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Copyright 1999 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.1999American Medical AssociationThis is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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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%). 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%).
Div of HIV/AIDS Prevention-Surveillance and Epidemiology, National Center for HIV, STD, and TB Prevention, CDC.
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 persons6 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 laws7 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.
Anonymous or Confidential HIV Counseling and Voluntary Testing in Federally Funded Testing Sites—United States, 1995-1997. JAMA. 1999;282(4):321–322. doi:10.1001/jama.282.4.321-JWR0728-4-1