J. Stan Lehman

HIV testing within at-risk populations in the United States and the reasons for seeking or avoiding HIV testing.

Objectives: We determined proportions of high‐risk persons tested for HIV, the reasons for testing and not testing, and attitudes and perceptions regarding HIV testing, information that is critical for planning prevention programs. Methods: Cross‐sectional interview study of persons at high risk for HIV infection (men who have sex with men [MSM]; injection drug users [IDUs]; and heterosexual persons recruited from gay bars, street outreach, and sexually transmitted disease clinics) among six states participating in the HIV Testing Survey (HITS) in 1995 to 1996 (HITS‐I) and 1998 to 1999 (HITS‐II). Results: Overall testing rates were lower in the HITS‐I (1226/1599 [77%]) than in the HITS‐II (1375/1711 [80%]) (p = .01). Persons <25 years old tested less frequently than those >25 years old (HITS‐I: 71 % vs. 78%, respectively, p = .007; HITS‐II: 63% vs. 85%, respectively, p < .001). The main reasons for testing and not testing were the same in both surveys, but the proportions of reasons for not testing differed (e.g., “unlikely exposed to HIV” [HITS‐I (17%) vs. HITS‐II (30%), p < .0001], “afraid of finding out HIV‐positive” [HITS‐I (27%) vs. HITS‐II (18%), p < .0001]). Attitudes regarding HIV testing differed among tested and untested respondents, especially among MSM. Conclusions: HIV testing rates were higher in the HITS‐II, but testing rates decreased among the youngest respondents. Denial of HIV risk factors and fear of being HIV‐positive were the principal reasons for not being tested. Availability of new HIV therapies may have contributed to decreased fear of finding out that one is HIV infected as a reason to avoid testing. The increased proportion of persons at risk who did not test because they believed they were unlikely to have been exposed highlights the need for prevention efforts to address risk perceptions.

Estimated future HIV prevalence, incidence, and potential infections averted in the United States: a multiple scenario analysis.

Objectives:To estimate the potential future burden of HIV in the United States under different intervention scenarios. Methods:We modeled future HIV incidence, prevalence, and infections averted using 2006 estimates of HIV incidence (55,400 new infections per year), prevalence (1,107,000 persons living with HIV), and transmission rate (5.0 per 100 persons living with HIV). We modeled 10-year trends for 3 base-case scenarios (steady incidence, steady transmission rate, declining transmission rate based on the 2000-2006 trend) and 2 intensified HIV intervention scenarios (50% reduction in transmission rate within 10 and 5 years). Results:Base-case scenarios predicted HIV prevalence increases of 24%-38% in 10 years. Reducing the transmission rate by 50% within 10 years reduces incidence by 40%; prevalence increases 20% to an estimated 1,329,000 persons living with HIV. Halving the transmission rate within 5 years reduces incidence by 46%; prevalence increases 13%, to 1,247,000. Although in year 10 incidence is similar regardless of the intervention time frame, more infections are averted when halving the transmission rate within 5 years. Conclusions:HIV prevalence will likely increase creating additional demands for health care services. These analyses are instructive for setting HIV prevention goals for the nation and assessing potential cost savings of intensified HIV prevention efforts.

HIV infection risk, behaviors, and attitudes about testing: are perceptions changing?

Background People at high risk for HIV infection could be increasing their risk behaviors, especially now that improved treatments for HIV infection are available. Goal The goal was to investigate whether risk behaviors, perceptions of personal risk for HIV infection, and attitudes toward HIV testing among high-risk persons in Oregon differed in 1996 and 1998. Study Design Data from the HIV Testing Survey (HITS), a cross-sectional survey administered to HIV-negative men who have sex with men (MSM), heterosexual adults at high-risk for sexually transmitted diseases (STD), and intravenous drug users (IDUs) at high risk for HIV infection in 1996 (HITS-I), were compared with data from a similar group surveyed in 1998 (HITS-II). Results Proportions of participants reporting specific risk behaviors remained relatively constant in 1996 and 1998. Personal risk of HIV infection was perceived as low by 54% of HITS-II participants and 61.2% of HITS-I participants (odds ratio [OR], 1.2; 95% confidence interval [CI], 0.9-1.7). IDUs in HITS-II were more likely than IDUs in HITS-I to perceive their risk as low (OR, 2.1; 95% CI, 1.2-3.7). Conclusion Persons at high risk might underestimate their risk for HIV infection while practicing risky behaviors. The prevalence of risk behaviors in these populations could be considered the baseline against which to measure future prevention efforts.

