Quick HIV Testing in Community Settings
In 2003, an estimated 1 million persons in the United States were living with human immunodeficiency virus (HIV) infection. Approximately 25% were unaware of their infection; however, that percentage might have been greater among persons at high risk for HIV infection, including racial/ethnic minority populations. To increase the proportion of persons aware of their HIV serostatus, CDC launched the Advancing HIV Prevention initiative in 2003. One strategy of the initiative is to implement new models for diagnosing HIV infections outside medical settings. During 2004--2006, CDC funded a demonstration project to provide rapid HIV testing and referral to medical care, targeted to racial/ethnic minority populations and others at high risk in outreach and other community settings.
This report summarizes the results of that project, which indicated that, of 23,900 clients who received a rapid HIV test, 39% were non-Hispanic blacks, 31% were Hispanics, 17% reported male-male sex, and 6% were injection-drug users. A total of 267 (1%) persons had confirmed HIV-positive test results; of these, 195 (74%) were either non-Hispanic blacks or Hispanics. The project results demonstrate that rapid HIV testing in outreach and other community settings can identify large numbers of persons in racial/ethnic minority populations and others at high risk who are unaware they are infected with HIV.
Rapid HIV testing was conducted by eight community-based organizations (CBOs) in seven U.S. cities: Boston, Massachusetts; Chicago, Illinois; Detroit, Michigan; Kansas City, Missouri; Los Angeles, California; San Francisco, California; and Washington, D.C. (DC). CBOs identified testing venues where persons at high risk congregated, resided, or sought medical care (e.g., parks, shelters, hotels, clubs, health fairs, syringe-exchange sites, and community clinics). Trained CBO staff members offered counseling and rapid HIV testing to clients either in mobile testing units or inside venues. Persons eligible for testing were those capable of providing written, informed consent who met age of consent criteria for HIV testing in the state in which the CBO was operating; persons not meeting these criteria and persons with a previous diagnosis of HIV infection were excluded. CBO staff members collected information from persons tested regarding their demographic characteristics, risk behaviors, and HIV testing history. HIV testing was performed with rapid tests (Oraquick[Note (R)] Rapid HIV-1 Antibody Test or OraQuick[Note (R)] Advance[Note :] Rapid HIV-1/2 Antibody Test [OraSure Technologies, Bethlehem, Pennsylvania]) on either oral fluid or whole-blood specimens, and results were provided to clients 20--40 minutes after specimens were collected. For persons with reactive (i.e., preliminary positive) rapid test results, testing staff members collected either oral fluid or whole-blood specimens for confirmatory Western blot testing and scheduled a follow-up appointment to give the client the confirmatory test results. HIV-positive persons who returned for confirmatory test results were referred to clinics affiliated with participating CBOs or to other local health-care providers for medical care.
Of 24,172 persons who agreed to be tested, 44 persons did not meet age of consent criteria, and 84 persons reported a previous diagnosis of HIV infection. Data on the total number of persons offered testing were not collected. Of the 24,044 persons who met eligibility criteria for participation and agreed to be tested, 144 were excluded from the analysis because they either did not receive their rapid HIV test results or had missing test-result information. A total of 23,900 persons were included in the analysis: 5,536 from Los Angeles; 5,162 from Boston; 4,586 from DC; 2,985 from Kansas City; 1,931 from San Francisco; 1,868 from Detroit; and 1,832 from Chicago. Among participants, 39% were non-Hispanic blacks, 31% were Hispanics, and 21% were non-Hispanic whites. Sixty-three percent of participants were male, 50% reported not having any public or private health insurance, 40% reported not visiting a health-care provider during the preceding year, and 9% reported being homeless (Table).
Sixty-six percent of participants reported having multiple sex partners, 17% reported male-male sex, and 6% reported injection-drug use during the preceding year. A total of 7,034 (30%) participants had never been tested for HIV; among the 16,543 (70%) who had been tested, 6,982 (43%) had not been tested during the preceding year. Of 14,096 persons who had seen a health-care provider during the preceding year, 6,257 (44%) had received an HIV test during that period, and 3,299 (24%) had never been tested for HIV, including 19 persons who were confirmed to have HIV infection.
A total of 331 persons (1%) had a preliminary positive rapid HIV test result; of these, 286 (86%) received a confirmatory test (Figure). The most common reason cited by persons with preliminary positive HIV test results for refusing confirmatory testing was that they wanted to have the testing performed elsewhere. Of the 286 persons who received a confirmatory test, 267 (93%) were confirmed to have HIV infection, and 17 had negative confirmatory test results (i.e., false preliminary positive rapid HIV test results). The positive predictive value of a preliminary positive rapid result for a confirmed test was 94% (267 of 284). Of the 267 persons with newly diagnosed HIV infection, 200 (75%) received their confirmatory test results. The most common reason cited by participating sites for why clients with preliminary positive test results did not receive their confirmatory test results was that the clients could not be located. Of the 200 persons who received their confirmatory results, 171 (86%) accepted referrals to medical care for HIV; the reasons that 29 persons (14%) did not accept referrals to medical care are not known. Referral to care encompassed a range of actions, including escorting clients to medical care, scheduling medical appointments, or providing contact information for clients to schedule their own appointments.
This project demonstrated that rapid HIV testing in a range of settings can effectively target multiple populations at high risk for HIV infection. Offering rapid HIV testing in outreach and other community settings provides opportunities to identify HIV infections and to link persons with positive test results to prevention and medical care.