HIV Counseling and Testing-United States, 1993

Counseling and testing are important components of state and local HIV prevention programs [1]. Analysis of national data sources indicates that HIV antibody tests are obtained from a variety of testing sites, including private physicians, hospitals, and outpatient clinics (66.7%), and publicly funded sites (33.1%) [2]. This report uses data from CDC's 1993 Behavioral Risk Factor Surveillance System (BRFSS) to examine variations in rates of use of private and public HIV counseling and testing sites by state.

In 1993, a total of 49 states and the District of Columbia participated in the BRFSS, a state-specific, population-based, random-digit-dialed telephone survey that collects information monthly from U.S. adults aged 18 years or older. Thirteen questions about HIV/AIDS-related knowledge and attitudes, and HIV antibody testing history during the preceding year were asked only of respondents aged 65 years or younger. In 1993, a total of 84,039 persons responded to these questions (state-specific range: 993 to 3,367) [3]. Data for each state were weighted by demographic characteristics and by selection probability; results are representative of persons aged 18 to 65 years in each state.

A median of 25.5% of persons (range: 14.4% [Iowa] to 37.5% [Alaska]) answered yes to the question: "Except for donating or giving blood, have you ever had your blood tested for the AIDS virus infection?" The number (weighted estimate) of adults who had ever been tested for HIV was highest in California (6.3 million).

A median of 9.6% of persons (range: 4.1% [Maine and South Dakota] to 16.9% [District of Columbia]) reported obtaining HIV antibody tests primarily for diagnostic reasons. For this study, diagnostic HIV antibody tests were defined as those administered primarily to learn infection status, rather than voluntary tests to qualify for insurance, military induction, immigration, marriage license application, or employment. Persons categorized as having obtained diagnostic HIV antibody tests were identified by one of three responses to the question "What was the main reason you had your last AIDS blood test?":

1. "To find out if infected"

2. "Because of referral by a doctor or health department or sex partner"

3. "For routine checkup." This response was included in "diagnostic" reasons to avoid excluding respondents who initiated a routine examination to determine whether they were infected with HIV.

In 43 states and the District of Columbia, at least 50% (median: 60.9%) of respondents had obtained their last diagnostic test from a private physician, health maintenance organization, or private outpatient clinic. A median of 16.2% of persons (range: 5.0% [North Dakota] to 37.6% [Mississippi]) had obtained their last diagnostic test at a publicly funded prevention site (including health departments; AIDS, sexually transmitted disease [STD], or tuberculosis clinics; and drug treatment programs).

The estimated number of persons who obtained a diagnostic test at a publicly funded site during the preceding year correlated with the number of tests reported to CDC's HIV Counseling and Testing System by publicly funded sites in each state [4].

A median of 60.7% of persons who had obtained their most recent diagnostic HIV antibody test at a publicly funded site (range: 30.8% [New Jersey] to 95.7% [Oklahoma]) received counseling with their test results. In comparison, a median of 28.2% of persons who had obtained their tests from a private site (range: 7.7% [Kentucky] to 77.3% [Oklahoma]) received counseling. In 90% of the reporting areas, the number of persons who received counseling with their HIV test results was at least 1.5 times greater for persons tested at publicly funded sites than those tested at private sites.

Editorial Note from the CDC: The findings from the 1993 BRFSS document a high degree of state-specific variability in self-reported HIV antibody tests in the United States. This variability may reflect state-specific differences in such factors as the prevalence of HIV infection, and HIV testing in high-risk groups, the presence and impact of HIV prevention programs, and age distribution. The BRFSS estimates of the number of persons last tested for voluntary or diagnostic reasons at a publicly funded clinic correlated highly with estimates from CDC's HIV Counseling and Testing System, and the median percentage of respondents ever tested for HIV (25%) is consistent with estimates based on CDC's National Health Interview Survey (22%).

Health-care visits to seek and obtain HIV tests are important opportunities to counsel persons about the risk for HIV infection and methods to reduce such risk.1 The data in this report indicate that, in most states, approximately threefold more persons reported having obtained their HIV test from a private provider than from a public site; however, persons who had obtained their test from a private provider were substantially less likely to have reported receiving counseling than those who obtained tests at a public site. This finding underscores the need for physicians and other health-care providers in private settings to offer HIV counseling at the time patients receive their HIV test results.

Limitations

The findings in this report are subject to at least two limitations.

First, the sample size of persons who reported having had an HIV antibody test in individual states did not enable stratification by other respondent characteristics. For example, state-specific sample sizes precluded analysis to determine whether specific high-risk populations that obtained HIV antibody testing also received counseling.

Second, because the BRFSS is a telephone-based system, some persons at high risk for HIV infection most likely were excluded from the survey.

The BRFSS is a unique source for information about HIV antibody testing behaviors of U.S. adults--particularly patterns of HIV testing outside of public clinics--and can be used both at the federal and state levels to improve HIV prevention and intervention programs. Questions about CT in the 1993 BRFSS were developed based on input from state health departments; subsequent BRFSS surveys may incorporate additional HIV-related behavioral questions.