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AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
HIV testing in US emergency departments, outpatient ambulatory medical departments, and physician offices, 1992–2010 a
Miao Tai & Roland C. Merchant
bc
a
Department of Biostatistics, Center for Statistical Sciences, School of Public Health, Brown University, Providence, RI, USA b
Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA c
Click for updates
Department of Emergency Medicine, Rhode Island Hospital, Providence, RI, USA Published online: 02 Jan 2014.
To cite this article: Miao Tai & Roland C. Merchant (2014) HIV testing in US emergency departments, outpatient ambulatory medical departments, and physician offices, 1992–2010, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 26:9, 1105-1108, DOI: 10.1080/09540121.2013.871220 To link to this article: http://dx.doi.org/10.1080/09540121.2013.871220
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
AIDS Care, 2014 Vol. 26, No. 9, 1105–1108, http://dx.doi.org/10.1080/09540121.2013.871220
HIV testing in US emergency departments, outpatient ambulatory medical departments, and physician offices, 1992–2010 Miao Taia and Roland C. Merchantb,c* a
Department of Biostatistics, Center for Statistical Sciences, School of Public Health, Brown University, Providence, RI, USA; Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA; cDepartment of Emergency Medicine, Rhode Island Hospital, Providence, RI, USA b
Downloaded by [USC University of Southern California] at 12:14 13 March 2015
(Received 29 July 2013; accepted 28 November 2013) In 1993, 2001, and 2006, the US Centers for Disease Control and Prevention (CDC) released revised recommendations aimed to expand HIV screening in health-care settings, increase the number of people who are aware of their infection, improve the health of those who are infected, and reduce HIV transmission. It is unclear how responsive health-care settings have been on a national level to these three successively revised sets of CDC recommendations. This study estimated the extent of HIV testing in US emergency departments (EDs), outpatient ambulatory medical care departments (OPDs), and physician offices among 13- to 64-year-olds from 1992 to 2010 to determine their responsiveness to CDC recommendations to expand HIV testing. The report includes data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Ambulatory Medical Care Survey (NAMCS), which are national probability sample surveys conducted by the National Center for Health Statistics (NCHS) for CDC. Over the entire study period, HIV testing was significantly greater in OPDs than in EDs (p < 0.01) and physician offices (p < 0.01). Multivariable logistic regression analysis showed that Hispanic and Black patients and those receiving Medicaid were more likely to be tested for HIV. Logistic regression tests of trend for the entire study period did not demonstrate significant increases in testing at EDs (Odds ratios [OR] 1.00 [0.97–1.03]) or OPDs (OR 1.01 [0.98–1.04]). For physician offices, there was no change in HIV testing for 1993–1999 (OR 1.03 [0.99–1.06]), but there was a relative increase for the entire study period (OR 1.04 [1.02–1.06]) because of more HIV testing in 2009 and 2010 in this setting. However, there were no differences in HIV testing for each setting for the interval years after revised CDC HIV testing recommendations were released for 1993–2001, 2002–2006, and 2007–2010. Keywords: HIV testing; CDC recommendations; NHAMCS; NAMCS; multivariable logistic regression
Introduction In 1993, 2001, and 2006, the US Centers for Disease Control and Prevention (CDC) released revised recommendations aimed to expand HIV screening in healthcare settings, increase the number of people who are aware of their infection, improve the health of those who are infected, and reduce HIV transmission (Branson et al., 2006; Centers for Disease Control and Prevention, 1993, 2001). In 1993, CDC encouraged health-care providers to ask patients routinely about their risks for HIV infection and to offer HIV counseling and voluntary testing services to patients at risk (Centers for Disease Control and Prevention, 1993). CDC also suggested that hospitals whose patients have an HIV seroprevalence of at least 1% (or AIDS diagnoses of 1.0 per 1000 patient discharges) should enact policies enabling them to offer HIV counseling and testing among patients 15- to 54years-old. In 2001, CDC recommended expanding
testing from not only acute-care hospital settings but also to additional venues in private and public sectors (Centers for Disease Control and Prevention, 2001). The current CDC recommendations, released in 2006, included further calls to expand HIV testing; changes in HIV testing methods, including nontargeted, routine, large-scale, and opt-out HIV screening for 13- to 64year-olds in all health-care settings with a prevalence of undiagnosed HIV infection of ≥ 0.1%; at least annual HIV testing of people at higher risk for HIV infection; and removal of separate signed consent for HIV testing and instead incorporation of consent for testing into the general consent for medical care (Branson et al., 2006). It is unclear how responsive health-care settings have been on a national level to these three successively revised sets of CDC recommendations. This report examines HIV testing from 1992 to 2010 among 13- to 64-year-old patients in three US healthcare settings: emergency departments (EDs), outpatient
*Corresponding author. Email: [email protected] Preliminary findings from the study were presented at the 2012 National Summit on HIV and Viral Hepatitis Diagnosis, Prevention, and Access to Care, Washington, DC, November 27, 2012.
