A population-based study of HIV testing practices and perceptions in 4 U.S. states

OBJECTIVE: To evaluate testing practices and perceptions of HIV risk among a geographically diverse, population-based sample of sexually active adults who reported behaviors that could transmit HIV. DESIGN: Secondary analysis of the Centers for Disease Control and Preventions Behavioral Risk Factor Surveillance System (BRFSS) 2000 survey. PATIENTS/PARTICIPANTS: Sexually active adults less than 50 years old, who completed the Sexual Behavior Module of the BRFSS 2000 survey administered in 4 U.S. states. MEASUREMENTS AND MAIN RESULTS: Nineteen percent of the study population reported one or more behaviors in the past year that increased their risk of HIV infection (men 23%; women 15%). In this subgroup at any increased risk of HIV infection, 49% reported having had an HIV test in the past year. For 71% of those tested, the HIV test was self-initiated. Younger age was the only factor independently associated with whether or not individuals with behaviors that increased their risk of HIV infection had had a recent HIV test. Among the 51% of individuals at risk who reported no recent HIV test, 84% perceived their risk as low or none. CONCLUSIONS: In this study, about half of the individuals who reported behaviors that could transmit HIV had not been recently tested for HIV. Of those not tested, most considered their risk of HIV to be low or none. Interventions to expand HIV testing and increase awareness of HIV risk appear to be needed to increase early detection of HIV infection and to reduce its spread.     

Discordance of voluntary HIV testing with HIV sexual risk-taking and self-perceived HIV infection risk among social media-using black,Hispanic, and white young-men-who-have-sex-with-men (YMSM)

Discordance between self-perceived HIV risk and actual risk-taking may impede efforts to promote HIV testing among young adult men-who-have-sex-with-men (YMSM) in the United States (US). Understanding the extent of, and reasons for, the discordance of HIV risk self-perception, HIV risk-taking and voluntary HIV testing among black, Hispanic and white YMSM could aid in the development of interventions to increase HIV testing among this higher HIV risk population. HIV-uninfected 18–24-year-old black, Hispanic, and white YMSM were recruited from across the US through multiple social media websites. Participants were queried about their voluntary HIV testing history, perception of currently having an undiagnosed HIV infection, and condomless anal intercourse (CAI) history. We assessed the association between previous CAI and self-perceived possibility of currently having an HIV infection by HIV testing status using Cochran-Mantel-Haenszel testing. Of 2275 black, Hispanic and white social media-using 18–24 year-old YMSM, 21% had never been tested for HIV voluntarily, 87% ever had CAI with another man, 77% believed that it was perhaps possible (as opposed to not possible at all) they currently could have an undiagnosed HIV infection, and 3% who reported CAI with casual or exchange partners, but had not been tested for HIV, self-perceived having no possibility of being HIV infected. Of 471 YMSM who had not been HIV tested, 57% reported CAI with casual or exchange partners, yet self-perceived having no possibility of being HIV infected. Per the Cochran-Mantel-Haenszel test results, among those reporting HIV risk behaviors, the self-perception of possibly being HIV-infected was not greater among those who had never been tested for HIV, as compared to those who had been tested. Future interventions should emphasize promoting self-realization of HIV risk and translating that into seeking and accepting voluntary HIV testing among this higher HIV risk population.     

Voluntary testing for HIV among a sample of Tanzanian teachers: a search for socio-demographic and socio-psychological correlates

Knowledge of HIV status is paramount in prevention, treatment and care. This study determined the prevalence and factors associated with testing for HIV. We collected data through a cross-section questionnaire survey among 918 primary school teachers in Mwanza region, Tanzania (mean age 38.4 years). About 20% (181) of the participants had voluntarily tested for HIV. Teachers who: were aged between 21 to 30 years, had easy access to HIV testing services, had a partner with tertiary education, and perceived their health status positively were significantly more likely to have tested for HIV. Teachers who had tested for HIV were significantly less likely: to perceive that it is not necessary to test for HIV in absence of vaccine or cure for HIV/AIDS; to support that only people who suspect that they are HIV infected should test for HIV; and to believe that HIV infected people are likely to die quicker if they are tested for HIV and be informed about their positive results. The results of this study underscore the need to promote positive views of voluntary testing for HIV among Tanzanian teachers.     

