Publicly Funded HIV Counseling and Testing -- United States, 1985-1989

CDC provides support to 63 human immunodeficiency virus (HIV) prevention programs through health departments in 50 states, four cities, seven territories, the District of Columbia, and Puerto Rico. Each calendar quarter, the 63 programs report to CDC aggregate data regarding the number of 1) pretest counseling sessions, HIV-antibody tests, positive tests, and post-test counseling sessions, by type of testing site; 2) HIV-antibody tests and positive tests, by risk exposure category; and 3) HIV-antibody tests and positive tests, by age group, sex, and race/ethnicity.

From 1985 through 1989,* the programs performed approximately 2.5 million HIV-antibody tests; 149,639 (6.0%) tests were positive. This report summarizes demographic, risk, and site type data from the 63 programs from January 1988 through September 1989.Number and Type of Testing Sites

From January 1988 through September 1989, the number of counseling and testing sites in the 63 programs increased from 1577 to 5013. In 1989, these included 1297 (25.9%) freestanding HIV counseling and testing sites, 877 (17.5%) sexually transmitted diseases (STD) clinics, 633 (12.6%) family-planning clinics, 522 (10.4%) other health department sites, 504 (10.1%) prenatal/obstetric clinics, 443 (8.8%) tuberculosis clinics, 183 (3.7%) private physicians' offices and clinics, 173 (3.5%) drug-treatment centers, 162 (3.2%) other nonhealth department testing sites, 109 (2.2%) prisons, 29 (0.6%) colleges, and 81 (1.6%) unclassified facilities.Characteristics of Counseling and Testing Sites

From January 1988 through September 1989, the 63 programs reported 1,403,240 HIV-antibody tests and 64,347 positive tests (Table 1). Of these, freestanding HIV counseling and testing sites and STD clinics together accounted for 916,290 (65.3%) of all tests and 44,425 (69.0%) of all positive tests. Family planning and prenatal/ obstetric clinics accounted for 8.1% of all reported tests and 1.3% of positive tests. In contrast, drug-treatment centers and prisons accounted for 5.3% of total tests and 7.1% of positive tests.Risk Category and Demographic Data

Information on self-reported risk category was available for 1,040,392 reported tests (Table 2). Of these, seropositivity rates were highest for homosexual/bisexual intravenous-drug users (IVDUs) (17.1%), homosexual/bisexual males (16.5%), persons with hemophilia (14.0%), and heterosexual IVDUs (11.6%). These four categories accounted for 24.4% of tests from persons who reported their risk category and 70.6% of all positive tests from the same population.

Two groups accounted for 72.9% of tests with a self-reported risk category: 1) 456,188 (43.9%) were from persons categorized as "heterosexuals with reported risk" (including heterosexuals whose sex partners are at risk for or infected with HIV, heterosexuals with multiple sex partners, and heterosexuals with any other factor considered by local health authorities to pose a risk for HIV infection); and 2) 302,005 (29.0%) were from persons classified as "other heterosexual" (primarily heterosexual persons who correctly or incorrectly reported no history of risk behavior or no partner(s) at risk for or infected with HIV) (Table 2). These two heterosexual groups had a combined seropositivity rate of 2.0%, yet accounted for 28.1% of reported positive tests for persons whose risk category was reported. For the "heterosexual with reported risk" category, seropositivity rates by reported partner characteristic were: partner infected with HIV, 11.7% (1455/12,440); partner with hemophilia, 5.1% (34/667); IV-drug-using partner, 5.0% (1792/36,167); and bisexual partner, 4.1% (2312/56,830).

Of 828,847 tests for which some demographic information was given, race/ethnicity was specified for 754,900 (91.1%). Of tested persons with known race/ethnicity, seropositivity was highest in Hispanics (8.6%) (Table 3). When compared to the overall U.S. population, both blacks and Hispanics were substantially overrepresented among HIV-antibody tests and positive tests.

Males accounted for 459,046 (55.4%) of the 828,847 tests and 30,758 (79.7%) of all positive tests. Seropositivity in males and females was 6.7% and 2.1%, respectively. Of 735,584 persons for whom age was known, most (73.1%) tests and most (78.9%) positive tests were from persons aged 20-39 years. Seropositivity rates for persons aged 20-29 and 30-39 years were 3.6% and 6.0%, respectively. Reported by: Program Development, Technical Support Section, Program Operations Br, Div of STD/HIV Prevention, and Office of the Director, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Of all HIV prevention efforts, counseling and testing activities receive the highest level of resource support from CDC. The data reported here indicate a large and increasing demand for HIV counseling and testing in the United States; from January 1988 through September 1989, one in 22 persons seeking publicly funded HIV counseling and testing services were confirmed to be infected. Knowledge of HIV-infection status and appropriate counseling can assist persons in initiating changes in behavior that will reduce the risk of infecting others or of becoming infected (1,2). Positive behavioral changes can also occur in the large number of persons who elect not to be tested but who receive risk-reduction counseling. In addition, early detection of HIV infection and referral (3) can lead to optimal medical management and partner notification.

Because of duplicate testing, the total number of persons tested and found to be HIV-antibody positive in U.S. publicly funded settings is not known.** However, four publicly funded HIV prevention programs that have monitored repeat tests estimated that 12%-30% (mean: 23%) of HIV-antibody tests and 3%-18% (mean: 13%) of positive tests represented previously tested persons (CDC, unpublished data). When these rates are applied to the data reported here, an estimated 2 million persons have been tested since 1985 through publicly funded counseling and testing programs, and 123,000-145,000 persons have been found to be infected.

Many of the estimated 1 million HIV-infected persons in the United States remain unaware of their infection (4). Of persons who are aware of their HIV infection, a substantial proportion had their infection identified in publicly funded counseling and testing programs.

To ensure that persons with undetected HIV infection receive appropriate counseling and testing, priorities should include increasing the number of persons, especially those engaging in risk behaviors, who come to the test sites and the number of persons who receive the full range of counseling and testing, referral, and partner notification services. Programs should attempt to maximize the proportion of persons at risk who 1) are offered and receive pretest counseling; 2) accept and receive HIV-antibody testing; 3) return for HIV-antibody test results; 4) are offered and receive post-test counseling; 5) if infected, participate in partner notification; and 6) if infected, are referred for and receive further medical and prevention services.

References

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

2. Stempel RR, Moss AR. A review of studies of behavioral response to HIV-antibody testing among gay men (Poster session). V International Conference on AIDS. Montreal, June 4-9, 1989:730.

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

4. CDC. Estimates of HIV prevalence and projected AIDS cases: summary of a workshop, October 31-November 1, 1989. MMWR 1990;39:110-2,117-9.foots *Estimated 12-month total for 1989 based on adjustment of data received for January through September. **In addition to the tests reported here, a large but unknown number of persons are tested for HIV antibody in hospitals, outpatient medical facilities, physicians' offices, blood-donation centers, military facilities, and other settings.

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