Results of the Expanded HIV Testing Initiative --- 25 Jurisdictions, United States, 2007--2010
Approximately 20% of the estimated 1.2 million persons living with human immunodeficiency virus (HIV) infection in the United States at the end of 2008 were not aware of their infection (1). Testing, diagnosis, medical care, treatment with highly active antiretroviral therapy (HAART), and access to prevention services soon after HIV infection can prevent morbidity and mortality and reduce a person's risk for transmitting HIV (2--6). In 2006, CDC recommended screening patients aged 13--64 years for HIV infection in health-care settings that have a prevalence of undiagnosed HIV infection of ≥0.1% (7). In October 2007, CDC initiated the Expanded HIV Testing Initiative (ETI), through which it funded 25 health departments to facilitate HIV screening and increase diagnoses of HIV infections and linkage to care among populations disproportionately affected by HIV, especially non-Hispanic blacks. This report describes the results of that effort. Annual progress reports designed to provide data specific to ETI indicated that 2,786,739 HIV tests were conducted, of which 29,503 (1.1%) were positive and 18,432 (0.7%) resulted in new HIV diagnoses. Blacks accounted for 1,411,780 (60%) of tests and 11,638 (70%) of new HIV diagnoses. Clinical settings comprised at least 75% of the 1,331 testing venues and accounted for 90% of all tests and 81% of all new HIV diagnoses. Based on follow-up data available for 16,885 persons with new HIV diagnoses, 12,711 (75.3%) were linked successfully to HIV primary care. Through expanded HIV testing activities, substantial numbers of persons previously unaware of their HIV infection were identified and linked to care. Health departments should continue to partner with clinical-care providers to provide routine HIV screening, especially in populations disproportionately affected by HIV.
In October 2007, CDC launched ETI to supplement existing HIV testing efforts and improve the availability and accessibility of HIV testing services, facilitate adoption of HIV screening in health-care settings, and increase identification of undiagnosed HIV infection in populations disproportionately affected by HIV, particularly blacks. During the 3-year program period, CDC provided an additional $111 million to health departments in 25 U.S. jurisdictions* that had reported 140 or more AIDS diagnoses among blacks in 2005. Health departments were required to focus at least 80% of their activities on promoting opt-out HIV screening in high-morbidity clinical settings; they had the option of directing up to 20% of their efforts toward supporting innovative methods to increase targeted HIV testing among high-risk populations (e.g., social networking approaches to increase testing among men who have sex with men). In addition, health departments had to ensure that all persons newly diagnosed with HIV† through ETI received their HIV tests results, were linked to medical care,§ and were referred for partner services. Semiannually, health departments used progress report forms developed by CDC to report ETI-specific activities and outcomes, including the number of HIV tests and the venues in which tests were conducted, basic demographic information about test recipients, the number of confirmed new and previously diagnosed HIV infections identified, and the proportions of persons with new HIV diagnoses successfully linked to medical care and referred to partner services.
During October 2007--September 2010, a total of 2,786,739 HIV tests were conducted, of which 29,503 (1.1%) were positive for HIV infection. Among persons who were HIV-infected, 18,432 (62%) were unaware of their infection. Among 17,247 persons with new HIV diagnoses for whom some follow-up data were available, 15,737 (91%) received their test results, 12,711 (75%) were linked to care, and 14,234 (83%) were referred to partner services (Table 1). Compared with nonclinical settings, more persons who were tested in clinical settings received their test results (93% versus 84%) and were linked to care (78% versus 63%).
Men accounted for 55% of all tests and 72% of new HIV diagnoses; their test positivity rate was more than twice that among women (0.9% versus 0.4%) (Table 2). Non-Hispanic blacks, compared with non-Hispanic whites and Hispanics, accounted for approximately three times as many tests (60% versus 18% and 16% respectively) and approximately five times as many new HIV diagnoses (70% versus 14% and 12%, respectively). Similarly, the test positivity rate among blacks (0.8%) was 1.6 times that among whites (0.5%) and Hispanics (0.5%).
By the third year of the program, 1,331 venues were funded by health departments through ETI to conduct HIV testing. In total, 90% of tests were conducted in clinical settings, and 10% in nonclinical settings. Emergency departments (EDs), which accounted for 8% of the testing venues, performed 30% of all tests and identified 32% of all new HIV diagnoses (Table 3). Sexually transmitted disease (STD) clinics accounted for 21% of testing venues, 21% of all tests, and 20% of new HIV diagnoses. Substance abuse clinics, although accounting for 6% of all testing venues, accounted for 0.9% of tests and new HIV diagnoses. Community-based organizations (CBOs), which performed targeted testing based on risk and accounted for the majority of tests performed in nonclinical settings, accounted for a larger share of new diagnoses (11%) than tests performed (6%) or testing venues (7%). CBOs also produced the highest test positivity rate for new HIV diagnoses (1.2%), but the largest numbers of new diagnoses came from clinical settings, where lower test positivity rates (e.g., 0.8% for EDs and 0.6% for STD clinics) were offset by the larger numbers of persons screened.
