New York City (NYC) bears one of the highest burdens of HIV in the country, with more than 110,000 city residents living with HIV/AIDS, representing approximately 10% of those infected nationally1,2 and approximately 6.4% of estimated incident infections nationally.3,4 The Bronx, one of NYC's 5 boroughs, has a crude death rate from HIV of 21.9 per 100,000, almost double the City's overall rate of 12.8 HIV deaths per 100,000.5 The Bronx has high rates of new HIV diagnoses (56.8 per 100,000) and reported people living with HIV/AIDS (PLWHA) as a percent of the population (1.8%), compared with the city's overall rates of new HIV diagnoses (45.8 per 100,000) and reported PLWHA as a percent of the population (1.4%).6
National estimates indicate that approximately 21.0% of HIV-infected people are not yet diagnosed7; the proportion that is HIV infected but not yet diagnosed in NYC is not known, but is likely setting dependent and in the range of 5%–28%.8,9 There is reason to believe that the Bronx has a substantial population who are HIV-infected but not yet diagnosed based on the relatively high proportion of Bronx residents who live in poverty,10 a factor associated with HIV infection.11,12 The Bronx also has high rates of sexually transmitted diseases13 that are both biologically associated with HIV acquisition and markers of sexual risk behavior.14
HIV testing is a major part of the nation's HIV prevention strategy15; prompt determination of HIV status through HIV testing offers many benefits to the individual and the community, through entry into medical care, initiation of treatment, and earlier potential for viral load suppression.16,17 In accordance with these benefits, the Centers for Disease Control and Prevention (CDC) now recommends routine, opt-out HIV testing for those aged 13–64 years in all health-care settings, and HIV screening at least annually for anyone at high risk of HIV.18 Furthermore, men who have sex with men (MSM) with multiple or anonymous partners or illicit drug use are advised to be tested every 3–6 months.19 Despite these recommendations, largely adopted by states,20 routine HIV screening remains an elusive goal; data from the National Health Interview Survey (NHIS) show that only 44.6% of adults have ever been tested for HIV.21
As the current HIV epidemic remains concentrated in urban areas,22 community-wide urban testing programs have been initiated. After Washington, DC, launched Come Together DC—Get Screened for HIV in 2006, increases were noted in the number of publicly funded HIV tests performed, the proportion of persons self-reporting an HIV test in the past 12 months, and the proportion of persons newly diagnosed with HIV who also had a CD4 count within 3 months.23,24 Furthermore, these findings were accompanied by a decrease in the overall number and rate of newly diagnosed AIDS cases.24 From 2007 to 2010, several other jurisdictions launched similar initiatives, including Oakland, California (Get Screened Oakland, 2007), Bronx, New York (The Bronx Knows, 2008), and Miami, Florida (Test Miami, 2009), among others; to date, published outcomes from these campaigns are limited.
In June 2008, NYC launched The Bronx Knows, a 3-year initiative with dual goals of testing every Bronx resident who had never been screened for HIV and linking those who tested positive to HIV care and services. The Bronx was selected for its high HIV prevalence and death rate and in response to requests from community leaders that NYC Department of Health and Mental Hygiene (DOHMH) launch an HIV testing initiative. Furthermore, productive collaborations between DOHMH and Bronx clinics and hospitals already existed,25 and the already high testing percentage in the Bronx (40% vs. 17%–30% in the other NYC boroughs) provided an opportunity to establish HIV testing as a normative health behavior in the adult population.26 Although several Bronx hospitals and clinics already received DOHMH funding for HIV testing before the initiative, The Bronx Knows provided additional financial support for funded partners and others without this history; technical assistance was also provided. A borough-wide coordinated social marketing campaign was also conducted (Fig. 1). Partner agencies agreed to publicly support the mission of expanded HIV screening, participate in workshops, and report aggregate HIV testing data to DOHMH. By the second anniversary of its launch, more than 385,000 HIV tests had been performed in the borough, exceeding the initiative's 3-year goal of 250,000.27 However, the population-based impact of these efforts had not been fully evaluated.
While awaiting data on prespecified endpoints that will comprise the formal evaluation of The Bronx Knows initiative for the 2008–2011 period of its full duration, we analyzed available data to assess population-based changes in HIV testing and diagnosis in Bronx since 2005. Specifically, we used NYC's Community Health Survey (CHS) and HIV/AIDS surveillance data to (1) evaluate changes in population-based estimates of HIV testing among Bronx adults aged 18–64 years (between 2005 and 2009), (2) identify factors associated with having been tested in the past 12 months (2009 only), and (3) analyze changes in the proportion of concurrent HIV/AIDS diagnoses (between 2005 and 2009) and assess their concordance with changes in testing in this population.