© 2013 Taylor & Francis
1106
M. Tai and R.C. Merchant
ambulatory medical care departments (OPDs), and physician offices. The report includes data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Ambulatory Medical Care Survey (NAMCS), which are national probability sample surveys conducted by the National Center for Health Statistics (NCHS) for CDC. The objective of this study was to determine the responsiveness on a national level of these health-care settings to CDC recommendations to expand HIV testing particularly in light of the maturing HIV epidemic over this time period.
Downloaded by [USC University of Southern California] at 12:14 13 March 2015
Methods ED and OPD visits from the NHAMCS and physician offices visits from the NAMCS were analyzed using data collected for 1992–2010. The NHAMCS and NAMCS involve data collected from health-care facilities on a visit level, instead of a patient level. As such, incidence rates cannot be estimated because the same patients might be included more than once across and within healthcare settings and data-sets. To enable a uniform assessment of HIV testing utilization over time, we selected visits by patients 13- to 64-years-old, which is the age group for whom HIV screening is recommended in the 2006 CDC HIV testing recommendations. Demographic characteristics of patient visits by health-care setting were summarized. HIV testing proportions along with corresponding 95% confidence intervals (CIs) were estimated by calculating the number of visits during which testing was performed out of the total number of visits for each health-care setting per year. HIV testing data were not collected for some survey years and settings; proportions were calculated only for the years data were available. To provide some
context for testing, data on newly diagnosed HIV infections for 1993–2010 were derived from CDC surveillance reports and summarized; these estimates were not available for 1992 (Centers for Disease Control and Prevention, 2011). Student’s t-tests were used to compare HIV testing proportions across health-care settings. Logistic regression models were constructed to evaluate trends in HIV testing for each health-care setting over the study period. Multivariable logistic regression was used to identify demographic characteristics associated with greater HIV testing for each setting. Odds ratios (ORs) with corresponding 95% CIs were estimated. All analyses were adjusted as per CDC recommendations for the multistage sampling design of the surveys.
Results HIV testing proportions and corresponding 95% CIs for 13- to 64-year-olds in the three US health-care settings over the study period are shown in Figure 1. HIV testing in OPDs ranged from 0.65% to 1.63% of all visits over the study period, and was significantly greater than HIV testing in EDs (p < 0.01), which ranged from 0.19% to 0.55%. HIV testing also was higher in OPDs than physician offices (p < 0.0001), which ranged from 0.29% to 0.83%. Logistic regression tests of trend for the entire study period did not demonstrate significant increases in testing in EDs (OR 1.00 [0.97–1.03]) or OPDs (OR 1.01 [0.98–1.04]). For physician offices, there was no change in HIV testing for 1993–1999 (OR 1.03 [0.99–1.06]), but there was a relative increase for the entire study period (OR 1.04 [1.02–1.06]) because of more HIV testing in 2009 and 2010 in this setting. However, there were no differences in HIV testing for each setting for the interval
Figure 1. HIV testing and new HIV infections among 13- to 64-year-olds in emergency departments, outpatient departments, and physician offices.