Correlates of HIV infection among patients with mental illness in Brazil

People living with mental illness are at increased risk for HIV. There are scarce data on correlates and prevalence of HIV infection, and none with a nationally representative sample. We report on correlates of HIV infection from a cross-sectional national sample of adults receiving care in 26 publicly funded mental health treatment settings throughout Brazil. Weighted prevalence rate ratios were obtained using multiple log-binomial regression modeling. History of homelessness, ever having an STD, early age of first sexual intercourse before 18 years old, having suffered sexual violence, previous HIV testing, self-perception of high risk of HIV infection and not knowing one's risk were statistically associated with HIV infection. Our study found an elevated HIV seroprevalence and correlates of infection were not found to include psychiatric diagnoses or hospitalizations but instead reflected marginalized living circumstances and HIV testing history. These adverse life circumstances (history of homelessness, having suffered sexual violence, reporting a sexually transmitted disease, and early sexual debut) may not be unique to people living with mental illness but nonetheless the mental health care system can serve as an important point of entry for HIV prevention in this population.     

HIV testing practices among men who have sex with men in Buenos Aires,Argentina

The objective of the study was to explore HIV-testing practices among men who have sex with men (MSM) in Buenos Aires, Argentina, in light of current international health guidelines that recommend frequent HIV testing for MSM who engage in high-risk behavior. Participants, who were recruited using respondent-driven sampling (RDS), were 500 mostly young, nongay-identified MSM of low socioeconomic status, high levels of unemployment, living mainly in the less-affluent areas surrounding Buenos Aires, and lacking health insurance. They provided blood samples for HIV testing and responded to a Computer Assisted Self Interview. Fifty-two percent had never been tested for HIV, and 20% had been tested only once; 17% were found to be HIV infected, of whom almost half were unaware of their status. Main reasons for never having tested previously were: not feeling at risk, fear of finding out results, and not knowing where to get tested. Among those previously tested, men had been tested a median of 2 times with their most recent test having occurred a median of 2.7 years prior to study enrollment. Of those who had not tested positive before entering the study, only 41% returned for their results. HIV testing was infrequent and insufficient for early detection of infection, entry into treatment, and protection of sexual partners. This was particularly the case among nongay-identified MSM. Testing campaigns should aim to help MSM become aware of their risk behavior, decrease fear of testing by explaining available treatment resources and decreasing the stigma associated with HIV, and by publicizing information about free and confidential testing locations. Rapid HIV testing should be made available to eliminate the need for a return visit and make results immediately available to individuals who are tested.     

HIV Testing in Substance Abusers

HIV testing among substance abusers in the United States is a significant public and individual health issue in need of further examination. We analyzed interview data gathered over 15 months in 1992 and 1993 from 2315 patients on presentation for addiction treatment to determine the frequency of and factors associated with previous HIV testing. Among this group of alcohol, heroin, and cocaine abusers, 53% (1231) reported previous HIV testing. Although in bivariate and multivariable analyses those with identifiable risk factors for HIV were more likely to have been tested, 27% of injection drug users, 38% with multiple sexual partners, and 39% of those with a history of a sexually transmitted disease (STD) had not been HIV tested. Other factors associated with previous HIV testing included having a primary care physician, the primary care physician’s awareness of the patient’s substance abuse problem, and having received prior addiction care. However, 38% of substance abusers who had previously received addiction treatment beyond detoxification had not been tested. Of those tested, 10% (n = 122) reported a positive test, and 7% (n = 81) had not received the test results. Of those with positive test results, 37% were not injection drug users. Promotion of HIV testing among alcohol and other drug abusers in both medical and substance abuse treatment settings should be a priority.     

