HIV Counseling and Testing Services From Public and Private Providers -- United States, 1990

Human immunodeficiency virus (HIV) counseling and testing (CT) services are key elements of the national HIV-prevention strategy (1,2). Although the number and characteristics of persons receiving CT through publicly funded programs are monitored by CDC's CT data system (3), this system does not provide information about persons tested for HIV antibody by physicians in the private sector, hospitals, and other nonpublicly funded sources. This report summarizes data from CDC's 1990 National Health Interview Survey (NHIS) AIDS Supplement (4) regarding CT received from public and private providers.

The NHIS is an annual cross-sectional survey based on nationally representative samples of the U.S. civilian, noninstitutionalized population aged greater than or equal to 18 years. The 1990 AIDS Supplement obtained information on HIV/acquired immunodeficiency syndrome (AIDS)-related knowledge and attitudes and HIV testing from a sample of 40,513 respondents (approximately 85% of eligible respondents). Voluntary tests were HIV-antibody tests that respondents had obtained by their own choice primarily to determine infection status (i.e., excludes tests required for blood donations, military induction, employment, insurance, or other purposes). In 1990, the NHIS began collecting information on source of HIV tests for all tests reported by respondents, enabling comparison of persons reporting voluntary tests from public and private providers.* Respondents were categorized as being at increased risk for HIV infection based on self-report of any of the following (without stating which one) since 1977: 1) receiving clotting factor concentrates for hemophilia, 2) engaging in male sexual activity with other males, 3) using illegal drugs by needle, 4) immigrating to the United States from a country where HIV infection is endemic, 5) engaging in sexual activity with persons in categories 1-4, and 6) exchanging sex for money or drugs. Standard errors and significance tests were evaluated using methods that take into account the complex sample design (5). All differences noted in the text are significant at the pless than 0.05 level.

In 1990, nearly one fourth of respondents (23.8%; 95% confidence interval [CI]=23.1-24.4) reported having been tested at least once; 15.9% (95% CI=15.4-16.4) were tested for blood donation, and 5.6% (95% CI=5.3-6.0) were tested for other required purposes. Of the respondents, 4.8% (95% CI=4.6-5.1) (representing an estimated 8.8 million adults) had obtained a voluntary HIV-antibody test to determine their infection status. For persons at increased risk (995 [2%] respondents), 45.0% (95% CI=41.2-48.8) reported having been tested at least once; 25.1% (95% CI=21.8-28.5) had received a voluntary test.

Private-sector providers were twice as likely to have been the source of the most recent voluntary test (Table 1). Among public providers, public health departments and AIDS clinic/CT sites were the most frequent sources reported (12.4 and 3.7%, respectively) (Table 2).

A higher percentage of persons who were at increased risk used public programs for voluntary HIV-antibody testing than did those at no increased risk (Figure 1). In addition, a higher percentage of non-Hispanic blacks and Hispanic adults used public programs than did non-Hispanic whites; a higher percentage of persons below the poverty level and persons who had fewer years of education used public programs than did those above the poverty level and those with more years of education (Figure 1).

Among all persons obtaining voluntary tests, 45.4% reported receiving pretest counseling and 30.8% reported receiving posttest counseling (Table 3). Rates of pre- and posttest counseling were higher from public sources (58.3% and 43.2%, respectively) and among persons at increased risk (65.6% and 53.0%). Rates of counseling were also higher for blacks and persons below the poverty level.

Reported by: Behavioral and Prevention Research Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs; Illness and Disability Statistics Br, Div of Health Interview Statistics, National Center for Health Statistics, CDC.

Editorial Note

Editorial Note: Important purposes of HIV CT are to assist in promoting behavior changes that will reduce the risk for transmission (6) and to detect HIV infection in persons so that their need for medical treatment and other services can be assessed (1,2). Previous reports have provided information about tests performed in publicly funded sites that report data to CDC (7). Although questions regarding AIDS have been included as a special supplement to the NHIS since 1987, the 1990 NHIS is the first survey in which data on the source of HIV-antibody testing were obtained, enabling examination of national estimates of respondent-reported testing experience in both public and private settings.

Because rates of CT derived from the NHIS are based on respondents' self-reports of their experience, they may be subject to recall bias or other reporting errors. For example, differing rates of counseling from the NHIS and from CDC program data may reflect differences in activities the NHIS respondents considered to be counseling and those activities reported by programs. Of NHIS respondents reporting voluntary tests from public providers, 58.3% reported receiving pretest counseling; in comparison, the CDC CT data system indicated that nearly all persons received pretest counseling.

The estimated number of persons who reported receiving publicly funded HIV-antibody tests in the 1990 NHIS is consistent with the number of publicly funded tests reported to the CDC CT data system. In addition, the NHIS finding that about two thirds of tests are obtained from private-sector sources is consistent with data from Oregon, which are from a required HIV-antibody test reporting system in that state (8).

The NHIS estimate of adults having one or more HIV risk factors (2%) is low when compared with findings from other national surveys (9,10). Because the NHIS is a general health survey conducted by personal interviews in the household, the prevalence of some sensitive behaviors associated with HIV infection may be under- reported. In addition, the NHIS represents persons living in households, which may exclude disproportionate numbers of the homeless or runaway youth or persons using illegal drugs. Despite these limitations, in the NHIS data, self-reported risk is strongly associated with receiving CT.

Public programs must continue providing CT and other services to their clients. In addition, because most voluntary tests are performed in private settings, physicians in the private sector and hospitals also should be encouraged to provide appropriate services to persons receiving HIV tests, including pretest and posttest counseling; to refer infected persons for medical treatment, partner notification, and other services; and to remain current regarding appropriate CT messages.

References

1. Roper WL. Current approaches to prevention of HIV infections. Public Health Rep 1991;106:111-5.

2. Hinman AR. Strategies to prevent HIV infection in the United States. Am J Public Health 1991;81:1557-9.

3. CDC. CTS summary record database: U.S. total, 1990 annual report. Atlanta: US Department of Health and Human Services, Public Health Service, 1991.

4. Hardy AM. AIDS knowledge and attitudes for October-December 1990: provisional data from the National Health Interview Survey. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1991. (Advance data no. 204).

5. Shah BV. SESUDAAN: standard errors program for computing of standardized rates from sample survey data. Research Triangle Park, North Carolina: Research Triangle Institute, 1981.

6. Higgins DL, Galvotti C, O'Reilly KR, et al. Evidence for the effects of counseling and testing on risk behaviors. JAMA 1991;266:2419-29.

7. CDC. Publicly funded HIV counseling and testing -- United States, 1991. MMWR 1992;41:613-7.

8. CDC. Testing for HIV in the public and private sectors -- Oregon, 1988-1991. MMWR 1992;41:581-4.

9. Fay RE, Turner CF, Klassen AD, Gagnon JH. Prevalence and patterns of same-gender sexual contact among men. Science 1989;243:334-48.

10. CDC. Number of sex partners and potential risk of sexual exposure to human immunodeficiency virus. MMWR 1988;37:565-8.

• Respondents who reported receiving tests from doctors or health maintenance organizations, hospitals or emergency rooms, or employer clinics were placed in the "private provider" category even though some tests may have been obtained from public hospitals.

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