Abigail H. Viall, MA, Samuel W. Dooley, MD, Bernard M. Branson, MD, Nadezhda Duffy, MD, Jonathan Mermin, MD, Janet C. Cleveland, MS, Chris Cagle, PhD, Wendy A. Lyon, Div of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. Corresponding contributor: Abigail H. Viall, firstname.lastname@example.org, 404-639-2010.
Historically, HIV testing often has been targeted based on individual risk factors. However, the demographic evolution of the U.S. HIV epidemic over the course of 30 years has gradually diminished the effectiveness of using risk-based testing to identify many HIV-infected persons who are unaware of their infections. CDC has responded to the shifting contours of the epidemic by recommending routine HIV screening for persons aged 13--64 years, and the data in this report indicate that screening according to CDC's recommendations identifies a substantial number of persons infected with HIV. During the 3-year course of ETI, 18,432 persons were newly diagnosed with HIV through ETI, and the majority of these new diagnoses came from clinical settings. In general, the number of tests conducted and new HIV infections identified in a particular venue type were strongly aligned, and the yield of new HIV diagnoses exceeded CDC's recommended screening threshold (0.1% undiagnosed prevalence) in every clinical venue in which expanded screening was implemented.
CDC encouraged participating health departments to use locally available epidemiologic data to identify and solicit participation from clinical venues that served high-prevalence communities or substantial numbers of persons from populations disproportionately affected by HIV, particularly blacks. By directing support for screening programs to sites where the yield of new diagnoses likely would represent a good return on investment, health departments were able to maximize the public health value of CDC funds. This is consistent with the venue-based perspective taken in CDC's 2006 HIV screening recommendations, which indicate that routine screening is not warranted in settings where the prevalence of undiagnosed HIV infection is found to be <0.1% (7).
The continued success of HIV screening efforts in health-care settings requires the development, implementation, and maintenance of sustainable practices, including integrated staffing models, absorption of screening into an organization's clinical flow, and supportive reimbursement policies and rates that value HIV screening in a manner similar to other commonly accepted screening tests (e.g., cholesterol screening). The successful development and diffusion of such integrated screening models under ETI, in conjunction with an increased emphasis on coverage for prevention services, might increase the availability and efficiency of HIV screening in health-care settings.
The findings in this report are subject to at least two limitations. First, health departments collected information on testing events, not persons tested. Thus, the number of persons tested through ETI might be lower than that indicated by the total number of tests conducted because some persons might have been tested more than once. Second, health departments reported data in aggregate rather than at the level of an individual test event or client. Therefore, it is not possible to link individual demographic or outcome variables to determine, for example, whether newly diagnosed persons who were referred for partner services also were more likely to be successfully linked to care, or whether blacks with newly diagnosed HIV infections were more or less likely than persons of other races/ethnicities to be linked to care.
Detailed data collection is not consistent with routine screening activities, so CDC did not mandate collection of data (e.g., individual behavioral risk) that, although important, would have imposed substantial additional burden on clinical staff members implementing routine HIV screening activities. Instead, CDC limited the data it required health departments to submit to those basic demographic and outcome data necessary to ensure program integrity and assess performance against critical program objectives. Consequently, ETI raises a number of important questions that might warrant special studies in the future, including whether persons who already were aware of their HIV infection at the time of testing also were currently in care and, if not, what proportion of persons with previously diagnosed HIV infections were reengaged in care as a consequence of HIV screening efforts in health-care settings.
The National HIV/AIDS Strategy outlines goals to reduce HIV incidence, improve access to care and health outcomes for persons living with HIV, and reduce HIV-related health disparities and inequities (8). Specific objectives include increasing the proportion of persons living with HIV who are aware of their serostatus from 79% to 90% and increasing the proportion of persons with newly diagnosed HIV infections who are linked to clinical care within 3 months of their HIV diagnosis from 65% to 85% (8). CDC's experience through ETI suggests that to meet those goals, health departments, clinical-care providers, and CBOs should continue to forge partnerships that advance implementation of routine HIV screening in clinical venues and targeted testing in community settings, particularly those that serve populations disproportionately affected by HIV, and ensure that persons newly diagnosed with HIV through such screening activities are effectively linked to care.