Decisional Balance, Perceived Risk and HIV Testing Practices

Improving our understanding of how individuals decide to take an HIV test is essential for designing effective programs to increase testing. This paper assesses the relationship of decisional balance and perceived risk to HIV testing history in a cross-sectional community sample of 1523 HIV-negative men and women at risk due to drug use or sexual behavior. We developed scales to measure perceived advantages (pros) and perceived disadvantages (cons) of taking an HIV test and assessed their content using factor analysis. Perceived risk was highly related to the pros and cons scales. Multivariate analyses revealed that the pros scale had positive associations with having ever tested and the number of tests taken, while the cons scale had negative associations with these testing measures. Perceived risk was not related to testing practices. These results suggest that interventions to increase HIV testing need to address anticipated positive and negative outcomes of getting tested.     

Sexual Harassment, Sexual Coercion, and HIV Risk Among U.S. Adults 18-49 Years

Sexual harassment and sexual coercion have received considerable public attention. However, the extent of these problems nationally and the breadth of their health consequences are not fully understood. We estimated the national prevalence of sexual harassment and sexual coercion, and examined their relationship to HIV risk in the general U.S. population. Data came from a 1992 telephone survey of a random probability sample of 2,030 U.S. adults aged 18–49 years. Nationally, 16% of men and 33% of women reported having been sexually harassed, and 4% of men and 16% of women reported having been sexually coerced. Significantly higher HIV risk was observed among male victims of sexual harassment compared to nonvictims (32% vs. 22%), but not among women (17% vs. 14%). HIV risk for men did not differ by having experienced sexual coercion (31% vs. 23%), but female victims reported more risk behavior than nonvictims (26% vs. 13%). Greater HIV risk found among victims argues for prevention efforts that focus on their particular needs.     

Correlates of HIV/STD Testing and Willingness to Test among Rural-to-Urban Migrants in China

This study investigates socio-demographic, behavioral, psychological, and structural factors associated with self-reported HIV/STD testing and willingness to test among 1,938 Chinese migrants. Overall, 6% and 14% of participants had ever been tested for HIV and STD, respectively. The results of multivariate analyses indicate that working at entertainment sectors, engaging in commercial sex, and utilization of health care were positively associated with both HIV and STD testing. Younger age, selling blood, perceived peer sexual risk involvement, and satisfaction with life were associated with HIV testing only. Female gender, early sexual debut, multiple sexual partners, and perceived vulnerability to HIV/STD were associated with STD testing only. Male gender, having premarital sex, perceived higher severity of and vulnerability to HIV/STD, and utilization of health care were associated with willingness to be tested for both HIV and STD. Interventions designed to raise the perception of vulnerability to HIV/STD and to improve access to and utilization of health care may be effective in encouraging more HIV testing in this vulnerable population.     

Social support and mental health among adults prior to HIV counseling and testing in Durban,South Africa

Poor social support and mental health may be important modifiable risk factors for HIV acquisition, but they have not been evaluated prior to HIV testing in South Africa. We sought to describe self-perceived mental health and social support and to characterize their independent correlates among adults who presented for voluntary HIV testing in Durban. We conducted a large cross-sectional study of adults (≥18 years of age) who presented for HIV counseling and testing between August 2010 and January 2013 in Durban, South Africa. We enrolled adults presenting for HIV testing and used the Medical Outcomes Study’s Social Support Scale (0 [poor] to 100 [excellent]) and the Mental Health Inventory (MHI-3) to assess social support and mental health. We conducted independent univariate and multivariable linear regression models to determine the correlates of lower self-reported Social Support Index and lower self-reported MCH scores. Among 4874 adults surveyed prior to HIV testing, 1887 (39%) tested HIV-positive. HIV-infected participants reported less social support (mean score 66 ± 22) and worse mental health (mean score 66 ± 16), compared to HIV-negative participants (74 ± 21; 70 ± 18; p < 0.0001). In a multivariable analysis, significant correlates of less social support included presenting for HIV testing at an urban hospital, not having been tested previously, not working outside the home, and being HIV-infected. In a separate multivariable analysis, significant correlates of poor mental health were similar, but also included HIV testing at an urban hospital and being in an intimate relationship less than six months. In this study, HIV-infected adults reported poorer social support and worse mental health than HIV-negative individuals. These findings suggest that interventions to improve poor social support and mental health should be focused on adults who do not work outside the home and those with no previous HIV testing.     

