Publicly Funded HIV Counseling and Testing -- United States, 1990

A critical component of CDC's national human immunodeficiency virus (HIV)-prevention program is support for HIV counseling and testing (CT) services. Sixty-five HIV-prevention programs are in health departments in 50 states, the District of Columbia, six cities, and eight territories.* Each calendar quarter, the programs report to CDC aggregate or client record data about the number of

1. pretest counseling sessions, HIV-antibody tests, positive tests, and posttest counseling sessions, by CT site; 2) HIV-antibody tests and positive tests, by self-reported risk category; and 3) HIV-antibody tests and positive tests, by age group, sex, and race/ethnicity.** This report summarizes data reported for 1990. Serologic Testing Results by CT Site

During 1990, the 65 programs performed 1,366,537 HIV-antibody tests; 51,170 (3.7%) were positive (Table 1). Of these, freestanding HIV CT sites (sites that provide HIV CT services exclusively) and sexually transmitted diseases (STD) clinics together accounted for 832,985 (61.0%) of reported tests and 32,851 (64.2%) of positive test results. Family planning and prenatal/obstetric clinics accounted for 14.4% of reported tests and 3.2% of positive tests; drug-treatment centers and prisons accounted for 9.2% of reported tests and 13.6% of positive tests. Risk Category

Of 1,283,222 reported tests for which information on self-reported risk category was available, the percentage of seropositive tests was highest for homosexual/bisexual male injecting drug users*** (IDUs) (19.5%), homosexual/bisexual males (14.7%), heterosexual IDUs (10.7%), and persons with hemophilia (8.9%) (Table 2). These four categories accounted for 18.1% of tests and 60.7% of positive results from persons who reported their risk category.

Persons categorized as "heterosexuals with reported risk" (including heterosexuals whose sex partners are at risk for or are infected with HIV and heterosexuals with multiple sex partners) represent 536,455 (41.8%) of tests and 10,010 (20.2%) of all positive results. Persons who reported "other" than established risks for HIV infection or "no acknowledged risk" (heterosexuals who indicated no history of risk behavior or no partner(s) at risk for or infected with HIV) accounted for 489,672 (38.2%) tests. Combined, these predominantly heterosexual persons--heterosexuals with reported risk and others with no acknowledged risk--had a seropositivity rate of 1.8%, yet accounted for 38.1% of reported positive results. Demographic Categories

Of 1,309,385 tests for which demographic information was given, race/ethnicity was specified for 1,280,294 (97.8%). Whites, blacks, and Hispanics accounted for 49.5%, 35.3%, and 11.3%, respectively, of HIV tests performed, compared with their representation in the U.S. population of 78.4%, 11.8%, and 7.8%, respectively (1). The racial/ethnic distribution of those tested was similar to that of new reports of persons with AIDS in 1990, of whom 51.5% were white, 30.4% were black, and 17.6% were Hispanic (2) (Table 3). Blacks, whites, and Hispanics accounted for 41.7%, 35.9%, and 18.5%, respectively, of total positive tests (Table 3). Seropositivity was highest among Hispanics (6.0%), followed by blacks (4.4%) and whites (2.7%). Males accounted for 666,250 (50.9%) of the 1,309,385 tests and 37,668 (77.6%) of the 48,566 positive results. Seropositivity in males and females was 5.5% and 1.7%, respectively. Of persons for whom age was known, persons aged 20-29 years accounted for 43.0% of tests and 36.5% of positive results, and persons aged 30-39 years accounted for 27.8% of tests and 41.8% of positive results. Seropositivity rates for persons aged 20-29 and 30-39 years were 3.1% and 5.5%, respectively. For adolescents aged 13-19 years, 173,826 tests were performed; of these, 1090 (0.6%) were positive. Posttest Counseling

Client record data, representing a 43% subset of the aggregate CT data and providing greater detail about persons receiving CT, indicate that posttest counseling was completed for at least 72.5% of persons with HIV-antibody-positive test results and 55.7% of those with negative test results (3). Overall, at least 56.4% of persons in the client record database received posttest counseling; however, the proportion of persons was higher for freestanding test sites (81.6%) than for STD clinics (33.9%). Reported by: HIV-prevention programs of state and local health depts. Program Development, Technical Support Section, Program Operations Br, Div of STD/HIV Prevention, and Office of the Director, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Knowledge of HIV-infection status and appropriate counseling can assist persons in initiating changes in behavior that will reduce the risk for infecting others or for becoming infected (4,5). Early intervention, including medical evaluation, antiviral 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 (6). However, a large proportion of the estimated 1 million HIV-infected persons in the United States remain unaware of their infection (7).

Because the data in this report reflect characteristics only of 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 attendance is largely voluntary; therefore, data regarding risk factors may be less reliable than those obtained in population-based surveys or epidemiologic investigations. In addition to the tests reported here, a large number of persons not reported here are tested for HIV antibody in hospitals, outpatient medical facilities, physicians' offices, blood-donation centers, military facilities, and other settings.

Because testing of some clients is repeated, neither the total number of persons tested nor the total number who are HIV-antibody-positive in publicly funded settings are known. However, based on monitoring in four publicly funded programs, an estimated 12%-30% (mean: 23%) of HIV-antibody tests and 3%-18% (mean: 13%) of positive tests represented persons tested previously (CDC, unpublished data). By using these rates to adjust cumulatively reported CT data, an estimated 3,250,000 persons have been tested since 1985 through publicly funded programs, and an estimated 185,000 of these persons have been seropositive. Studies are under way to determine the most effective strategy for ensuring that those persons who test positive but do not return for their test results will be notified of their status.

One possible explanation for the difference in the return rate for freestanding sites and STD clinics is that persons attend freestanding sites specifically to obtain an HIV antibody test, whereas those who attend STD clinics primarily for clinical care of an STD may be offered HIV CT as a component of that clinical care.

National HIV prevention and intervention efforts are dependent on self-perceptions of risk and subsequent risk-reduction efforts in response to that risk. To ensure that persons with undetected HIV infection receive appropriate CT, public health priorities should focus on increasing the number of persons, especially those engaging in risk behaviors, who are tested and the number who receive the full range of recommended CT, referral, and partner-notification services. HIV CT services should continue to expand to settings such as tuberculosis, STD, and drug-treatment clinics (Table 1). 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 book: state and metropolitan area--regions, divisions, and states. Washington, DC: US Department of Commerce, Bureau of the Census, May 1983:509.

2. CDC. HIV/AIDS surveillance. Atlanta: US Department of Health and Human Services, Public Health Service, January 1991:14-5.

3. CDC. CTS client record database: 1990 annual report. Atlanta: US Department of Health and Human Services, Public Health Service, 1991.

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

5. 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.

6. 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). VII International Conference on AIDS, Florence, Italy, June 16-21, 1991;1:382.

7. 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.

*The cities are Chicago, Houston, Los Angeles, New York City, Philadelphia, and San Francisco. The territories are American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Palau, Puerto Rico, and 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 totals in the tables do not correspond. ***CDC is now using the term ``injecting drug user'' (IDU) (replacing ``intravenous-drug user'' (IVDU)) to describe persons who are at risk for HIV infection because of drug injection. This term indicates recognition that injection routes other than intravenous have been associated with HIV infection.

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