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Anonymous or Confidential HIV Counseling and Voluntary Testing in Federally Funded Testing Sites -- United States, 1995-1997

Human immunodeficiency virus (HIV) counseling and voluntary testing (CT) programs have been an important part of national HIV prevention efforts since the first HIV antibody tests became available in 1985 (1). In 1995, these programs accounted for approximately 15% of annual HIV antibody testing in the United States, excluding testing for blood donation (1). CT opportunities are offered to persons at risk for HIV infection at approximately 11,000 sites, including dedicated HIV CT sites, sexually transmitted disease (STD) clinics, drug-treatment centers, hospitals, and prisons. In 39 states, testing can be obtained anonymously, where persons do not have to give their name to get tested. All states provide confidential testing (by name) and have confidentiality laws and regulations to protect this information. This report compares patterns of anonymous and confidential testing in all federally funded CT programs from 1995 through 1997 and documents the importance of both types of testing opportunities.

In CT programs, demographic and HIV risk information is collected, combined with laboratory test results, and reported to CDC after removal of personal identifying information. Federally funded CT programs provided 2.5 million tests (40,605 HIV-positive) in 1995, 2.6 million (39,119 HIV-positive) in 1996, and 2.3 million (34,875 HIV-positive) in 1997. Of the 7.4 million federally funded HIV tests performed during 1995-1997, client information on 6.3 million tests was available for analysis. Because some persons had more than one HIV test in a year, the proportion of persons tested who had positive results could not be calculated. Thus, the proportion positive reflects the number of positive tests divided by the number of tests provided.

From 1995 to 1997, the number of anonymous tests declined 26.6% (from 636,069 to 466,560), and the number of confidential tests increased 2.9% (from 1,394,921 to 1,434,709). Although more tests were provided to women than men each year, more anonymous tests were provided to men than women. In each year, the highest numbers of positive anonymous tests were among white and black men, and the highest number of positive confidential tests were among blacks.

In 1997, the most recent year for which complete data were available, STD clinics provided more tests overall (551,838) and more confidential tests (494,414) than other sites, and dedicated HIV CT sites provided the largest number of anonymous tests (302,273). Overall, most HIV-positive tests were reported from specially designated HIV CT sites (10,523 [2.0%] of 538,574), STD clinics (8390 [1.5%] of 551,838), prisons (3120 [3.5%] of 88,183), community health centers (2941 [2.1%] of 139,331), and drug-treatment centers (2574 [2.4%] of 109,037).

In 1997, of tests provided to men who have sex with men (MSM), 55.3% were anonymous. Most anonymous tests were among MSM who were injecting-drug users (IDUs) (37.3%), followed by men whose only risk was heterosexual contact (24.7%) and male IDUs (22.1%).

Among men, the highest proportion of tests that were anonymous were among Asians/Pacific Islander (A/PI) MSM (71.6%) and among white MSM (61.9%) (Table 1). A lower proportion of anonymous tests were for American Indian/Alaskan Native (AI/AN) MSM (55.4%), Hispanic MSM (47.9%), and black MSM (32.5%).

Among women, the highest proportion of anonymous tests was among A/PI IDU (40.0%), A/PI with heterosexual contact (35.9%), whites with heterosexual contact (30.8%), AI/AN with heterosexual contact (29.7%), and AI/AN IDUs (29.2%) (Table 2).

Reported by: Div of HIV/AIDS Prevention-Surveillance and Epidemiology, National Center for HIV, STD, and TB Prevention, CDC.

Editorial Note:

The benefits of early HIV CT are greater now than at any time during the epidemic. For HIV-infected persons, highly active antiretroviral therapy (HAART) has improved dramatically the quality and duration of life (2). For public health, reduced HIV transmission may occur because many infected persons probably will reduce sexual risk behavior after HIV-infection diagnosis (3). In addition, HAART may reduce the risk for transmission by reducing the amount of infectious virus in body fluids of HIV-infected persons (4,5). For these reasons, public health programs should work to diagnose HIV infection in each of the approximately 200,000 infected persons (6) who do not know their HIV status, link them to care and prevention services, and assist them in adhering to treatment regimens and in sustaining risk-reduction behavior.

