High Degree of Variability in HIV Testing Throughout the US

ATLANTA–Human immunodeficiency virus (HIV) infection is one of the leading causes of morbidity and mortality in the United States. Testing for HIV, in conjunction with counseling and other preventive services, can reduce the risk for HIV infection and appropriately link infected persons to treatment. To characterize HIV testing by region, state, and sex, the Centers for Disease Control (CDC) analyzed data from the 1996 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of that analysis, which indicate a high degree of variability in HIV testing throughout the United States.

The BRFSS

The BRFSS is a state-specific, random-digit-dialed telephone survey of the US population 18 years of age and older. In 1996, all 50 states and the District of Columbia participated in the BRFSS.

The 1996 survey included 14 questions about HIV/acquired immunodeficiency syndrome (AIDS)–related knowledge and attitudes and HIV-antibody testing history. The questions were restricted to persons under age 65 years, except in California, where the questions were asked of persons under age 45 years.

In 1996, 97,006 persons responded to these questions (state-specific range, 899 to 3,653). Data were weighted by demographic characteristics and by selection probabilities. Confidence intervals were calculated using SUDAAN software to account for the complex survey design.

Survey Results

A mean of 42% of persons surveyed—range, 26% (South Dakota) to 60% (Washington, DC)—answered yes to the question “Have you ever had your blood tested for HIV?” Persons who answered “yes” were asked “What was the main reason you had your last blood test for HIV?” Responses were divided into two categories:

Those who chose to be tested for personal or health reasons (ie, voluntarily tested). These people gave responses such as “just to find out if infected,” “for routine check-up,” “doctor referral,” “sex partner referral,” “because of pregnancy,” or “other.”

Those who were tested for other reasons (eg, military induction, insurance, and employment).

A mean of 22% of persons—range, 10% (South Dakota) to 45% (Washington, DC)—reported obtaining HIV-antibody tests for voluntary reasons.

The rate of AIDS cases in 1996 was compared with HIV testing percentages in 1996. In general, in states where the AIDS rate was high, HIV testing also tended to be high (see Figure). For example, Washington, DC, had the highest AIDS rate and the highest testing percentage; Florida ranked third in both categories. In comparison, rates of overall testing and voluntary testing were lower in the Midwest, where the rate of AIDS is low.

A mean of 44% of men reported having ever been tested for HIV—range, 28% (South Dakota) to 62% (Washington, DC). A mean of 40% of women reported having ever been tested for HIV—range, 23% (North Dakota) to 57% (Washington, DC). In 45 states and Washington, DC, a greater percentage of men reported ever being tested for HIV than women. The states with the greatest difference by sex of ever being tested for HIV were North Dakota (11%), Hawaii (10%), and New York (9%). The states with the smallest differences were Alaska, Delaware (both 0.5%), and Texas (0.6%).

A mean of 20% of men reported that their most recent HIV test was voluntary—range, 8% (South Dakota) to 46% (Washington, DC). A mean of 25% of women reported that their most recent HIV test was voluntary—range, 12% (North Dakota) to 45% (Washington, DC). In 49 states, a greater percentage of women reported being voluntarily tested than men. The sex-specific difference in reports of being voluntarily tested ranged from 0.1% in New York and Indiana to 13% in California.

Editorial Note From the CDC

The findings in this report document a high degree of state-specific variability in self-reported HIV-antibody tests. Previous reports suggest that this variability probably represents state-specific differences in such factors as prevalence of HIV infection and the activities of HIV prevention and education programs.

The success of a health-promotion program depends on the level of participation of clients. Although HIV testing and counseling do not affect behavior change similarly across all population groups, in general, persons who voluntarily receive HIV testing are more likely to undergo counseling and to modify their behaviors than are those who receive testing for other reasons. As a result, tracking overall testing rates and voluntary testing rates can help target health-promotion efforts.

The findings in this report are subject to at least two limitations. First, because BRFSS excluded persons without telephones, some persons at high risk for HIV infection probably were excluded. Second, because the BRFSS relies on self-reported data, some bias is expected.

HIV testing can help reach at-risk persons with counseling and other prevention services, and link infected persons with needed health care services. General population surveys, such as BRFSS, provide data to assess the use of HIV testing services across geographical areas. However, not all persons need to be tested. The CDC recommends HIV counseling and testing services for persons with specific risk factors for HIV infection and in specific screening settings (eg, tissue donation and pregnancy). HIV prevention programs should be structured to increase the proportion of at-risk persons who receive HIV-testing services.