Downloaded by [USC University of Southern California] at 12:14 13 March 2015
AIDS Care years after revised CDC HIV testing recommendations were released for 1993–2001, 2002–2006, and 2007–2010. Supplemental Table 1 provides the demographic characteristics of the patient visits for each year HIV testing estimates were available. HIV testing varied by demographic characteristics within and across health-care settings over the entire study period (Table 1). Hispanic and Black patients and those receiving Medicaid were more likely to be tested than white and privately insured patients, respectively, in all health-care settings. However, men and women were just as likely to be tested for HIV. In EDs, testing also was greater among those who were classified as “other” race had no health-care insurance (self-pay/no charge/other), or were patients in the northeastern region of the US. In OPDs, testing also was greater among patients without health-care insurance, and in physician offices, testing also was greater among patients in the southern region of the US. However, the demographic characteristics of those more likely to be tested varied over time within and across healthcare settings without clear trends over the study period (Supplemental Table 2).
Discussion As estimated using national probability surveys, US HIV testing did not change significantly in the three healthcare settings (EDs, OPDs, and physician offices), except for a slight increase in testing in 2009 and 2010 in physician offices. Testing did not change or changed little
1107
despite CDC’s successive recommendations to expand HIV testing. Furthermore, HIV testing did not increase significantly despite improvements in HIV testing technologies over this period, breakthroughs in antiretroviral medications to combat HIV, reductions in AIDS-related mortality, and recent efforts by CDC to streamline HIV testing methods. In addition, HIV testing varied by demographic characteristics across settings, which indicates that testing is not being utilized uniformly despite CDC recommendations. Of note, HIV testing did not change or changed slightly even though there was a slow but steady increase in the number of new HIV infections reported to CDC over the study period. Several explanations for this phenomenon are possible, but cannot be assessed with these data. First, the number of states reporting new HIV infections expanded over this time (from 26 states in 1993 to 46 states in 2010), which clearly accounts for some of the increase in HIV infections reported. Second, the yield of HIV testing could have increased over time while HIV testing remained unchanged (i.e., more infections detected per tests performed). Third, testing could have increased in other settings which lead to more cases being detected. This explanation is highly plausible, given that the databases used in this study do not account for testing performed routinely in other settings, such as blood donation centers, community-based organizations, the military, and Job Corps programs (Centers for Disease Control and Prevention, 2012). Further supporting this possibility, in August 2009, the US
Table 1. Comparison of HIV testing by demographic characteristics and health-care setting, 1992–2000. Demographic characteristics Gender Male Female Hispanic ethnicity Non-Hispanic Hispanic Race White Black Other Health-care insurance status Private Medicare Medicaid Self-pay/no charge/other Geographic region Midwest Northeast South West
Emergency departments
Outpatient departments
Physician offices
Reference 1.03 (0.87–1.21)
Reference 1.13 (0.87–1.49)
Reference 1.31 (0.99–1.73)
Reference 1.59 (1.22–2.08)
Reference 2.01(1.56–2.58)
Reference 1.58 (1.07–2.32)
Reference 2.08 (1.65–2.63) 1.52 (1.03–2.24)
Reference 2.11 (1.66–2.68) 1.91 (0.78–4.66)
Reference 2.35 (1.64–3.36) 1.47 (1.14–1.90)
Reference 1.10 (0.76–1.60) 2.02 (1.55–2.63) 2.05 (1.60–2.62)
Reference 1.04 (0.54–1.98) 2.38 (1.74–3.25) 1.84 (1.41–2.40)
Reference 0.27 (0.07–0.99) 2.04 (1.29–3.23) 1.04 (0.75–1.43)
Reference 1.64 (1.09–2.46) 1.01 (0.67–1.54) 0.86 (0.58–1.30)
