased during 1991-1993 (Table_1). During 1991-1993, the proportion of women tested who had higher perceived risk for HIV did not increase; however, the proportion tested with low or no perceived risk nearly doubled. Women Who Had a Live-Born Infant During the Preceding 5 Years

In 1991, a higher proportion of women who reported having had a live-born infant during the preceding 5 years had been tested for HIV (25.7%) compared with all women aged 18-44 years (18.8%) (Table_1). Among women who reported a high or medium risk for becoming or being infected, percentages were similar for those who had had a live-born infant during the preceding 5 years (41.0%) and all women (39.6%). Among women who reported having had a live-born infant during the preceding 5 years, testing rates were highest among Hispanics (35.0%) and blacks (33.4%), women with less than 12 years of education (34.0%), and those living in poverty (36.2%). Approximately twice as many never-married women who reported having had a live-born infant during the preceding 5 years had been tested for HIV (32.5%), compared with all never-married women in this age group (17.4%).

Reported by: Div of Health Interview Statistics, National Center for Health Statistics, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that the proportion of women aged 18-44 years in the United States who reported being tested for HIV infection increased in the early 1990s. This trend may reflect increased knowledge and awareness about HIV and AIDS among women. However, the data in this report probably underestimate current rates of HIV testing in pregnant women because they do not reflect recent changes in testing practices and because testing among women who had a live-born infant during the preceding 5 years is not a good proxy for recent pregnancy. During the period of the surveys, prenatal HIV testing was targeted toward women known to be at increased risk for HIV infection (5). Since then, studies have indicated that such testing strategies failed to identify and offer services to many HIV-infected women (6,7). In 1995, based on these findings and advances in prevention and treatment for HIV infection, including zidovudine therapy to reduce perinatal HIV transmission, the Public Health Service issued recommendations for universal HIV counseling and voluntary testing for pregnant women (4).

The higher rates of testing among poor, less educated minority women may reflect trends in related factors, such as the use of sexually transmitted disease and family-planning clinics as a primary source of health care. In the survey, clinics were a primary site of HIV testing for lower-income minority women. The higher rates of testing among black and Hispanic women also reflect trends in the incidence of AIDS cases in the United States. In particular, the incidence of AIDS among women and minorities has not declined as it has among white males (8). Poor access to medical care, high rates of sexually transmitted diseases, and other sociodemographic characteristics continue to be associated with increased risk for infection among minority women. Reducing the risk for HIV infection and AIDS will require culturally appropriate HIV-prevention interventions that address the particular concerns of black and Hispanic women (9,10).

Congress recently passed legislation stating that HIV counseling and voluntary testing should be the standard of care for all pregnant women in the United States *****. Surveys such as the NHIS-AIDS and other studies will provide important data to help public health and other health-care professionals evaluate the extent of implementation of this prevention measure and its impact on reducing HIV-related morbidity and mortality among women and children.

References

1. CDC. HIV/AIDS surveillance report, 1995. Atlanta: US Department of Health and Human Services, Public Health Service, 1996. (Vol 7, no. 2).

2. CDC. Update: mortality attributable to HIV infection among persons aged 25-44 years -- United States, 1994. MMWR 1996;45:121-5.

3. Davis SF, Byers RH, Lindegren ML, Caldwell MB, Karon JM, Gwinn M. Prevalence and incidence of vertically acquired HIV infection in the United States. JAMA 1995;274:952-5.

4. CDC. U.S. Public Health Service recommendations for human immunodeficiency virus counseling and voluntary testing for pregnant women. MMWR 1995;44(no. RR-7).

5. CDC. Recommendations for assisting in the prevention of the perinatal transmission of human T-lymphotropic virus type III/lymphadenopathy-associated virus and acquired immunodeficiency syndrome. MMWR 1985;34:721-32.

6. Barbacci MB, Dalabetta GA, Repke JT, et al. Human immunodeficiency virus infection in women attending an inner-city prenatal clinic: ineffectiveness of targeted screening. Sex Transm Dis 1990;17:122-6.

7. Fehrs LJ, Hill D, Kerndt PR, Rose TP, Henneman C. Targeted HIV screening at a Los Angeles prenatal/family planning health center. Am J Public Health 1991;81:619-22.

8. Rosenberg PS. Scope of the AIDS epidemic in the United States. Science 1995;270:1372-5.

9. Sikkema KJ, Koob JJ, Cargill VC, et al. Levels and predictors of HIV risk behavior among women in low-income public housing developments. Public Health Rep 1995;110:707-13.

10. O'Donnell L, San Doval A, Vornfett R, O'Donnell CR. STD prevention and the challenge of gender and cultural diversity: knowledge, attitudes, and risk behaviors among black and Hispanic inner-city STD clinic patients. Sex Transm Dis 1994;21:137-48.

* Data about HIV testing and other AIDS-related knowledge and attitudes were collected in 1994 and 1995; however these data are not yet available for analysis. 

** Numbers for other racial groups were too small for meaningful analysis. 

*** Poverty statistics are based on a definition originated by the Social Security Administration in 1964, that was subsequently modified by federal interagency committees in 1969 and 1980, and prescribed by the Office of Management and Budget as the standard to be used by federal agencies for statistical purposes. 

