Kinsler, Janni J. PhD*; Cunningham, William E. MD, MPH*; Davis, Cynthia MPH†; Wong, Mitchell D. MD, PhD*
From the *Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California; and †Charles R. Drew University of Medicine and Science, Lynwood, California
This research was supported by the Health Resources and Services Administration (grant no. 1H97HA00203-01). Dr. Cunningham also received partial support from the NIMH (R-01 #MH69087), the UCLA-Drew Project Export, NIH, National Center on Minority Health & Health Disparities (P20-MD00148-01), and the UCLA Center for Health Improvement in Minority Elders/Resource Centers for Minority Aging Research, NIH, National Institute of Aging (AG-02-004).
Correspondence: Janni J. Kinsler, PhD, Department of Health Services, UCLA School of Public Health, 10833 LeConte Ave., Room 31-254A CHS, Los Angeles, CA 90095-1772. E-mail: firstname.lastname@example.org.
Received for publication April 7, 2006, and accepted September 11, 2006.
HIV COUNSELING AND TESTING ARE fundamental to HIV prevention strategies in the United States. This prevention strategy relies on the underlying premise that knowledge of HIV serostatus provides the basis for patient-centered risk reduction counseling.1 Therefore, the impact of HIV counseling and testing may be greatly reduced if persons tested for HIV do not return to receive HIV test results and posttest counseling. This failure to return represents missed opportunities for preventing infections and offering early medical treatment, social services, and psychologic support.
Studies conducted by the Centers for Disease Control and Prevention during 2000 estimated that approximately one third of the 2 million who get tested every year do not return for results, and an estimated one fourth of positive results are never delivered.2 In U.S. sexually transmitted disease (STD) clinics, the overall rate of return for HIV test results was 44.9% in 1998.3 Other national and local studies conducted from 1998 through 2004 revealed failure to return rates across various testing sites ranging from 9.9% to 80%.4–7
Although the studies described here document a wide range in rates for failing to return for test results and posttest counseling at one point in time or over a short period of time, time trends in failure to return rates over several years have not been addressed in previous research. Changes in HIV risk behavior over the last decade suggest the possibility that HIV test return behavior may also have changed.8 If so, it would be important for public health officials, clinicians, and researchers to know, because it may affect the implementation and interpretation of HIV prevention interventions. The purpose of this study, which can be viewed as primarily historical, is to examine time trends of failure to return for HIV test results between June 1997 and December 2004 among an underserved population reached by a mobile HIV testing van program in Los Angeles, California.
From July 1997 through December 2004, the Charles R. Drew University of Medicine and Science’s Center for Community and Preventive Medicine implemented a mobile HIV testing and outreach project (MoHOP) targeting medically underserved, ethnic and minority populations in Los Angeles County. Street outreach teams experienced in working with the homeless, recent immigrants, youth, women, gay, bisexual, transgender, and transsexual populations coordinated outreach and referrals for HIV screening services. This is the only mobile van program authorized to conduct HIV testing throughout Los Angeles County. Interested individuals met the mobile van at designated sites, including such high-risk areas as South Central Los Angeles, East Los Angeles, and Skid Row. All clients received pretest counseling and were offered anonymous or confidential HIV testing.
Counselors, who were certified in HIV pre-/posttest counseling, used a standard HIV Counseling and Testing Report Form to obtain information about client demographics, most recent HIV test result, HIV testing history, sexual risk history, injection drug and substance use, and hepatitis and STD history.9 The MoHOP project staff provided testing on-site where clients lived, worked, or congregated to make it convenient for them to return to the site within 7 days to receive their test results. Clients were offered the standard HIV antibody blood test or the standard oral swab test called ORASURE. No test results were issued by telephone or mail. Individuals identified as HIV-positive were referred to an early intervention treatment program. Each HIV test, rather than each client, was assigned a unique identification number; thus, persons testing multiple times received different identification numbers for each test received.
We conducted bivariate analyses to compare demographics and behavioral characteristics of the MoHOP clients by year tested using Stata 8.0 software. A standard logistic regression analysis using year tested as a continuous variable rather than a categorical variable was used to test for a linear time trend between the proportion failing to return for test results and the year tested.10 We then conducted a multiple logistic regression analysis using year tested as a categorical variable to determine the relative odds of failure to return for HIV test results by year tested controlling for demographics, most recent HIV test result, HIV testing history, and HIV risk behaviors. This research was approved by the Institutional Review Board of the Charles R. Drew University of Medicine and Science.
A total of 9,340 clients sought HIV testing from MoHOP between July 1997 and December 2004 (54% male, 58% black, 28% Latino, mean age 34 years). Eighty-three percent of clients were heterosexual, 13% intravenous drug users, and 4% men who have sex with men. Sample characteristics by year tested are shown in Table 1.
A statistically significant time trend was found in the percentage of clients who failed to return for their test results by year tested. Failure to return rates by year tested were as follows: 18% (1997), 24% (1998), 28% (1999), 37% (2000), 43% (2001), 37% (2002), 41% (2003), and 35% (2004) (P <0.001 for adjusted and unadjusted rates) (Table 1). On average, 1.6% of clients who failed to return for their test results between 1997 and 2004 were HIV-positive. HIV-positive test result rates for clients who failed to return for their test results varied by year tested and ranged from 0.3% to 2.71% (Table 1).