Ultimately, achieving the broader National HIV/AIDS Strategy prevention goals of reducing HIV incidence and transmission will require more than strengthening mechanisms for identifying persons with undiagnosed HIV infection and linking these persons to care. Persons with HIV must enter and progress along a spectrum of care to reduce their risk for transmission: ETI focused on the first two elements of this spectrum (diagnosis and linkage to care). However, for efforts like ETI to translate into better individual and population-level outcomes, persons infected with HIV must be engaged and retained in care, receive and adhere to effective treatment with HAART to maximize viral load suppression, and have access to ongoing prevention and support services, including risk-reduction counseling and other evidence-based behavioral interventions, partner services, substance use and mental health treatment, and case management. At present, attrition is substantial, such that only an estimated 19% of the HIV-infected population has achieved viral load suppression (9). To improve outcomes across this spectrum, CDC is working with its grantees, partners, and other federal agencies (e.g., the Health Resources and Services Administration) to develop, evaluate, and support the infrastructure and strategies needed to create a seamless integration of prevention, care, case management, and social services for persons living with HIV.
- CDC. HIV surveillance---United States, 1981--2008. MMWR 2011;60:689--93.
- Palella FJ, Deloria-Knoll M, Chmiel JS, et al. Survival benefit of initiating antiretroviral therapy in HIV-infected persons in different CD4+ cell strata. Ann Intern Med 2003;138:620--6.
- Antiretroviral Therapy Cohort Collaboration. Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. Lancet 2008;372:293--9.
- Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr 2005;39:446--53.
- Donnell D, Baeten JM, Kiarie J, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet 2010;375:2092--8.
- National Institute of Allergy and Infectious Diseases. Treating HIV-infected people with antiretrovirals protects partners from infection: findings result from NIH-funded international study. Bethesda, Maryland: US Department of Health and Human Services, National Institutes of Health, National Institute of Allergy and Infectious Diseases; 2011. Available at http://www.niaid.nih.gov/news/newsreleases/2011/pages/hptn052.aspx. Accessed June 17, 2011.
- CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 2006;55(No. RR-14).
- Office of National AIDS Policy. National HIV/AIDS Strategy. Washington, DC: Office of National AIDS Policy; 2010. Available at http://www.whitehouse.gov/administration/eop/onap/nhas. Accessed June 17, 2011.
- Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis 2011;52:793--800.
* Among the 25 jurisdictions, 23 (California; Los Angeles County, California; Chicago, Illinois; Connecticut; Florida; Maryland; Georgia; Louisiana; Massachusetts; Michigan; Missouri; New Jersey; New York; New York City, New York; North Carolina; Ohio; Pennsylvania; Philadelphia, Pennsylvania; South Carolina; Tennessee; Houston, Texas; Virginia; and District of Columbia) were funded for the full 3 years of the initiative. An additional two jurisdictions (Texas and Mississippi) received 2 years of funding, beginning in year 2 of the initiative.
† Persons were defined as being newly diagnosed with HIV based on the absence of evidence to the contrary. Operationally, this means that 1) during the testing encounter, the person indicated that he or she had not previously received a diagnosis of HIV infection and 2) the health department had no record of a previous diagnosis in its HIV surveillance system.
§ In the context of ETI, "linked to medical care" was defined as having attended a first appointment at an HIV care clinic.
What is already known about this topic?
In the United States, approximately 20% of persons with human immunodeficiency virus (HIV) infection are unaware of their infections and therefore do not access medical care and prevention services that can prevent morbidity and mortality and reduce further HIV transmission. Often, persons with HIV infection visit health-care settings years before receiving a diagnosis but are not tested for HIV because neither these persons nor their health-care providers recognize that they are at risk for HIV infection.
What is added by this report?
CDC's Expanded HIV Testing Initiative, launched in 2007, represents the first national effort to promote routine HIV screening in various clinical and nonclinical venues. During October 2007--September 2010, a total of 2,786,739 tests were conducted, and 18,432 HIV infections were newly diagnosed; clinical settings accounted for 90% of all tests and 81% of all new HIV diagnoses.
What are the implications for public health practice?
Expanding opportunities for HIV testing, particularly in health-care settings, can lead to the diagnosis of a substantial number of new infections, which can lead to reduced morbidity, mortality, and transmission. To meet national goals for reducing the number of HIV-infected persons who are unaware of their serostatus, health departments should continue to partner with clinical-care providers to expand implementation of routine HIV screening in health-care settings, especially in populations disproportionately affected by HIV.
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