Late versus early testing of HIV - 16 sites, United States, 2000-2003

Morbidity and Mortality Weekly Report, June 27, 2003

Knowledge of human immunodeficiency virus (HIV) serostatus has been an important element of HIV-prevenrion and -treatment efforts (1). In 2000, among the estimated 850,000-950,000 persons living with HIV in the United States, approximately one fourth (180,000-280,000) were unaware that they were HIV infected (2). In addition, many persons with HIV are tested late in the course of infection, usually as a result of illness (3). During 1994-1999, among persons who had HIV diagnosed, 43% were tested late in the infection (i.e., had acquired immunodeficiency syndrome [AIDS] diagnosed within one year of HIV diagnosis) (4). Late testing results in missed opportunities for prevention and treatment of HIV. To characterize HIV-testing patterns among HIV-infected persons, CDC analyzed data from a multisite interview project. During May 2000-February 2003, persons at 16 U.S. sites who were tested early in the course of HIV disease (early testers) were compared with persons who were tested late in the course of HIV diseas e (late testers). This report summarizes the results of the analysis, which indicate that late testers were more likely than early testers to be black or Hispanic, less educated, and exposed to HIV through heterosexual contact. Reducing the incidence of both new infections and HIV-associated morbidity and mortality will require earlier testing and improved access to prevention and care services for persons infected with HIV. A new CDC initiative, "Advancing HIV Prevention: New Strategies for a Changing Epidemic," is aimed at reducing barriers to early diagnosis of HIV infection and increasing access to quality medical care, treatment, and ongoing prevention services (5).

CDC's Supplement to HIV/AIDS Surveillance (SI-LAS) project is an ongoing, cross-sectional, multisite interview study that began in 1990 (6). SHAS data collected by 16 state or local health departments * were analyzed. Trained personnel conducted face-to-face interviews with persons aged [greater than or equal] 18 years with HIV/AIDS who were reported recently to local or state HIV/AIDS reporting systems. Facility- (eight sites) and population-based (eight sites) methods were used to recruit participants (6). The date of AIDS diagnosis was obtained from the HIV/AIDS reporting system. Early testers were defined as persons who reported that they had their first positive HIV test [greater than or equal] 5 years before the diagnosis of AIDS or had [greater than or equal] 5 years without a diagnosis of AIDS after their first positive HIV test. Late testers were defined as persons who had their first positive HIV test [less than or equal to]1 year before the diagnosis of AIDS. The following groups were excluded from the analysis: persons who tested > 1 year but < 5 years before AIDS diagnosis, persons who were not followed for an adequate follow-up time (i.e., <5 years after a positive HIV test without a diagnosis of AIDS being made), and persons for whom the relation between the HIV testing and AIDS diagnosis dates could not be determined.

Among persons interviewed during May 2000--February 2003, characteristics of early and late testers were compared. Chi-square testing was used to examine the association between late testing and sex, age, race/ethnicity, mode of HIV exposure, level of education, history of having an HIV negative test before the first positive HIV test, reasons for getting tested, and type of testing site where diagnosed initially. Data were not validated by chart review.

Of 7,584 persons invited to participate, 5,980 (79%) completed the interview (range by state: 57-1,071), of which 4,290 (72%) were men, 3,324 (56%) were black, 1,285 (22%) were white, and 1,160 (19%) were Hispanic. Overall, 2,281 (38%) HIV exposures were attributed to men having sex with men (MSM), 2,166 (36%) to heterosexual transmission, 1,010 (17%) to current or former injection-drug use (IDU), and 477 (8%) to MSM/IDU.

Of the 5,980 persons interviewed, 4,127 (69%) had received an AIDS diagnosis, and 1,853 (31%) had HIV that had not progressed to AIDS (HIV [non-AIDS]). Of the 1,853 persons with HIV (non-AIDS), 519 (28%) had HIV diagnosed for >5 years and were classified as early testers; the remaining 1,334 (72%) persons with HIV (non-AIDS) were excluded from the analysis because of inadequate follow-up time. Among the 4,127 persons in whom AIDS had been diagnosed, 1,054 (24%) early testers and 1,877 (45%) late testers were included in the analysis; 860 (21%) persons with AIDS who rested positive for HIV >1 year but <5 years before AIDS diagnosis and 336 (8%) persons for whom it was not possible to determine the relation between HIV testing and AIDS diagnosis dates were excluded from the analysis.

Compared with the 1,573 early testers, the 1,877 late testers were significantly more likely to be younger (aged 18-29 years), to be black or Hispanic, to have been exposed to HIV through heterosexual contact, to have a high school or less education, or to have tested negative for HIV previously before their first positive HIV test (Table). When the analysis was restricted to persons from SHAS sites that conduct integrated HIV/AIDS surveillance, the demographic characteristics of participants by sex, race/ethnicity, and mode of exposure were similar to the overall population. The majority of late testers received HIV resting because of illness (65%), and the majority of early testers were tested because of self-perceived risk (29%) or because they wanted to know their HIV status (19%) (Figure); 87% of late testers and 69% of early testers had their first positive HIV test at an acute or referral medical care setting, and 8% of the late testers and 22% of early testers were tested anonymously.

Reported by: Supplement to HIV/AIDS Surveillance Project Group, participating state and local health depts. AK Nakashima, MD, ML Campsmith, DDS, MI Wolfe, MD, G Nakamura, PhD, EB Begley, MPH, Div of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention; EH Teshale, MD, EIS Officer, CDC.

Editorial Note: The findings in this report indicate that racial/ethnic minority populations, heterosexuals, or persons who have low education are more likely to test late for HIV. The majority of late testers sought testing because of illness; early testers were tested for several reasons, including perceived risk, desire to know their HIV status, and routine check-up in addition to illness. Late testers were more likely to have been tested previously; persons who tested negative might have assumed they were safe and therefore did not retest for a long time. Early testers were more likely to have been diagnosed initially through anonymous testing, illustrating the importance of this option to promote early HIV testing. Many persons with HIV (non-AIDS) were excluded from the analysis because follow-up time was insufficient for them to be classified as early testers; these persons probably will be classified eventually as early testers. Therefore, the association between young age and late testing might be a r eflection of the study design.