United States: opt-out HIV testing in clinical settings boosts HIV diagnoses among hard-to-reach groups

Expanded HIV testing in the United States in clinical settings identified over 18,000 new HIV infections between October 2007 and September 2010, the US Centers for Disease Control and Prevention has reported. The new diagnoses were the result of targeting health care settings in areas with a large number of AIDS diagnoses in African-Americans.

In 2006 the CDC recommended opt-out HIV testing for patients aged 13 to 64 in health care settings where the local prevalence of HIV infection is greater than 0.1%, and in 2007 launched the Expanded HIV Testing Initiative to target districts with high rates of late HIV diagnosis among African-Americans.

African-Americans are disproportionately affected by HIV in the United States, and rates of late diagnosis remain high in this population.

The Expanded HIV Testing Initiative targeted 25 districts in which more than 140 AIDS diagnoses had been reported in African-Americans in 2005, as a marker of high rates of undiagnosed HIV infection.

$111 million was made available to the 25 districts, 80% of which was spent on promoting opt-out HIV testing in clinical settings; the remainder could be spent on promoting innovative methods of increasing HIV testing uptake among high-risk populations such as men who have sex with men.

2,786,739 tests were conducted between October 2007 and September 2010, resulting in 18,432 new HIV diagnoses. Ninety-one per cent of all tests took place in clinical settings, yielding 81% of all new HIV diagnoses.

Emergency departments accounted for 8% of testing venues but 30% of all tests and 32% of all HIV diagnoses. 0.8% of all tests performed in emergency departments were positive.

Sexually transmitted disease clinics accounted for 21% of testing venues, 21% of all tests and 20% of new HIV diagnoses.

Although substance abuse clinics made up 9% of testing venues, they accounted for only 0.9% of HIV tests and new HIV diagnoses.

Testing conducted by community-based organisations yielded a disproportionate number of new diagnoses. Although comprising only 7% of testing venues and carrying out 6% of tests, community-based organisations accounted for 11% of new diagnoses, indicating the importance of supporting community-based organisations to improve rates of HIV diagnosis.

The Expanded HIV Testing Initiative was also successful in offering testing to groups who are less likely to have regular contact with health care providers in the United States. Fifty-five per cent of the tests were carried out on men, who accounted for 72% of new HIV diagnoses. Men were twice as likely to test positive as women.

Sixty per cent of tests were carried out in African-Americans, who were 60% more likely to test positive (0.8% HIV prevalence, compared to 0.5% prevalence in whites and Hispanics).

But despite the large number of new diagnoses, the survey also showed that problems remain in linkage to care.

Nine per cent of people who tested positive did not receive their results and 25% of people who tested positive failed to be linked to care. Rates of result notification and linkage to care were lower outside clinical settings. The US National HIV/AIDS Strategy has set a target of improving the proportion of people who are linked to care within three months of diagnosis from 65% to 85%.

The report notes that the Expanded HIV Testing Initiative addressed only two stages in the spectrum of care, and that to achieve a reduction in new infections as a result of earlier diagnosis and treatment, linkage to care must be followed by retention in care, initiation of treatment, adherence, sustained viral suppression, and access to ongoing prevention and support services. US researchers have previously estimated that only 19% of the HIV-infected population in the United States has achieved viral load suppression.