Both anonymous and confidential testing opportunities help to facilitate test seeking among persons at risk for HIV infection. The findings in this report indicate a decline in anonymous tests from 1995 through 1997. Reasons for this decline are unclear but may reflect changes in the characteristics of persons counseled and tested for HIV, a perception that HIV-infection is a treatable and less stigmatizing disease, and the impact of new laws (7) and regulations on the risk for confidentiality violations and other factors. However, anonymous testing continues to be of value; anonymous testing has been associated with entry into medical care earlier in disease (8). Among groups at risk for HIV infection, MSM--particularly A/PI and white MSM--most frequently choose anonymous testing over confidential in publicly funded facilities. These data are consistent with other studies indicating that MSM have high levels of concern about the confidentiality of their HIV test results (9). Because of the potential benefits of anonymous testing, CDC encourages states to include anonymous testing as an integral component of CT programs.

The low proportion of women and black men who choose anonymous testing may reflect a lack of awareness that these services exist, a greater willingness to test confidentially, preferentially receiving care in settings where provider practices favor confidential testing, or being tested because of the presence of HIV-related symptoms. A better understanding of the factors that contribute to differences in testing patterns may improve the effectiveness of voluntary testing programs. On the basis of recent trends, HIV-infection programs should assure the provision of voluntary HIV CT in settings that serve at-risk women and black men.

From 1995 through 1997, the number of federally funded confidential tests increased. Three quarters of publicly funded testing is confidential and accounts for nearly 25,000 positive tests each year. Confidential testing is offered in HIV CT sites, prisons, and medical settings (e.g., clinics, community health centers, and hospitals). More than half of positive confidential tests were in federally funded clinical-care settings (e.g., STD, drug-treatment, and tuberculosis and community health centers). Data from emergency departments in hospitals in areas where the prevalence of HIV infection is high indicate that half of infected persons are unaware of their HIV infection (CDC, unpublished data, 1999). To increase the number of infected persons who are aware of their HIV status, voluntary testing will need to be increased in settings where persons at risk for HIV infection seek care for non-HIV-related conditions.

The findings in this report are subject to at least three limitations. First, the data are not representative of all persons tested for HIV during the observation period; the data include approximately 15% of annual nonblood donation tests in the United States. Second, the proportion of positive tests is not the same as the proportion of persons who tested positive. Some persons were tested multiple times; therefore, the proportion of persons who tested positive was not available. Finally, some test sites report summary data, which could not be used in this analysis, rather than individual client test records; the analyzed individual client record data represent 87% of all federally funded tests provided in 1997.

CDC encourages every adult and adolescent to assess their risk for HIV infection based on past behavior. Persons who believe they might have been exposed to HIV but who have not been tested should seek CT for HIV. Additional information about HIV CT is available on the World-Wide Web at http://www.hivtest.org* or from the National AIDS Hotline, telephone (800) 342-2437.

References

Valdiserri RO. HIV counseling and testing: its evolving role in HIV prevention. AIDS Edu Prev 1997;9:2-13.
Palella FJ, Delaney KM, Moorman AC. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. N Engl J Med 1998;338:853-60.
Denning P, Nakashima A, Wortley P, and the SHAS Project Group. High-risk sexual behaviors among HIV-infected adolescents and young adults [Abstract]. In: Program and Abstracts of the 6th Conference on Retroviruses and Opportunistic Infections. Chicago, Illinois: Foundation for Retrovirology and Human Health, 1999.
Gupta P, Mellors J, Kingsley L, et al. High viral load in semen of human immunodeficiency virus type 1-infected men at all stages of disease and its reduction by therapy with protease and nonnucleoside reverse transcriptase inhibitors. J Virol 1997;71:6271-5.
Vernazza PL, Gilliam BL, Flepp M, et al. Effect of antiviral treatment on shedding of HIV-1 in semen. AIDS 1997;11:1249-54.
Sweeney PA, Fleming PL, Karon JM, Ward JW. A minimum estimate of the number of living HIV infected persons confidentially tested in the United States [Abstract]. In: Program and Abstracts of the Interscience Conference on Antimicrobial Agents and Chemotherapy. Toronto, Canada: American Society of Microbiology, 1998.
Annas GJ. Protecting patients from discrimination--the Americans with Disabilities Act and HIV infection. N Engl J Med 1998;339:1255-9.
Bindman AB, Osmond D, Hecht FM, et al. A multi-state evaluation anonymous HIV testing and access to medical care. JAMA 1998;280:1416-20.
CDC. HIV testing among populations at risk for HIV infection--nine states, November 1995-December 1996. MMWR 1998;47:1086-91.

* References to sites of nonfederal organizations on the World-Wide Web are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites.

