Vital Signs

Human Immunodeficiency Virus Testing and Diagnosis Delays — United States

Andre F. Dailey, MSPH; Brooke E. Hoots, PhD; H. Irene Hall, PhD; Ruiguang Song, PhD; Demorah Hayes, MA; Paul Fulton, Jr.; Joseph Prejean, PhD; Angela L. Hernandez, MD; Linda J. Koenig, PhD; Linda A. Valleroy, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2017;66(47):1300-1306.

Methods

Data reported to CDC's National HIV Surveillance System from 50 states and the District of Columbia through June 2017 were used to estimate the total number of persons living with HIV infection (diagnosed and undiagnosed infection, or prevalence) at year-end 2015 and the median number of years and interquartile range between infection and diagnosis (diagnosis delay) of persons with HIV diagnosed in 2015.^[8,9] The first CD4 test after HIV diagnosis and a CD4 depletion model indicating disease progression were used to estimate year of infection and the distribution of time from HIV infection to diagnosis among persons with diagnosed infection.^[9] The distribution of diagnosis delay was used to estimate the annual number of HIV infections, which includes persons with diagnosed infection and persons with undiagnosed infection. HIV prevalence (persons with diagnosed or undiagnosed HIV infection) was estimated by subtracting reported cumulative deaths among persons with HIV infection from cumulative HIV infections.

The number of persons with undiagnosed HIV infection was estimated by subtracting the number of reported cumulative diagnoses from the number of estimated cumulative infections. The percentage of undiagnosed infections was determined by dividing the number of undiagnosed infections by the total HIV prevalence.

Data from NHBS were used to determine the percentage of persons at increased risk for infection who were tested in the past 12 months and the percentage who missed opportunities for testing.* NHBS monitors HIV-associated behaviors and HIV prevalence in cities^† with high acquired immunodeficiency syndrome (AIDS) prevalence among three populations with HIV risk behaviors: MSM, persons who inject drugs, and heterosexual persons at increased risk for HIV infection.

Cross-sectional data reported in this analysis are from MSM, persons who inject drugs, and heterosexual persons at increased risk for HIV infection recruited for face-to-face interviews and HIV testing through venue-based sampling (MSM) and respondent-driven sampling (persons who inject drugs and heterosexual persons) in NHBS surveys from 2008 to 2016. NHBS sampling procedures have been previously described.^[10] Persons were eligible to participate if they resided in a participating city, could complete the survey in English or Spanish, and met cycle-specific inclusion criteria (MSM: born male, aged ≥18 years, identified as male, and had oral or anal sex with another man; persons who inject drugs: aged ≥18 years, injected drugs in the past 12 months; and heterosexual persons: male or female [not transgender], aged 18–60 years, had sex with a member of the opposite sex in the past 12 months, never injected drugs, and met low income or low education criteria).^§ For inclusion in current analyses, participants must have tested negative during the NHBS cycle, MSM must have had sex with another man in the past 12 months, and persons who inject drugs must have been male or female (not transgender). Data were analyzed by sex, age, and race/ethnicity (American Indian or Alaska Native; Asian; black or African American [blacks]; Hispanic or Latino; Native Hawaiian or Other Pacific Islander; white; and multiple race).

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*Past year testing was assessed during the interview by asking participants, "When did you have your most recent HIV test? Please tell me the month and year." A missed opportunity was defined as a visit to a health care provider in the past 12 months for a person who did not report past year HIV testing or as not being offered an HIV test at any health care visits for a person who did not report past year HIV testing and had visited a health care provider in the past year.
^†During 2008–2015, 20 cities were included; during 2016, 17 cities were included. The following cities were included in all years: Atlanta, Georgia; Boston, Massachusetts; Dallas, Texas; Denver, Colorado; Los Angeles, California; Miami, Florida; Nassau–Suffolk, New York; New Orleans, Louisiana; Newark, New Jersey; Philadelphia, Pennsylvania; San Diego, California; San Francisco, California; San Juan, Puerto Rico; Washington, D.C. Additional cities were included as follows: 2008–2015, Baltimore, Maryland; Chicago, Illinois; Detroit, Michigan; Houston, Texas; New York City, New York; Seattle, Washington; 2016, Memphis, Tennessee; Portland, Oregon; Virginia Beach/Norfolk, Virginia.
^§Social-structural variables were used to identify a representative sample for NHBS of heterosexual persons at increased risk of HIV infection. Heterosexual persons at increased risk were defined as male or female (not transgender) in a metropolitan statistical area with high AIDS prevalence, who had sex with a member of the opposite sex in the past 12 months, never injected drugs, and met low income or low education criteria. Low income was defined as not exceeding U.S. Department of Health and Human Services poverty guidelines and low education as having a high school education or less.