Survey Data Collection and Survey Sample
The NYC DOHMH CHS is an annual random-digit dial telephone survey conducted among approximately 10,000 noninstitutionalized adults (≥18 years) using a computer-assisted telephone interview format. The survey, first administered in 2002, has always efficiently used this important and innovative technology.28 A stratified sample design is used to allow estimation at the neighborhood level. Sampling and attempts to contact homes were performed as per the CHS protocol.29 In 2005, only homes with a landline telephone were sampled; in 2009, homes with both landlines and cell phones were sampled. Of the 2009 final sample, 5.9% were adults who could only be contacted by cell phone.29 Adults aged 18–64 years were selected for analysis, because this age group most closely aligns with the 2006 CDC recommendations that all patients aged 13–64 years in health-care settings should be screened for HIV.18
The CHS survey instrument, designed to collect self-reported data, is modeled after CDC's Behavioral Risk Factor Surveillance System (BRFSS) and includes questions about HIV testing behavior and other health behaviors, health status, health-care access, and other preventive health practices. Specifically, questions about HIV testing in 2005 and 2009 included whether respondents had ever been tested and had been tested in the past 12 months. Covariates of interest include age, sex, race/ethnicity, combined annual household income (defined as percentage of federal poverty level), educational level, sexual identity, recent number of sex partners (past 12 months), recent same-sex behavior (past 12 months) among sexually active men, having a primary care provider (PCP), and having health insurance. Surveys were pretranslated into Spanish, Chinese, and Russian. In 2005 (but not 2009), a telephone translation service was used for participants who spoke only Hindi, Arabic, Farsi, or Haitian Creole.29
All laboratories in New York State are legally required to report all diagnoses of HIV and AIDS, including all HIV-related illness, all positive Western blot tests for HIV antibody, and all viral loads, CD4 values, and viral genotypes to health authorities.30 Laboratory data on NYC HIV cases are obtained from the NYC HIV Surveillance Registry, a record of all persons diagnosed in NYC with HIV since 2000 and AIDS since 1981. The NYC HIV Surveillance Registry is continuously updated with new, deduplicated diagnoses and laboratory results. Incoming diagnostic Western blot and viral load reports that cannot be matched to an existing registry record initiate a field investigation, involving medical record review, to confirm that the case meets surveillance definitions for HIV and/or AIDS,31 to record data elements to help establish a date of diagnosis, and to collect other data required for surveillance. Concurrent diagnosis is defined as an AIDS diagnosis within 31 days of an HIV diagnosis, adjusting for reporting lag. Additional details on NYC DOHMH HIV surveillance methods have been described previously.32
Statistical analysis was performed using SAS version 9.2 (Cary, NC) and SUDAAN (Research Triangle Institute, NC). Survey data were weighted as part of the analysis. Primary weights, to account for unequal selection probabilities, consisted of the number of adults in each household divided by the number of residential telephone lines. Poststratification weights, to adjust the sample estimates according to the precise age, race/ethnicity, and sex composition of each neighborhood based on the 2000 US Census, were also applied (as described previously).33 In 2009, responses were also weighted to account for the distribution of the adult population comprising 3 telephone usage categories (landline only, landline and cell phone, and cell phone only) using data from the 2008 NYC Housing and Vacancy Survey.29 For all 5 boroughs, the analytic sample size for 2005 was 9818 (79.3% of eligible households contacted); the analytic sample size for 2009 was 9934 (88% of eligible households contacted with a landline agreed to cooperate; 97% of eligible households contacted with a cell phone only agreed to cooperate).29
Prevalence estimates and 95% confidence intervals (CIs) of ever and past 12-month HIV testing were calculated for 2005 and 2009. Prevalence estimates and 95% CI of past 12-month HIV testing were also calculated for all covariates of interest for 2005 and 2009. The t tests were used to compare the weighted prevalence estimates between 2005 and 2009, both overall and among subpopulations.
Multivariable logistic regression was used to assess independent determinants of past 12-month HIV testing in 2009. Modeling was performed using past 12-month HIV testing rather than ever testing because this measure better reflects active uptake of testing, and recent changes in testing services and promotion of testing. First, age-adjusted models were created with past 12-month HIV testing and all covariates mentioned above, except for same-sex behavior. Variables shown to be statistically significant in age-adjusted models (at P ≤ 0.25), or with the potential to act as confounders (based on clinical assessment or literature review), were entered into the multivariable model. Independent variables that did not contribute significantly to the model (at the P < 0.05 level) were individually deleted from the final model except in the case of sex (variable of known clinical importance). Age-adjusted and fully adjusted odds ratios (ORs) were reported with the corresponding 95% CI.