**** Respondents were asked whether they 1) had hemophilia or other clotting disorder and had received clotting concentrations since 1977; 2) had injected illegal drugs at any time since 1977; 3) had exchanged sex for money or drugs since 1977; and 4) had been the sex partner since 1977 of someone to whom any of these conditions applied. 

***** Public Law 101-545.

TABLE 1. Percentage of women aged 18-44 years who reported having ever been tested for HIV antibody,
by selected characteristics and year -- United States, National Health Interview Survey of AIDS
Knowledge and Attitudes, 1991 and 1993
======================================================================================================
                            1991 (n=13,411)      1991 * (n=3,996)        1993 (n=6,267)
                        --------------------   ---------------------  ----------------------
                          %                      %                      %
Characteristic          Tested   (95% CI + )   Tested    (95% CI)      Tested    (95% CI)
------------------------------------------------------------------------------------------------------
Race/Ethnicity @
 White, non-Hispanic    16.2   (15.3%-17.1%)   22.2    (20.3%-24.1%)   27.9    (26.3%-29.5%)
 Black, non-Hispanic    25.7   (23.3%-28.1%)   33.4    (29.4%-37.4%)   46.1    (42.4%-49.8%)
 Hispanic               27.5   (23.9%-31.1%)   35.0    (28.8%-41.2%)   39.7    (35.0%-44.4%)

Education (yrs)
 <12                    25.1   (22.4%-27.8%)   34.0    (29.3%-38.7%)   36.9    (32.5%-41.3%)
  12                    17.2   (16.0%-18.4%)   25.5    (23.0%-28.0%)   31.5    (29.2%-33.8%)
  13-15                 17.5   (16.1%-18.9%)   21.7    (18.8%-24.6%)   30.9    (29.1%-32.7%)
>=16                    18.9   (17.3%-20.5%)   22.6    (19.3%-25.9%)   30.4    (27.8%-33.0%)

Poverty level &
  At or above           17.5   (16.6%-18.4%)   23.2    (21.4%-25.0%)   30.3    (28.7%-31.9%)
  Below                 25.9   (23.1%-28.7%)   36.2    (31.3%-41.1%)   40.2    (36.4%-44.0%)
  Unknown               18.9   (15.8%-22.0%)   26.7    (20.3%-33.1%)   29.7    (24.7%-34.7%)

Marital status
  Married               18.4   (17.3%-19.5%)   24.1    (22.1%-26.1%)   31.4    (29.5%-33.3%)
  Previously married    24.0   (21.9%-28.6%)   32.2    (27.1%-37.3%)   40.3    (37.0%-43.6%)
  Never married         17.4   (15.8%-19.0%)   32.5    (28.0%-37.0%)   28.6    (26.1%-31.1%)

Residence
  MSA ** -central city  20.5   (19.3%-21.7%)   26.7    (24.3%-29.1%)   36.6    (34.3%-38.9%)
  MSA-noncentral city   19.3   (17.3%-21.3%)   27.7    (23.4%-32.0%)   30.0    (27.1%-32.9%)
  Non-MSA               18.1   (14.6%-21.6%)   27.0    (19.8%-34.2%)   28.1    (21.7%-34.5%)

Region ++
  Northeast             14.8   (13.2%-16.4%)   19.2    (16.2%-22.2%)   26.7    (24.1%-29.3%)
  Midwest               16.1   (14.7%-17.5%)   21.7    (18.3%-25.1%)   26.0    (23.4%-28.6%)
  South                 20.6   (18.6%-22.6%)   30.7    (27.1%-34.3%)   37.1    (34.4%-39.8%)
  West                  22.2   (20.3%-24.1%)   27.8    (24.2%-31.3%)   34.7    (31.5%-37.9%)

Perceived risk of
  getting or having HIV
  High or medium        39.6   (35.2%-44.0%)   41.0    (31.4%-50.6%)   40.1    (34.9%-45.3%)
  Low or none           17.8   (16.9%-18.7%)   25.2    (23.4%-27.0%)   31.0    (29.5%-32.5%)

Reported any HIV risk
  behavior since 1977
  Yes                   33.1   (27.7%-38.5%)   47.2    (39.2%-55.2%)   55.5    (48.7%-62.3%)
  No                    18.3   (17.4%-19.2%)   24.8    (23.0%-26.6%)   30.6    (29.1%-32.1%)

Total                   18.8   (17.8%-19.7%)   25.7    (23.9%-27.5%)   31.8    (30.3%-33.3%)
------------------------------------------------------------------------------------------------------
*  Women who reported having had a live-born infant during the 5 years preceding the survey
+  Confidence interval.
@  Numbers for other racial groups were too small for meaningful analysis.
&  Poverty statistics are based on a definition originated by the Social Security
   Administration in 1964, that was subsequently modified by federal interagency committees
   in 1969 and 1980, and prescribed by the Office of Management and Budget as the standard
   to be used by federal agencies for statistical purposes.
** Metropolitan statistical area.
++ Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York,
   Pennsylvania, Rhode Island, and Vermont; Midwest=Illinois, Indiana, Iowa, Kansas,
   Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and
   Wisconsin; South=Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia,
   Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina,
   Tennessee, Texas, Virginia, and West Virginia; West=Alaska, Arizona, California,
   Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington,
   and Wyoming.
======================================================================================================

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