Abstract
This study uses National HIV Behavioral Surveillance survey data to estimate the proportion of men who have sex with men and persons who inject drugs unaware of their HIV infection who missed opportunities for testing and diagnosis in clinical settings.
In 2015, an estimated 15% of persons living with HIV were unaware of their infection, but they accounted for approximately 40% of annual HIV transmissions in the United States.1,2 Although the US Centers for Disease Control and Prevention (CDC) recommends at least annual HIV testing for persons at high risk, including men who have sex with men (MSM) and persons who inject drugs (PWID),3 many of those persons are either not offered or do not receive HIV testing when visiting clinicians.4 We estimated the percentages of MSM and PWID unaware of their HIV infection with missed opportunities for testing and diagnosis in clinical settings.
Methods
The CDC’s National HIV Behavioral Surveillance (NHBS)5 collects biobehavioral data from high-risk populations in rotating annual cycles in cities with high HIV burden. Participants were recruited using respondent-driven sampling (for PWID) and venue-based sampling (for MSM) and completed an anonymous interview and a subsequent HIV test. NHBS was approved by local institutional review boards in each city; all participants provided oral consent. We analyzed NHBS data on adults 18 years or older from 19 US cities. Data from men who had ever had sex with another man were collected in 2014, and from men and women injecting drugs in the past year in 2012 and 2015, which were combined to ensure stable estimates. Persons were unaware of their HIV infection if they (1) reported no previous HIV-positive test result or no previous HIV test during interview, (2) had a confirmed HIV-positive NHBS test result (blood test), and (3) had no detectable antiretroviral drugs in their blood sample. Participants reported if, during the past year, they had received an HIV test, visited a clinician (“doctor, nurse, or other health care provider”), or been offered an HIV test by a clinician.6
Results
The full analysis sample included 9105 MSM and 19 357 PWID (Table 1). Of those, 2002 MSM (22%) and 1589 PWID (8%) had a positive test result for HIV infection. Of the participants who were HIV-positive, 151 MSM (8%) and 184 PWID (12%) were unaware of their infection. Among the unaware, 123 MSM (81%) and 120 PWID (65%) reported having visited a clinician in the past year and 65 MSM (43%) and 44 PWID (24%) reported being offered an HIV test by a clinician in that time. Sixty-seven unaware MSM (44%) and 141 unaware PWID (77%) reported not having had an HIV test in the past year (Table 2). Among those reportedly not tested in the past year, 35 MSM (52%) and 64 PWID (45%) reported not having been offered HIV testing, despite having visited a clinician.
Table 1. Characteristics of Men Who Have Sex With Men (MSM) and Persons Who Inject Drugs (PWID) From 19 US Cities, National HIV Behavioral Surveillance (NHBS).
| No. of Participants (%)a | |||
|---|---|---|---|
| Total Sample (N = 28 462)b |
With HIV-Positive Resultc | Unaware of Being HIV-Positived | |
| MSM (2014)e | 9105 | 2002 | 151 |
| Age, mean (SD), y | 35.3 (12.1) | 38.0 (11.7) | 30.8 (8.5) |
| Race/ethnicityf | |||
| Black (non-Hispanic) | 25 48 (28) | 915 (46) | 91 (61) |
| Hispanic/Latino | 2390 (26) | 415 (21) | 37 (25) |
| White (non-Hispanic) | 3427 (38) | 532 (27) | 14 (9) |
| Other (non-Hispanic) | 693 (8) | 132 (7) | 8 (5) |
| PWID (2012 and 2015 combined)g | 19 357 | 1589 | 184 |
| Age, mean (SD), y | 45.1 (11.9) | 47.9 (9.2) | 45.9 (8.6) |
| Race/ethnicityf | |||
| Black (non-Hispanic) | 7818 (41) | 861 (54) | 91 (50) |
| Hispanic/Latino | 4552 (24) | 346 (22) | 67 (37) |
| White (non-Hispanic) | 5981 (31) | 296 (19) | 24 (13) |
| Other (non-Hispanic) | 971 (5) | 81 (5) | 1 (1) |
| Sex | |||
| Men | 13 892 (72) | 1125 (71) | 135 (73) |
| Women | 5465 (28) | 464 (29) | 49 (27) |
Percentages may not sum to 100% due to rounding. Numbers in subcategories may not sum to total sample due to missing data.
Participants who consented and completed the NHBS interview and HIV test.
Participants who had an HIV-positive NHBS test result.