Reference 1.42 (0.94–2.15) 1.56 (1.00–2.42) 0.95 (0.59–1.53)
Reference 1.36 (0.81–2.30) 2.03 (1.23–3.36) 1.33 (0.81–2.17)
Downloaded by [USC University of Southern California] at 12:14 13 March 2015
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M. Tai and R.C. Merchant
Veterans Administration revised their policy on HIV testing to permit an expansion in testing; HIV testing increased among their patients from 2.49% in 2009 to 8.56% in 2011 (Veterans Health Administration, 2012). Fourth, HIV transmission could have increased over this period while HIV testing remained unchanged. Fifth, the NHAMCS and NAMCS data might not adequately capture all HIV tests performed. The reasons why testing did not increase substantially in these three health-care settings on a national level despite CDC’s call for an expansion of testing cannot be assessed using these data. Possible reasons might include the absence of a mandate for health-care facilities and clinicians to conduct HIV screening, lack of financial support to enable testing, ignorance of the CDC recommendations, inadequate dissemination of the recommendations, and lack of support for the recommendations by health-care settings and clinicians. Health-care facilities and clinicians might increase screening if these and other barriers are eliminated. This research has several limitations. Analysis is limited by the missing years of data when HIV testing was not reported. More importantly, unrecognized sampling biases (e.g., data were not truly representative of national trends) and errors in data collection might account for an inability to determine if HIV testing changed (Cooper, 2012; Green, 2013; McCaig & Burt, 2012). Supplemental Material All Supplemental Material is available alongside this article on www.tandfonline.com - go to http://dx.doi.org/10.1080/09540 121.2013.871220
References Branson, B. M., Handsfield, H. H., Lampe, M. A., Janssen, R. S., Taylor, A. W., Lyss, S. B., & Clark, J. E.. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recommendations Report, 55(RR-14), 1–17; quiz CE11–CE14. Centers for Disease Control and Prevention. (1993). Recommendations for HIV testing services for inpatients and outpatients in acute-care hospital settings. Center for Disease Control and Prevention. MMWR Recommendations Report, 42(RR-2), 1–6. Centers for Disease Control and Prevention. (2001). Revised guidelines for HIV counseling, testing, and referral. MMWR Recommendations Report, 50(RR-19), 1–57; quiz CE51-19a51-CE56-19a51. Centers for Disease Control and Prevention. (2011). HIV Surveillance Report, 2011. Retrieved from http://www. cdc.gov/hiv/topics/surveillance/resources/reports/ Centers for Disease Control and Prevention. (2012). HIV testing in the United States baseline Report 2002–2006. Retrieved from http://www.cdc.gov/hiv/resources/reports/ pdf/AHITS_Baseline_Report.pdf Cooper, R. J. (2012). NHAMCS: Does it hold up to scrutiny? Annals of Emergency Medicine, 60, 722–725. doi:10.1016/ j.annemergmed.2012.10.013 Green, S. M. (2013). Congruence of disposition after emergency department intubation in the national hospital ambulatory medical care survey. Annals of Emergency Medicine, 61, 423–426. doi:10.1016/j.annemergmed.2012.09.010 McCaig, L. F., & Burt, C. W. (2012). Understanding and interpreting the National Hospital Ambulatory Medical Care Survey: Key questions and answers. Annals of Emergency Medicine, 60, 716–721. doi:10.1016/j.annemergmed. 2012.07.010 Veterans Health Administration. (2012). HIV testing rates in VHA 2009–2011. Retrieved from http://www.hiv.va.gov/ provider/policy/testing-rates-2011-slides.asp
AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
HIV testing in US emergency departments, outpatient ambulatory medical departments, and physician offices, 1992–2010 a
Miao Tai & Roland C. Merchant
bc
a
Department of Biostatistics, Center for Statistical Sciences, School of Public Health, Brown University, Providence, RI, USA b
Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA c
Click for updates
Department of Emergency Medicine, Rhode Island Hospital, Providence, RI, USA Published online: 02 Jan 2014.