Table 1

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TABLE 1. Number of men receiving federally funded anonymous or confidential HIV
tests and number and percentage of positive tests, by race/ethnicity and mode of HIV
transmission -- United States, 1997
======================================================================================
                            Anonymous                  Confidential
                     ------------------------   -------------------------
                                  Positive                   Positive
                       No.     --------------     No.     ---------------
Characteristic       tested*    No.     (%)     tested*    No.      (%)     Total
-----------------------------------------------------------------------------------
White
  Men who have
   sex with men
   (MSM)              50,529   1,951   ( 3.9)    27,313   1,727    ( 6.3)    81,679
  MSM-injecting-
   drug user (IDU)     2,618     172   ( 6.6)     3,416     278    ( 8.1)     6,319
  IDU                  9,666     147   ( 1.5)    29,313     492    ( 1.7)    40,884
  Heterosexual        81,670     283   ( 0.3)   144,424     594    ( 0.4)   234,084
  Other                8,438      73   ( 0.9)    26,833     466    ( 1.7)    40,158

Black
  MSM                  6,215     817   (13.1)    12,606   1,998    (15.8)    19,136
  MSM-IDU                479      61   (12.7)     1,337     203    (15.2)     1,852
  IDU                  3,832     300   ( 7.8)    13,282   1,386    (10.4)    17,436
  Heterosexual        33,587     733   ( 2.2)   191,393   4,017    ( 2.1)   230,279
  Other                1,894      78   ( 4.1)    27,708     747    ( 2.7)    30,313

Hispanic
  MSM                  9,580     655   ( 6.8)    10,077     932    ( 9.2)    20,006
  MSM-IDU                538      36   ( 6.7)     1,070     125    (11.7)     1,640
  IDU                  3,000      89   ( 3.0)    13,667   1,042    ( 7.6)    16,880
  Heterosexual        20,871     265   ( 1.3)    73,521   1,180    ( 1.6)    95,812
  Other                2,445      38   ( 1.6)    10,529     271    ( 2.6)    13,943

Asian/
 Pacific Islander
  MSM                  1,850      55   ( 3.0)       629      19    ( 3.0)     2,584
  MSM-IDU                 32       2   ( 6.3)        27       3    (11.1)        62
  IDU                    119       3   ( 2.5)       175       3    ( 1.7)       306
  Heterosexual         2,996       8   ( 0.3)     3,875      19    ( 0.5)     7,056
  Other                  281       1   ( 0.4)       985      15    ( 1.5)     1,374

American Indian/
 Alaskan Native
  MSM                    410      19   ( 4.6)       266      23    ( 8.6)       740
  MSM-IDU                 60       4   ( 6.7)        74       9    (12.2)       151
  IDU                    193       7   ( 3.6)       470       5    ( 1.1)       801
  Heterosexual           875       4   ( 0.5)     1,659      11    ( 0.7)     2,924
  Other                  289       0       --       257       2    ( 0.8)       835
-----------------------------------------------------------------------------------
* Numbers may not add to total because of missing data.
======================================================================================

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Table 2

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TABLE 2. Number of women receiving federally funded anonymous or confidential HIV
tests and number and percentage of positive tests, by race/ethnicity and mode of HIV
transmission -- United States, 1997
======================================================================================
                        Anonymous               Confidential
                   --------------------    ----------------------
                              Positive                 Positive
                      No.     ---------      No.      -----------
Characteristic      tested*   No.   (%)    tested*     No.    (%)    Total
---------------------------------------------------------------------------
White
  Injecting-drug
   user (IDU)         7,950    94   1.2     21,530      388   1.8    31,098
  Heterosexual      114,383   309   0.3    243,806      810   0.3   371,506
  Other              16,366    37   0.2     64,734      177   0.3    88,503

Black
  IDU                 2,064   171   8.3      7,646      712   9.3     9,940
  Heterosexual       34,729   716   2.1    237,105    4,065   1.7   276,190
  Other               4,297    62   1.4     52,966      688   1.3    58,250

Hispanic
  IDU                 1,481    40   2.7       5132      409   8.0     6,784
  Heterosexual       24,324   215   0.9    139,933    1,297   0.9   166,184
  Other               2,865    28   1.0     29,809      175   0.6    34,391

Asian/Pacific
 Islander
  IDU                   106     0    --        145        1   0.7       265
  Heterosexual        4,628    12   0.3      7,942       21   0.3    12,882
  Other                 612     2   0.3      2,818        3   0.1     3,708

American Indian/
 Alaskan Native
  IDU                   236     7   3.0        389        9   2.3       808
  Heterosexual        1,498    10   0.7      2,652       16   0.6     5,043
  Other                 264     0    --        786        0    --     1,330
---------------------------------------------------------------------------
* Numbers may not add to total because of missing data.
======================================================================================

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