Participants were unaware of their HIV infection if they reported (1) no previous HIV-positive test result or no previous HIV test, (2) had a confirmed HIV-positive NHBS test result (blood test), and (3) had no detectable antiretroviral drugs in their blood sample.
MSM analysis was limited to men who reported ever having sex with another man, were aged ≥18 y, and lived in the participating NHBS city.
Race/ethnicity is presented because it is associated with differences in HIV prevalence and access to health care. Race/ethnicity were self-reported by participants using a standard 2-question measure of race/ethnicity. Participants were asked to report their race (black/African American, American Indian/Alaska Native, Asian, Native Hawaiian/other Pacific Islander, white, or multiple race) and ethnicity (Hispanic/Latino: yes/no) separately.6 A 4-category race/ethnicity variable was coded as follows: participants reporting Hispanic/Latino ethnicity were considered Hispanic, regardless of race; all non-Hispanics were categorized as black, white, or other race. “Other race” included American Indian/Alaska Native, Asian, Native Hawaiian/other Pacific Islander, and those of multiple race.
PWID analysis was limited to men and women who injected drugs not prescribed to them in the past 12 mo, were aged ≥18 y, and lived in the participating NHBS city.
Table 2. Past-Year HIV Testing and Opportunities for HIV Testing in Clinical Settings Among Persons Unaware of Their HIV Infection From 19 US Citiesa.
| MSM Unaware of Being HIV-Positive, 2014 (n = 151)b | PWID Unaware of Being HIV-Positive, 2012 and 2015 (n = 184)c | |
|---|---|---|
| No. of Participants/Total (%) | No. of Participants/Total (%) | |
| Visited clinician | 123/151 (81) | 120/184 (65) |
| Offered an HIV test by clinician | 65/151 (43) | 44/184 (24) |
| Tested for HIV in the past year | 84/151 (56) | 43/184 (23) |
| Did not visit clinician in past year | 9/84 (11) | 10/43 (23) |
| Visited clinician and were offered an HIV test by clinician | 52/84 (62) | 21/43 (49) |
| Visited clinician and were not offered an HIV test by clinician | 23/84 (27) | 12/43 (28) |
| Not tested for HIV in the past year | 67/151 (44) | 141/184 (77) |
| Did not visit clinician in past year | 19/67 (28) | 54/141 (38) |
| Visited clinician and were offered an HIV test by clinician | 13/67 (19) | 23/141 (16) |
| Visited clinician and were not offered an HIV test by clinician | 35/67 (52) | 64/141 (45) |
Abbreviations: MSM, men who have sex with men; PWID, persons who inject drugs.
Participants were unaware of their HIV infection if they (1) reported no previous HIV-positive test result or no previous HIV test, (2) had a confirmed HIV-positive National HIV Behavioral Surveillance (NHBS) test result (blood test), and (3) had no detectable antiretroviral drugs in their blood sample.
MSM analysis was limited to men who reported ever having sex with another man, were aged ≥18 y, lived in the participating NHBS city, and were unaware of their HIV-positive serostatus.
PWID analysis was limited to men and women who injected drugs not prescribed to them in the past 12 mo, were aged ≥18 y, lived in the participating NHBS city, and were unaware of their HIV-positive serostatus.
Discussion
Substantial numbers of MSM and PWID unaware of their HIV infection reported missed opportunities for earlier diagnosis. Approximately half of unaware MSM and PWID who reported not having been tested in the past year reported not being offered HIV testing by any clinician despite having seen one. Many HIV infections among MSM and PWID could be diagnosed sooner if HIV testing were more frequently offered during clinical visits.
This study had limitations. Data were self-reported and may be subject to social desirability bias. Whenever possible, laboratory results were used to mitigate these limitations (HIV and antiretroviral testing). Clinician visits or HIV testing may have been underreported or overreported due to recall error. Missed opportunities were defined as missing all opportunities and may underestimate prevalence of any missed opportunities among participants with multiple clinician visits in the past year. NHBS sampling methods underrepresent persons on the fringes of community social networks and may not yield generalizable data. Standard response rates cannot be calculated. The unaware sample size was small, preventing statistical weighting or weighted analyses. Observed percentages of being unaware were lower than others,2 especially for MSM, likely because NHBS data are from large cities with expanded testing services.
Eliminating missed opportunities for HIV testing and diagnosis in health care settings may reduce HIV transmission, especially among high-risk groups. Clinicians should routinely screen patients for HIV and identify persons with ongoing risk to ensure they are screened annually.3
Section Editor: Jody W. Zylke, MD, Deputy Editor.
References
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