To cite this article: Miao Tai & Roland C. Merchant (2014) HIV testing in US emergency departments, outpatient ambulatory medical departments, and physician offices, 1992–2010, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 26:9, 1105-1108, DOI: 10.1080/09540121.2013.871220 To link to this article: http://dx.doi.org/10.1080/09540121.2013.871220
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
AIDS Care, 2014 Vol. 26, No. 9, 1105–1108, http://dx.doi.org/10.1080/09540121.2013.871220
HIV testing in US emergency departments, outpatient ambulatory medical departments, and physician offices, 1992–2010 Miao Taia and Roland C. Merchantb,c* a
Department of Biostatistics, Center for Statistical Sciences, School of Public Health, Brown University, Providence, RI, USA; Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA; cDepartment of Emergency Medicine, Rhode Island Hospital, Providence, RI, USA b
Downloaded by [USC University of Southern California] at 12:14 13 March 2015
(Received 29 July 2013; accepted 28 November 2013) In 1993, 2001, and 2006, the US Centers for Disease Control and Prevention (CDC) released revised recommendations aimed to expand HIV screening in health-care settings, increase the number of people who are aware of their infection, improve the health of those who are infected, and reduce HIV transmission. It is unclear how responsive health-care settings have been on a national level to these three successively revised sets of CDC recommendations. This study estimated the extent of HIV testing in US emergency departments (EDs), outpatient ambulatory medical care departments (OPDs), and physician offices among 13- to 64-year-olds from 1992 to 2010 to determine their responsiveness to CDC recommendations to expand HIV testing. The report includes data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Ambulatory Medical Care Survey (NAMCS), which are national probability sample surveys conducted by the National Center for Health Statistics (NCHS) for CDC. Over the entire study period, HIV testing was significantly greater in OPDs than in EDs (p < 0.01) and physician offices (p < 0.01). Multivariable logistic regression analysis showed that Hispanic and Black patients and those receiving Medicaid were more likely to be tested for HIV. Logistic regression tests of trend for the entire study period did not demonstrate significant increases in testing at EDs (Odds ratios [OR] 1.00 [0.97–1.03]) or OPDs (OR 1.01 [0.98–1.04]). For physician offices, there was no change in HIV testing for 1993–1999 (OR 1.03 [0.99–1.06]), but there was a relative increase for the entire study period (OR 1.04 [1.02–1.06]) because of more HIV testing in 2009 and 2010 in this setting. However, there were no differences in HIV testing for each setting for the interval years after revised CDC HIV testing recommendations were released for 1993–2001, 2002–2006, and 2007–2010. Keywords: HIV testing; CDC recommendations; NHAMCS; NAMCS; multivariable logistic regression
Introduction In 1993, 2001, and 2006, the US Centers for Disease Control and Prevention (CDC) released revised recommendations aimed to expand HIV screening in healthcare settings, increase the number of people who are aware of their infection, improve the health of those who are infected, and reduce HIV transmission (Branson et al., 2006; Centers for Disease Control and Prevention, 1993, 2001). In 1993, CDC encouraged health-care providers to ask patients routinely about their risks for HIV infection and to offer HIV counseling and voluntary testing services to patients at risk (Centers for Disease Control and Prevention, 1993). CDC also suggested that hospitals whose patients have an HIV seroprevalence of at least 1% (or AIDS diagnoses of 1.0 per 1000 patient discharges) should enact policies enabling them to offer HIV counseling and testing among patients 15- to 54years-old. In 2001, CDC recommended expanding
testing from not only acute-care hospital settings but also to additional venues in private and public sectors (Centers for Disease Control and Prevention, 2001). The current CDC recommendations, released in 2006, included further calls to expand HIV testing; changes in HIV testing methods, including nontargeted, routine, large-scale, and opt-out HIV screening for 13- to 64year-olds in all health-care settings with a prevalence of undiagnosed HIV infection of ≥ 0.1%; at least annual HIV testing of people at higher risk for HIV infection; and removal of separate signed consent for HIV testing and instead incorporation of consent for testing into the general consent for medical care (Branson et al., 2006). It is unclear how responsive health-care settings have been on a national level to these three successively revised sets of CDC recommendations. This report examines HIV testing from 1992 to 2010 among 13- to 64-year-old patients in three US healthcare settings: emergency departments (EDs), outpatient
*Corresponding author. Email: [email protected] Preliminary findings from the study were presented at the 2012 National Summit on HIV and Viral Hepatitis Diagnosis, Prevention, and Access to Care, Washington, DC, November 27, 2012.