Cigarette smoking and alcohol use as predictors of HIV testing in the United States: results from the 2010 National Health Interview Survey

We examined the association between HIV risk perception and HIV testing among cigarette smokers, alcohol users, dual consumers of cigarette and alcohol, and abstainers. Data were analyzed from the 2010 National Health Interview Survey of the full sample of 22,946 and separately for 1547 African Americans. Multivariate logistic regression analysis revealed that alcohol users and dual consumers were significantly more likely to perceive themselves to be at risk of acquiring HIV. Cigarette smokers and alcohol users who considered themselves to be at risk for HIV and dual consumers who reported no perceived HIV risk were more likely to have been tested for HIV than abstainers who perceived no risk of acquiring HIV. Among African Americans, dual consumers and cigarette smokers only who perceived themselves at risk for HIV were more likely to have been tested for HIV than abstainers who perceived no risk of HIV infection. This study demonstrated that among the full sample and African Americans, cigarette smoking and alcohol use were significantly associated with HIV testing regardless of HIV risk perceptions.     

Psychosocial correlates of voluntary HIV antibody testing in college students.

Although past research has examined correlates of HIV testing, much of it has focused on demographic differences between tested and nontested individuals. The present study examined psychosocial differences between individuals seeking a voluntary HIV test at a college student health center and individuals who have never had an HIV test. Variables included in the model were four components of the health belief model (perceived susceptibility, perceived severity, perceived benefits, perceived barriers), as well as perceived norms, consideration of future consequences, and risky sexual behavior. Results suggest that individuals seeking an HIV test perceived more benefits of having a test, tended to perceive fewer barriers to having a test, were higher in consideration of Future Consequences, and engaged in riskier sexual behavior than individuals never having had an HIV test. Implications for both HIV testing interventions and the health belief model are discussed.     

HIV testing practices as reported by HIV-infected patients in four European countries

HIV testing constitutes an important strategy to control the HIV epidemic, which therefore merits an observation of HIV testing practices to help improve testing effectiveness. In 2008, a cross-sectional survey among recently diagnosed (≤ 3 years) HIV-infected patients was conducted in Belgium, Estonia, Finland and Portugal. Participants were questioned about reasons for HIV testing, testing place and testing conditions. Univariate and multivariate analyses were performed. Out of 1460 eligible participants, 629 (43%) were included. Forty-one per cent were diagnosed late and 55% had never undergone a previous HIV test with perceived low risk being the primary reason for not having been tested earlier. Heterogeneity in HIV testing practices was observed across countries. Overall, tests were most frequently conducted in primary care (38%) and specialised clinics (21%), primarily on the initiative of the health care provider (65%). Sixty-one per cent were tested with informed consent, 31% received pretest counselling, 78% received post-test counselling, 71% were involved in partner notification and 92% were in care three months after diagnosis. The results showed that HIV testing is done in a variety of settings suggesting that multiple pathways to HIV testing are provided. HIV testing practice is being normalised, with less focus on pretest counselling, yet with emphasis on post-test follow-up. Major barriers to testing are centred on the denial of risk. Efforts are needed to concurrently promote public awareness about HIV risk and benefits of HIV testing and train clinicians to be more proactive in offering HIV testing.     