Multivariate analyses showed that the adjusted odds of returning for test results significantly increased relative to 1997, the first year tested. The odds of returning for test results ranged from 1.56 (95% confidence interval [CI] = 1.21–2.00) in 1998 to 2.46 (95% CI = 1.89–3.19) in 2004 (Table 2). Failure to return for test results was more common among those testing positive (odds ratio [OR] = 2.16 compared with those testing negative; 95% CI = 1.40–3.35) (Table 2).
Failure to return for test results was also more common among women (OR = 1.18 compared with men; 95% CI = 1.07–1.31), black (OR = 1.34 compared with white; 95% CI = 1.11–1.61), Latino (OR = 1.28 compared with white; 95% CI = 1.05–1.56), and those who were older (OR ranges from 0.72–0.86 for persons older than 20 compared with age <20 years) (Table 2).
This study documented a worsening trend in failing to return for HIV test results between 1997 and 2004. Although overall rates of returning for test results were within the range reported by other studies,4–7 the rate of failing to return increased from 18% in 1997 to 35% in 2004. Throughout the 1990s, HIV risk behaviors steadily decreased, but then began to rise along with rates of STDs after 2000.11,12 These trends in risk behaviors may reflect a declining concern about the risk of contracting HIV, which might possibly explain the findings of our study.
On average, 1.6% of clients who failed to return for their test results were HIV-positive. In California, approximately 189,000 tests are performed annually, the majority of which are performed in Los Angeles County.13 If the rate of positives in our study reflects the rate of positives in all of California, on average, there may be 3,024 persons who were HIV-infected at the time of testing but did not return for their test results. These persons could have learned of their HIV status through a subsequent test. However, at best, these persons missed an important opportunity to learn of their HIV infection and delayed getting into care, and at worst, many may still be unaware of their HIV infection and are continuing to infect others.
The 7-day waiting period to receive HIV test results using the standard blood test or oral swab tests may have been an increasing barrier to returning for test results among clients testing in later years. The study population includes individuals with numerous HIV high-risk behaviors. Based on geographic areas covered by the mobile van, most individuals tested by the van are poor, many of whom are homeless or have temporary housing. Furthermore, many may have substantial social and financial barriers to returning to the various mobile van testing sites in 7 days to obtain their results. Although MoHOP serves diverse clientele in marginalized areas, the large proportion of clients who failed to return for test results has limited the effectiveness of the mobile HIV testing, counseling, and referral efforts, particularly in later years.
There are several potential strategies to address low rates of returning for test results, the most promising of which may be rapid testing. Rapid tests provide results in 20 minutes and obviate the need for individuals to return days later for their test results.14 Rapid tests are comparable to enzyme immune assays in regard to positive predictive ability, sensitivity, and specificity and are more cost-efficient than standard tests.15–17 Rapid HIV testing services have been shown to be effective in clinical settings18,19 and among hard-to-reach populations and nontraditional settings such as mobile STD/HIV clinics, needle exchange programs, and bathhouses.20,21
How quickly HIV testing programs have adopted rapid testing remains unclear. In addition, some barriers to rapid testing exist. The short shelf life of OraQuick Advance and lack of programmatic experience have resulted in some devices expiring before their use.15 Patients failing to return for their confirmatory HIV test results also remains a challenge.22 High false-negative rates were found in a population of HIV-infected children,23 indicating that further studies on the performance of rapid tests in pediatric populations are needed. Regardless, rapid tests may encourage universal and opt out testing and are intended to be universally used.
For those who receive traditional HIV testing or who fail to return for confirmatory test results using rapid testing, additional strategies to improve return rates should also be considered such as low-cost incentives to individuals. For example, bus tokens can help with transportation, which have been found to be an important barrier in populations similar to the MoHOP population.24,25 A more labor-intensive alternative might involve home visits to deliver test results, counseling, and initiate partner notification for those testing positive.26 Some persons test anonymously, however, and cannot be contacted later. Future studies need to evaluate the effectiveness and cost-effectiveness of various strategies to improve return for test result rates and associated counseling to reduce risk behaviors.
This preliminary study was conducted using 2 mobile vans, which targeted medically underserved racial/ethnic minorities residing in areas of high HIV prevalence in Los Angeles County. Thus, the time trend in failure to return rates in this population may not be representative of failure to return rates at other HIV testing sites or by other programs in the same geographic locations. It should also be noted some persons may have tested more than once with MoHOP as well as at other sites. Thus, it was not possible to control for clustering at the individual level. In addition, some individuals failing to return for one test could have returned for a subsequent test at MoHOP or another site. Although this limitation might lead to an overestimation in the numbers of persons who are unaware of their HIV diagnosis, it would not explain the apparent time trend.
Among persons receiving HIV tests at a mobile van program in Los Angeles, the proportion failing to return for test results was high and increased substantially between 1997 and 2004. Further studies need to be conducted to see whether this trend occurs in other HIV testing settings. Given the importance of identifying HIV-infected persons, understanding ways to broaden HIV testing and improve return rates is critical, especially for public health officials, clinicians, and researchers implementing and evaluating HIV prevention strategies.
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