Validation of Race/Ethnicity and Transmission Mode in the US HIV/AIDS Reporting System

Since 1981, the national HIV/AIDS reporting system (HARS) has provided data to track the progression of the AIDS epidemic, detect patterns of transmission, assess prevention programs, provide an epidemiological basis for planning, and allocate federal resources.1 The Centers for Disease Control and Prevention actively evaluate the quality of the data to ensure that the objectives of the system are based on accurate and complete information.2–5 The HARS relies on medical record reviews by health care providers or trained health department personnel for completion of case reports. Validity studies of medical record data have shown that accuracy and reliability vary according to the type of information and the diagnoses examined.2,4,6 To assess the accuracy of 2 HARS variables on which data are frequently stratified, we compared HARS data on race/ethnicity and transmission mode to self-reported data collected during a survey of people with AIDS.

HIV INFECTION AMONG NON-INJECTING DRUG USERS ENTERING DRUG TREATMENT, UNITED STATES, 1989-1992

ObjectiveTo describe HIV seroprevalence among non-injecting drug users (non-IDU) entering sentinel drug treatment centers in the United States. DesignAnonymous, blinded (unlinked) HIV seroprevalence surveys. SettingSixty-eight sentinel drug treatment centers in 37 United States metropolitan areas. ParticipantsConsecutive sample of clients admitted to sentinel drug treatment centers from January 1989 through December 1992. Of 84 617 clients, 37 633 (44.5%) had used illicit drugs but reported no injecting drug use since 1978. Main outcome measuresCenter-specific, metropolitan area-specific, and national median HIV seroprevalence rates. ResultsNational median center-specific HIV seroprevalence among non-IDU was 3.2% (range, 0–15.2%). Rates varied widely by geographic area. Median rates were highest in the northeast (5.6%; range, 0–15.2%), intermediate in the south (3.4%; range, 0.6–8.0%), and generally lower throughout the rest of the country: midwest (1.3%; range, 0–3.1 %) and west (1.8%; range, 0–14.5%). When stratified by treatment center, there were few statistically significant differences in seroprevalence among African Americans, Hispanics and whites. The median rate was 3.4% among men and 2.7% among women. Rates among non-IDU were lower than among IDU attending the same drug treatment centers, but consistently higher than among heterosexual patients attending sexually transmitted disease clinics in the same metropolitan areas. ConclusionsHIV seroprevalence among non-IDU entering drug treatment is high in many metropolitan areas. HIV prevention and education efforts in drug treatment centers should target sexual as well as drug-use risk reduction for all clients.

Changes in HIV Testing After Implementation of Name-Based HIV Case Surveillance in New Mexico

Name-based HIV case surveillance was implemented in New Mexico on January 15, 1998. The objective of the present study was to assess changes in HIV testing patterns after implementation of HIV case surveillance. The timing of the HIV Testing Survey (HITS), developed to gather data on HIV testing patterns among persons at risk for infection through the use of anonymous, cross-sectional surveys,1 offered a natural experiment in New Mexico: HITS-I took place in 1996, before implementation of HIV case surveillance, and HITS-II took place in 1998, after implementation. Participants were men who had sex with men (recruited from gay bars), injection drug users (recruited through street outreach), and heterosexual adults (recruited from a sexually transmitted disease clinic). Participants were required to be 18 years or older and to have been residents of New Mexico for at least 1 year. Study methods have been described in detail elsewhere.2 Fisher exact tests or χ2 tests were conducted to determine whether categorical variables differed significantly in comparisons of HITS-I and HITS-II. Most participants had been tested for HIV at least once: 233 (84%) in HITS-I and 226 (82%) in HITS-II. The percentage of participants tested anonymously was higher in HITS-II (56%) than in HITS-I (45%; P = .001). Concern about confidentiality (as indicated by the statement “You were worried your name would be reported to the government if you were positive”) was cited as a reason for not undergoing testing by 10 (23%) of 44 untested individuals in HITS-I and by 2 (4%) of 49 untested individuals in HITS-II (P = .01). Participants’ most common reasons for not being tested were fear of learning they were HIV positive and the belief that they were HIV negative. The percentage of participants who correctly identified the current HIV surveillance policy was higher in HITS-II (10%) than in HITS-I (3%; P = .001). The proportion of participants who had been tested did not differ among those who knew the policy and those who did not. Overall, reporting policies seemed to be a minor factor in the HIV testing decisions of individuals at risk. The present results help to allay concerns about whether implementing name-based HIV case surveillance serves as a deterrent to HIV testing. Our findings also support the recommendation that states offer anonymous testing to encourage people to learn their HIV serostatus.3 Ongoing assessment of the effect of surveillance policies on HIV testing is needed as more states implement HIV case surveillance.