Perceptions of Community HIV Prevalence,Own HIV Infection,and Condom Use among Teachers in KwaZulu-Natal,South Africa

A total of 120 teachers from KwaZulu-Natal, South Africa, underwent HIV/AIDS training. As part of the study, the teachers were surveyed, before and after the training, about their perceptions of HIV prevalences among pupils, other teachers, and community members, and about their perceptions of their own HIV status. Before the training, the teachers estimated average HIV prevalences among pupils, other teachers, and other community members to be 36%, 48%, and 61%, respectively. One-third of the teachers believed that they had a 50% or greater chance of currently being infected with HIV. Male teachers and teachers with a university degree gave lower HIV prevalence estimates for other people but not for themselves. Frequency of condom use was positively related to teachers’ HIV prevalence estimates for other people. Teachers’ estimates of HIV prevalence and perceived risk of own HIV infection increased significantly after the HIV/AIDS training.     

Behavior and health beliefs as predictors of HIV testing among women: a prospective study of observed HIV testing

Much of the research examining predictors of HIV testing has used retrospective self-report to assess HIV testing. Findings. therefore, may be subject to recall bias and to difficulties determining the direction of associations. In this prospective study, we administered surveys to women in community clinics to identify predictors of subsequent observed HIV testing, overcoming these limitations. Eighty-three percent were tested. In the adjusted multivariable model, being born in the U.S., perceived benefits of testing, worries about being infected with HIV, having had more than 15 lifetime sexual partners, and having had one or more casual sexual partners in the previous three months predicted acceptance of testing. Perceived obstacles to testing predicted non-acceptance. Those who had never been tested for HIV and those tested two to five years previously had greater odds of test acceptance than those who had been tested within the last year. The findings from this study with observed testing as the outcome, confirm some of the results from retrospective, self-report studies. Participants made largely rational decisions about testing, reflecting assessments of their risk and their history of HIV testing. Health beliefs are potentially modifiable through behavioral intervention, and such interventions might result in greater acceptance of testing.

Abbreviations: HIV: human immunodeficiency virus; AIDS: acquired immune deficiency syndrome; CDC: Centers for Disease Control and Prevention; ACASI: audio computer-assisted self-interview; TRA: theory of reasoned action; HBM: Health Belief Model; STI: sexually transmitted infection; STD: Sexually Transmitted Disease; AOR: adjusted odds ratio; CI: confidence interval     

HIV testing in substance abusers.

HIV testing among substance abusers in the United States is a significant public and individual health issue in need of further examination. We analyzed interview data gathered over 15 months in 1992 and 1993 from 2315 patients on presentation for addiction treatment to determine the frequency of and factors associated with previous HIV testing. Among this group of alcohol, heroin, and cocaine abusers, 53% (1231) reported previous HIV testing. Although in bivariate and multivariable analyses those with identifiable risk factors for HIV were more likely to have been tested, 27% of injection drug users, 38% with multiple sexual partners, and 39% of those with a history of a sexually transmitted disease (STD) had not been HIV tested. Other factors associated with previous HIV testing included having a primary care physician, the primary care physician's awareness of the patient's substance abuse problem, and having received prior addiction care. However, 38% of substance abusers who had previously received addiction treatment beyond detoxification had not been tested. Of those tested, 10% (n = 122) reported a positive test, and 7% (n = 81) had not received the test results. Of those with positive test results, 37% were not injection drug users. Promotion of HIV testing among alcohol and other drug abusers in both medical and substance abuse treatment settings should be a priority.     

Lack of HIV testing and awareness of HIV infection among men who have sex with men, Beijing, China.

