Trends in HIV Testing Among U.S. Older Adults Prior to and Since Release of CDC's Routine HIV Testing Recommendations: National Findings from the BRFSS

Objective

This study examined temporal trends in HIV testing among U.S. older adults (50–64 years of age) before and after the release of CDC''s routine HIV testing recommendations in 2006.

Methods

The sample (n=872,797; 51.4% female) comprised 2003–2010 Behavioral Risk Factor Surveillance System respondents in the oldest categories to which the recommendations apply: 50–54 years (34.5%, n=301,519), 55–59 years (34.1%, n=297,865), and 60–64 years (31.3%, n=273,413). We calculated (1) four-year pooled prevalences of past-year HIV testing before and after 2006, when the recommendations were released; and (2) annual prevalences of HIV testing overall and by age category from 2003–2010. Using weighted, multivariable logistic regression analyses, we examined binary (pre- vs. post-recommendations) and annual changes in testing, controlling for covariates. We stratified the data by recent doctor visits, examined racial/ethnic differences, and tested for linear and quadratic temporal trends.

Results

Overall and within age categories, the pooled prevalence of past-year HIV testing decreased following release of the recommendations (p<0.001). The annual prevalence decreased monotonically from 2003 (5.5%) to 2006 (3.6%) (b=–0.16, p<0.001) and then increased immediately after release of the recommendations, but decreased to 3.7% after 2009 (b=0.01, p<0.001). By race/ethnicity, testing increased over time among non-Hispanic black people only. Annual prevalence also increased among respondents with recent doctor visits.

Conclusion

CDC''s HIV testing recommendations were associated with a reversal in the downward trend in past-year HIV testing among older adults; however, the gains were neither universal nor sustained over time.In 2006, the Centers for Disease Control and Prevention (CDC) began recommending routine opt-out human immunodeficiency virus (HIV) testing of all adults <65 years of age seeking health care in any setting where HIV prevalence is ≥0.1%.¹ Routine testing is an efficient, cost-effective strategy for early detection of HIV infection.² It involves screening every patient (except those who decline testing) regardless of any reported risk behaviors; therefore, it can facilitate detection of undiagnosed HIV infection among people unlikely to seek an HIV test, including those presumed to have little or no HIV risk.³Routine testing may be particularly important for older adults (i.e., those aged ≥50 years), among whom 11% of U.S. HIV infections occur. Of concern, HIV-infected older adults are disproportionately diagnosed late in the course of HIV disease.^4,5 Late diagnosis is associated with rapid progression to acquired immunodeficiency syndrome (AIDS), and it exacerbates the management of both HIV disease and the non-HIV conditions that are prevalent among older adults (e.g., hypertension).^6–9 Rates of HIV testing generally decrease with age;^10–13 however, it is unclear if the release and implementation of the recommendations have helped to improve HIV testing levels in this age group.^14,15To understand the recommendations'' potential influence on HIV testing among older adults, we examined trends in HIV testing from January 1, 2003, to December 31, 2010, among Behavioral Risk Factor Surveillance System (BRFSS) respondents in the three categories of older adulthood (50–54, 55–59, and 60–64 years of age) to which the routine HIV testing recommendations apply. The study period began four years prior to CDC''s publication of the recommendations and concluded four years thereafter, enabling us to compare HIV testing levels before and after their release. Full implementation should produce a sustained increase in testing that begins in 2007 and is most apparent among people with a recent doctor visit. This study sought to determine if:

1. The annual prevalence of past-year HIV testing increased among older adults since release of the routine HIV testing recommendations,
2. Racial/ethnic differences in past-year HIV testing exist over time among older adults,
3. The odds of testing increased more for those with vs. without a recent doctor visit since release of the recommendations, and
4. The characteristics of older testers changed over time.