Table 1. Diagnoses of human immunodeficiency virus (HIV) infection and estimated median number of years infected at time of HIV diagnosis — National HIV Surveillance System, United States, 2015
Characteristic	HIV diagnosesNo. (%)	Years infected at time of diagnosis
Characteristic	HIV diagnosesNo. (%)	Median	Interquartile range*	p-value^†
Total	39,720	3.0	(0.7–7.8)	—
Sex
Male	32,294 (81.3)	3.1	(0.7–7.8)	Referent
Female	7,426 (18.7)	2.4	(0.6–8.0)	<0.01
Age group at diagnosis (yrs)
13–24	8,956 (22.5)	2.4	(0.7–5.6)	Referent
25–34	13,059 (32.9)	2.6	(0.6–7.6)	0.27
35–44	7,669 (19.3)	3.5	(0.7–9.6)	<0.01
45–54	6,306 (15.9)	4.0	(0.8–10.6)	<0.01
≥55	3,730 (9.4)	4.5	(0.8–0.6)	<0.01
Race/Ethnicity
American Indian or Alaska Native	195 (0.5)	3.4	(0.7–7.7)	0.06
Asian	938 (2.4)	4.2	(0.9–8.2)	<0.01
Black or African American	17,331 (43.6)	3.3	(0.7–7.6)	<0.01
Hispanic or Latino	9,678 (24.4)	3.3	(0.7–8.2)	<0.01
Native Hawaiian or Other Pacific Islander	80 (0.2)	3.9	(0.8–8.2)	0.01
White	10,445 (26.3)	2.2	(0.6–7.6)	Referent
Multiple races	1,053 (2.7)	3.0	(0.7–8.6)	0.01
Transmission category
Male
Male-to-male sexual contact	26,459 (81.9)	3.0	(0.7–7.4)	<0.01
Injection drug use	1,343 (4.2)	2.9	(0.7–8.2)	<0.01
Male-to-male sexual contact and injection drug use	1,270 (3.9)	2.1	(0.6–7.3)	<0.01
Heterosexual contact	3,187 (9.9)	4.9	(0.8–11.5)	Referent
Female
Injection drug use	1,004 (13.5)	2.0	(0.6–5.4)	<0.01
Heterosexual contact	6,401 (86.2)	2.5	(0.6–8.5)	<0.01

*The interquartile range describes the middle 50% of values (i.e., 25% of values are less than the lower value and 25% are greater than the higher value).^† p-value is for testing the difference between two medians.

Table 2. Human immunodeficiency virus (HIV) testing in the past 12 months, reasons for not testing, and missed opportunities for testing among men who have sex with men, persons who inject drugs, and heterosexual persons* at increased risk for acquisition of HIV infection — National HIV Behavioral Surveillance, United States, 2014–2016
Characteristic	MSM, 2014^†		Persons who inject drugs, 2015^§		Heterosexual persons at increased risk, 2016^¶
Characteristic	No. in sample	No. (%)	No. in sample	No. (%)	No. in sample	No. (%)
HIV testing, past year (overall)	6,834	4,862 (71.1)	9,574	5,537 (57.8)	7,256	2,972 (41.0)
Sex
Male	6,834	4,862 (71.1)	6,905	3,962 (57.4)	3,257	1,276 (39.2)
Female	NA	NA	2,669	1,575 (59.0)	3,999	1,696 (42.4)
Race/Ethnicity
American Indian or Alaska Native	43	31 (72.1)	94	52 (55.3)	51	19 (37.3)
Asian	144	106 (73.6)	27	15 (55.6)	11	6 (54.6)
Black or African American	1,536	1,169 (76.1)	3,098	1,948 (62.9)	5,205	2,398 (46.1)
Hispanic or Latino	1,932	1,316 (68.1)	2,145	1,214 (56.6)	1,461	368 (25.2)
Native Hawaiian or Other Pacific Islander	37	31 (83.8)	15	6 (40.0)	21	5 (23.8)
White	2,789	1,951 (70.0)	3,804	2,081 (54.7)	216	58 (26.9)
Other/Multiple races	317	230 (72.6)	374	211 (56.4)	279	114 (40.9)
Age group (yrs)
18–24	1,576	1,169 (74.2)	570	312 (54.7)	1,504	628 (41.8)
25–34	2,656	2,024 (76.2)	2,317	1,379 (59.5)	1,843	870 (47.2)
35–44	1,198	836 (69.8)	2,108	1,254 (59.5)	1,401	601 (42.9)
45–54	966	588 (60.9)	2,458	1,397 (56.8)	1,727	604 (35.0)
≥55	438	245 (55.9)	2,121	1,195 (56.3)	781	269 (34.4)
Persons not tested who visited an HCP in past year	1,971	1,325 (67.2)	4,036	2,887 (71.5)	4,284	3,205 (74.8)
Persons not tested who visited an HCP in the past year but were not offered an HIV test	1,316	1,052 (79.9)	2,849	2,146 (75.3)	3,183	2,511 (78.9)
Main reason for not testing, no. (column %)
Think risk for infection is low	—	896 (45.2)	—	790 (19.6)	—	740 (17.3)
Afraid of finding out they had HIV	—	327 (16.5)	—	836 (20.8)	—	642 (15.0)
Didn't have time	—	203 (10.3)	—	467 (11.6)	—	532 (12.4)
Some other reason	—	89 (4.5)	—	195 (4.8)	—	164 (3.8)
No particular reason	—	466 (23.5)	—	1,737 (43.2)	—	2,201 (51.4)
Total	—	1,981 (100.0)	—	4,025 (100.0)	—	4,279 (100.0)

Abbreviations: HCP = health care provider; MSM = men who have sex with men; NA = not applicable.*Aged 18–60 years.^† Data include all participants with complete, valid survey data from 20 cities who reported having sex with another man in the 12 months before interview and who had negative HIV test results.^§ Data include all participants with complete, valid survey data from 20 cities who reported male or female gender and who had negative HIV test results.^¶ Data include all participants with complete, valid survey data from 17 cities who reported male or female gender, who ever had sex with a member of the opposite sex, never injected drugs, and who had negative HIV test results.