In China, men who have sex with men (MSM) are at high risk for HIV. However, little is known about their HIV testing behavior. From September 2001 to January 2002, we recruited 482 men through social networks and MSM venues. We conducted HIV testing and counseling, and anonymous, standardized face-to-face interviews. Eighty-two percent of participants had never tested for HIV before the study. The most common reasons for not testing were perceived low risk of HIV infection (72%), not knowing the location of test sites (56%), fear of positive test results (54%), fear of people learning about his homosexuality (47%), and fear of breach of confidentiality about test results (47%). We identified five statistically significant independent correlates of having been tested for HIV: being older, having a college degree, being more "out" (disclosing MSM activities to people), being recruited through social networks, and having a lifetime history of sexually transmitted diseases. Of 15 participants (3.1%) who tested positive for HIV in our study, 14 (93%) did not know their status before being tested in the study. The prevalence of HIV testing among MSM in Beijing is low; almost all HIV-positive men in our study were unaware of their infection. Our findings suggest an urgent need to promote HIV testing among MSM in Beijing.     

HIV testing among youth in a high-risk city: prevalence,predictors, and gender differences

While HIV is prevalent among adolescents and young adults, testing levels remain low and little is known about gender differences in HIV testing. The objectives of this study were to describe the prevalence of past-year HIV testing and evaluate associations between HIV testing and individual- and partner-level factors by gender among heterosexually experienced youth (15–24 years) in Baltimore, Maryland (N = 352). Past-year HIV testing was prevalent (60.1%) and differed by gender (69.4% among women vs. 49.6% among men, p = 0.005). For women, African-American race (AOR 3.09) and recent older partner by ≤2 years (AOR 4.04) were significantly associated with testing. Among men, only African-American race was associated with testing (OR 4.23), with no patterns identified based on risk behavior or perceived partner risk. HIV testing among adolescent and young adults was prevalent in this highly affected urban area. Findings emphasize the value of a gender lens, and provide direction for optimizing engagement in HIV testing.     

HIV testing among clients in high HIV prevalence venues: disparities between older and younger adults

The Centers for Disease Control and Prevention recommends routine human immunodeficiency virus (HIV) testing of every client presenting for services in venues where HIV prevalence is high. Because older adults (aged ≥50 years) have particularly poor prognosis if they receive their diagnosis late in the course of HIV disease, any screening provided to younger adults in these venues should also be provided to older adults. We examined aging-related disparities in recent (past 12 months) and ever HIV testing in a probability sample of at-risk adults (N = 1238) seeking services in needle exchange sites, sexually transmitted disease clinics, and Latino community clinics that provide HIV testing. Using multiple logistic regression with generalized estimating equations, we estimated associations between age category (<50 years vs. ≥50 years) and each HIV testing outcome. Even after controlling for covariates such as recent injection drug use, older adults had 40% lower odds than younger adults did of having tested in the past 12 months (odds ratio [OR] = 0.6; 95% confidence interval [CI] = 0.40–0.90) or ever (OR = 0.6; 95% CI = 0.40–0.90). Aging-related disparities in HIV testing exist among clients of these high HIV prevalence venues and may contribute to known aging-related disparities in late diagnosis of HIV infection and poor long-term prognosis.     

Frequency of HIV testing among persons with disabilities: results from the National Health Interview Survey, 2002.

We examined rates of HIV testing of persons with disabilities relative to HIV testing rates of people without disabilities in the United States. Using data from the 2002 NHIS we examined the association between self-reported disability and having ever been tested for HIV. Adults with disability were more likely than nondisabled adults to report having been tested (odds ratio [OR] = 1.56; 95% confidence interval [CI] = 1.33, 1.84). However, this association differed by dis- ability. Individuals with mental health or physical disabilities were more likely to report having been tested (OR = 1.64; 95% CI = 1.32, 2.03 and OR = 1.50; 95% CI = 1.18, 1.91, respectively); individuals with intellectual disability were least likely to report having been tested (OR = 0.27; 95% CI = 0.09, 0.84). Findings were not statistically significant within the sensory or multiple disability categories. Findings may reflect factors unique to disabled populations, including increased risk of certain HIV risk factors. Targeted outreach and provider education are needed to ensure individuals with intellectual disability receive appropriate counseling and testing.