© 2013 Taylor & Francis
1106
M. Tai and R.C. Merchant
ambulatory medical care departments (OPDs), and physician offices. The report includes data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Ambulatory Medical Care Survey (NAMCS), which are national probability sample surveys conducted by the National Center for Health Statistics (NCHS) for CDC. The objective of this study was to determine the responsiveness on a national level of these health-care settings to CDC recommendations to expand HIV testing particularly in light of the maturing HIV epidemic over this time period.
Downloaded by [USC University of Southern California] at 12:14 13 March 2015
Methods ED and OPD visits from the NHAMCS and physician offices visits from the NAMCS were analyzed using data collected for 1992–2010. The NHAMCS and NAMCS involve data collected from health-care facilities on a visit level, instead of a patient level. As such, incidence rates cannot be estimated because the same patients might be included more than once across and within healthcare settings and data-sets. To enable a uniform assessment of HIV testing utilization over time, we selected visits by patients 13- to 64-years-old, which is the age group for whom HIV screening is recommended in the 2006 CDC HIV testing recommendations. Demographic characteristics of patient visits by health-care setting were summarized. HIV testing proportions along with corresponding 95% confidence intervals (CIs) were estimated by calculating the number of visits during which testing was performed out of the total number of visits for each health-care setting per year. HIV testing data were not collected for some survey years and settings; proportions were calculated only for the years data were available. To provide some
context for testing, data on newly diagnosed HIV infections for 1993–2010 were derived from CDC surveillance reports and summarized; these estimates were not available for 1992 (Centers for Disease Control and Prevention, 2011). Student’s t-tests were used to compare HIV testing proportions across health-care settings. Logistic regression models were constructed to evaluate trends in HIV testing for each health-care setting over the study period. Multivariable logistic regression was used to identify demographic characteristics associated with greater HIV testing for each setting. Odds ratios (ORs) with corresponding 95% CIs were estimated. All analyses were adjusted as per CDC recommendations for the multistage sampling design of the surveys.
Results HIV testing proportions and corresponding 95% CIs for 13- to 64-year-olds in the three US health-care settings over the study period are shown in Figure 1. HIV testing in OPDs ranged from 0.65% to 1.63% of all visits over the study period, and was significantly greater than HIV testing in EDs (p < 0.01), which ranged from 0.19% to 0.55%. HIV testing also was higher in OPDs than physician offices (p < 0.0001), which ranged from 0.29% to 0.83%. Logistic regression tests of trend for the entire study period did not demonstrate significant increases in testing in EDs (OR 1.00 [0.97–1.03]) or OPDs (OR 1.01 [0.98–1.04]). For physician offices, there was no change in HIV testing for 1993–1999 (OR 1.03 [0.99–1.06]), but there was a relative increase for the entire study period (OR 1.04 [1.02–1.06]) because of more HIV testing in 2009 and 2010 in this setting. However, there were no differences in HIV testing for each setting for the interval
Figure 1. HIV testing and new HIV infections among 13- to 64-year-olds in emergency departments, outpatient departments, and physician offices.
Downloaded by [USC University of Southern California] at 12:14 13 March 2015
AIDS Care years after revised CDC HIV testing recommendations were released for 1993–2001, 2002–2006, and 2007–2010. Supplemental Table 1 provides the demographic characteristics of the patient visits for each year HIV testing estimates were available. HIV testing varied by demographic characteristics within and across health-care settings over the entire study period (Table 1). Hispanic and Black patients and those receiving Medicaid were more likely to be tested than white and privately insured patients, respectively, in all health-care settings. However, men and women were just as likely to be tested for HIV. In EDs, testing also was greater among those who were classified as “other” race had no health-care insurance (self-pay/no charge/other), or were patients in the northeastern region of the US. In OPDs, testing also was greater among patients without health-care insurance, and in physician offices, testing also was greater among patients in the southern region of the US. However, the demographic characteristics of those more likely to be tested varied over time within and across healthcare settings without clear trends over the study period (Supplemental Table 2).
