June 24, 2011
Historically, HIV testing often has been targeted based on individual risk factors. However, the demographic evolution of the U.S. HIV epidemic over the course of 30 years has gradually diminished the effectiveness of using risk-based testing to identify many HIV-infected persons who are unaware of their infections. CDC has responded to the shifting contours of the epidemic by recommending routine HIV screening for persons aged 13-64 years, and the data in this report indicate that screening according to CDC's recommendations identifies a substantial number of persons infected with HIV. During the 3-year course of ETI, 18,432 persons were newly diagnosed with HIV through ETI, and the majority of these new diagnoses came from clinical settings. In general, the number of tests conducted and new HIV infections identified in a particular venue type were strongly aligned, and the yield of new HIV diagnoses exceeded CDC's recommended screening threshold (0.1% undiagnosed prevalence) in every clinical venue in which expanded screening was implemented.
CDC encouraged participating health departments to use locally available epidemiologic data to identify and solicit participation from clinical venues that served high-prevalence communities or substantial numbers of persons from populations disproportionately affected by HIV, particularly blacks. By directing support for screening programs to sites where the yield of new diagnoses likely would represent a good return on investment, health departments were able to maximize the public health value of CDC funds. This is consistent with the venue-based perspective taken in CDC's 2006 HIV screening recommendations, which indicate that routine screening is not warranted in settings where the prevalence of undiagnosed HIV infection is found to be <0.1%.7
The continued success of HIV screening efforts in health-care settings requires the development, implementation, and maintenance of sustainable practices, including integrated staffing models, absorption of screening into an organization's clinical flow, and supportive reimbursement policies and rates that value HIV screening in a manner similar to other commonly accepted screening tests (e.g., cholesterol screening). The successful development and diffusion of such integrated screening models under ETI, in conjunction with an increased emphasis on coverage for prevention services, might increase the availability and efficiency of HIV screening in health-care settings.
The findings in this report are subject to at least two limitations. First, health departments collected information on testing events, not persons tested. Thus, the number of persons tested through ETI might be lower than that indicated by the total number of tests conducted because some persons might have been tested more than once. Second, health departments reported data in aggregate rather than at the level of an individual test event or client. Therefore, it is not possible to link individual demographic or outcome variables to determine, for example, whether newly diagnosed persons who were referred for partner services also were more likely to be successfully linked to care, or whether blacks with newly diagnosed HIV infections were more or less likely than persons of other races/ethnicities to be linked to care.
Detailed data collection is not consistent with routine screening activities, so CDC did not mandate collection of data (e.g., individual behavioral risk) that, although important, would have imposed substantial additional burden on clinical staff members implementing routine HIV screening activities. Instead, CDC limited the data it required health departments to submit to those basic demographic and outcome data necessary to ensure program integrity and assess performance against critical program objectives. Consequently, ETI raises a number of important questions that might warrant special studies in the future, including whether persons who already were aware of their HIV infection at the time of testing also were currently in care and, if not, what proportion of persons with previously diagnosed HIV infections were reengaged in care as a consequence of HIV screening efforts in health-care settings.
The National HIV/AIDS Strategy outlines goals to reduce HIV incidence, improve access to care and health outcomes for persons living with HIV, and reduce HIV-related health disparities and inequities.8 Specific objectives include increasing the proportion of persons living with HIV who are aware of their serostatus from 79% to 90% and increasing the proportion of persons with newly diagnosed HIV infections who are linked to clinical care within 3 months of their HIV diagnosis from 65% to 85%.8 CDC's experience through ETI suggests that to meet those goals, health departments, clinical-care providers, and CBOs should continue to forge partnerships that advance implementation of routine HIV screening in clinical venues and targeted testing in community settings, particularly those that serve populations disproportionately affected by HIV, and ensure that persons newly diagnosed with HIV through such screening activities are effectively linked to care.
Ultimately, achieving the broader National HIV/AIDS Strategy prevention goals of reducing HIV incidence and transmission will require more than strengthening mechanisms for identifying persons with undiagnosed HIV infection and linking these persons to care. Persons with HIV must enter and progress along a spectrum of care to reduce their risk for transmission: ETI focused on the first two elements of this spectrum (diagnosis and linkage to care). However, for efforts like ETI to translate into better individual and population-level outcomes, persons infected with HIV must be engaged and retained in care, receive and adhere to effective treatment with HAART to maximize viral load suppression, and have access to ongoing prevention and support services, including risk-reduction counseling and other evidence-based behavioral interventions, partner services, substance use and mental health treatment, and case management. At present, attrition is substantial, such that only an estimated 19% of the HIV-infected population has achieved viral load suppression.9 To improve outcomes across this spectrum, CDC is working with its grantees, partners, and other federal agencies (e.g., the Health Resources and Services Administration) to develop, evaluate, and support the infrastructure and strategies needed to create a seamless integration of prevention, care, case management, and social services for persons living with HIV.
* Among the 25 jurisdictions, 23 (California; Los Angeles County, California; Chicago, Illinois; Connecticut; Florida; Maryland; Georgia; Louisiana; Massachusetts; Michigan; Missouri; New Jersey; New York; New York City, New York; North Carolina; Ohio; Pennsylvania; Philadelphia, Pennsylvania; South Carolina; Tennessee; Houston, Texas; Virginia; and District of Columbia) were funded for the full 3 years of the initiative. An additional two jurisdictions (Texas and Mississippi) received 2 years of funding, beginning in year 2 of the initiative.
† Persons were defined as being newly diagnosed with HIV based on the absence of evidence to the contrary. Operationally, this means that 1) during the testing encounter, the person indicated that he or she had not previously received a diagnosis of HIV infection and 2) the health department had no record of a previous diagnosis in its HIV surveillance system.
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