Discussion As estimated using national probability surveys, US HIV testing did not change significantly in the three healthcare settings (EDs, OPDs, and physician offices), except for a slight increase in testing in 2009 and 2010 in physician offices. Testing did not change or changed little
1107
despite CDC’s successive recommendations to expand HIV testing. Furthermore, HIV testing did not increase significantly despite improvements in HIV testing technologies over this period, breakthroughs in antiretroviral medications to combat HIV, reductions in AIDS-related mortality, and recent efforts by CDC to streamline HIV testing methods. In addition, HIV testing varied by demographic characteristics across settings, which indicates that testing is not being utilized uniformly despite CDC recommendations. Of note, HIV testing did not change or changed slightly even though there was a slow but steady increase in the number of new HIV infections reported to CDC over the study period. Several explanations for this phenomenon are possible, but cannot be assessed with these data. First, the number of states reporting new HIV infections expanded over this time (from 26 states in 1993 to 46 states in 2010), which clearly accounts for some of the increase in HIV infections reported. Second, the yield of HIV testing could have increased over time while HIV testing remained unchanged (i.e., more infections detected per tests performed). Third, testing could have increased in other settings which lead to more cases being detected. This explanation is highly plausible, given that the databases used in this study do not account for testing performed routinely in other settings, such as blood donation centers, community-based organizations, the military, and Job Corps programs (Centers for Disease Control and Prevention, 2012). Further supporting this possibility, in August 2009, the US
Table 1. Comparison of HIV testing by demographic characteristics and health-care setting, 1992–2000. Demographic characteristics Gender Male Female Hispanic ethnicity Non-Hispanic Hispanic Race White Black Other Health-care insurance status Private Medicare Medicaid Self-pay/no charge/other Geographic region Midwest Northeast South West
Emergency departments
Outpatient departments
Physician offices
Reference 1.03 (0.87–1.21)
Reference 1.13 (0.87–1.49)
Reference 1.31 (0.99–1.73)
Reference 1.59 (1.22–2.08)
Reference 2.01(1.56–2.58)
Reference 1.58 (1.07–2.32)
Reference 2.08 (1.65–2.63) 1.52 (1.03–2.24)
Reference 2.11 (1.66–2.68) 1.91 (0.78–4.66)
Reference 2.35 (1.64–3.36) 1.47 (1.14–1.90)
Reference 1.10 (0.76–1.60) 2.02 (1.55–2.63) 2.05 (1.60–2.62)
Reference 1.04 (0.54–1.98) 2.38 (1.74–3.25) 1.84 (1.41–2.40)
Reference 0.27 (0.07–0.99) 2.04 (1.29–3.23) 1.04 (0.75–1.43)
Reference 1.64 (1.09–2.46) 1.01 (0.67–1.54) 0.86 (0.58–1.30)
Reference 1.42 (0.94–2.15) 1.56 (1.00–2.42) 0.95 (0.59–1.53)
Reference 1.36 (0.81–2.30) 2.03 (1.23–3.36) 1.33 (0.81–2.17)
Downloaded by [USC University of Southern California] at 12:14 13 March 2015
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M. Tai and R.C. Merchant
Veterans Administration revised their policy on HIV testing to permit an expansion in testing; HIV testing increased among their patients from 2.49% in 2009 to 8.56% in 2011 (Veterans Health Administration, 2012). Fourth, HIV transmission could have increased over this period while HIV testing remained unchanged. Fifth, the NHAMCS and NAMCS data might not adequately capture all HIV tests performed. The reasons why testing did not increase substantially in these three health-care settings on a national level despite CDC’s call for an expansion of testing cannot be assessed using these data. Possible reasons might include the absence of a mandate for health-care facilities and clinicians to conduct HIV screening, lack of financial support to enable testing, ignorance of the CDC recommendations, inadequate dissemination of the recommendations, and lack of support for the recommendations by health-care settings and clinicians. Health-care facilities and clinicians might increase screening if these and other barriers are eliminated. This research has several limitations. Analysis is limited by the missing years of data when HIV testing was not reported. More importantly, unrecognized sampling biases (e.g., data were not truly representative of national trends) and errors in data collection might account for an inability to determine if HIV testing changed (Cooper, 2012; Green, 2013; McCaig & Burt, 2012). Supplemental Material All Supplemental Material is available alongside this article on www.tandfonline.com - go to http://dx.doi.org/10.1080/09540 121.2013.871220
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