Final CHS survey sample sizes for Bronx adults aged 18–64 years were 1224 in 2005 and 1232 in 2009. The 2009 weighted population aged 18–64 years (793,000) is similar to the 2009 NYC DOHMH intercensal population estimate aged 18–64 years (860,418, representing 62% of the 2009 estimated Bronx population).34 Additionally, the 2009 weighted population roughly reflects the 2009 estimated Bronx population by sex and race ethnicity.34 Of note, most Bronx adults aged 18–64 years are black or Hispanic; non-Hispanic white residents represent just 14.3% of the 2009 weighted population and 11.9% of the 2009 estimated Bronx population.
Estimates of the proportion of the Bronx population reporting HIV testing increased significantly between 2005 and 2009. Ever HIV testing increased from 69.3% (95% CI: 65.7 to 72.7) to 79.1% (95% CI: 75.9 to 81.9), a relative increase of 14.1% (P < 0.001). Past 12-month HIV testing increased by an even greater degree, from 36.9% (95% CI: 33.5 to 40.5) to 48.8% (95% CI: 45.0 to 52.7), a relative increase of 32.2% (P < 0.001).
Past 12-month HIV testing also increased between 2005 and 2009 among various Bronx subpopulations (Table 1). Significant increases were noted among certain age groups, males, race/ethnicities, economic strata, educational strata, sexual identities, and by PCP and health-insurance status. The most significant increases were noted among those aged 24–44 years (40.5%–58.1%; relative increase, 43.5%; P < 0.001), men (31.9%–45.8%; relative increase, 43.6%; P = 0.001), non-Hispanic blacks (42.0%–59.0%; relative increase, 40.5%; P < 0.001), Hispanics (37.0%–54.0%; relative increase, 45.9%; P < 0.001), those with a combined annual household income of less than 200% of the federal poverty level (40.1%–55.7%; relative increase, 38.9%; P < 0.001), those with less than a high school education (39.6%–58.0%; relative increase, 46.5%; P = 0.001), those with a heterosexual identity (35.9%–48.4%; relative increase, 34.8%; P < 0.001) or bisexual identity (54.7%–94.5%; relative increase, 72.8%; P < 0.001), those with a PCP (38.8%–49.9%; relative increase, 28.6%; P < 0.001), and those with health insurance (38.3%–51.6%; relative increase, 34.7%; P < 0.001). The only significant decrease in past 12-month HIV testing among Bronx subpopulations was among whites (33.2%–16.9%; relative decrease, 49.1%; P = 0.020).
Correlates of HIV Testing, 2009
Among Bronx adults in 2009, age, non-white race/ethnicity, bisexual identity and health-insurance status were independently correlated with being tested in the past 12 months (Table 2). Specifically, in both the age-adjusted and fully adjusted models, odds of past 12-month testing were higher among Bronx adults aged 24–44 years compared with those aged 45–64 years, all non-white racial/ethnic groups compared with whites, bisexuals compared with heterosexuals, and those with health insurance compared with those without it. The most significant independent determinants of recent HIV testing were black race (OR: 8.4, 95% CI: 4.0 to 17.6), Hispanic ethnicity (OR: 7.1, 95% CI: 3.4 to 15.0), Asian/Pacific Islander or other race (OR: 6.5, 95% CI: 2.2 to 19.0), and bisexual identity (OR: 13.9, 95% CI: 2.1 to 93.5). Combined annual household income, educational level, number of sexual partners, or PCP status were not independent correlates of past 12-month HIV testing.
Comparison in Proportion of Concurrent HIV/AIDS Diagnoses, 2005 Versus 2009
Overall, the proportion of concurrent HIV/AIDS diagnoses among Bronx residents aged 18–64 years fell from 30.1% to 23.6% between 2005 and 2009, a 21.8% relative decrease (Table 3). Among Bronx subpopulations, the proportion of concurrent diagnoses fell among all age groups, men and women, all race/ethnicities except for Asian/Pacific Islanders or other race, and all transmission risk categories. Despite generally decreasing concurrency, some groups still had high proportions of concurrent diagnoses in 2009, including those aged 45–64 years (33.0%) and those with heterosexual (27.7%) or unknown (28.0%) transmission risk. Other groups had relatively low proportions of concurrent diagnoses in 2009, including those aged 18–24 (7.9%), whites (13.8%), and MSM (12.6%).
Comparison of Concurrent Diagnoses and Testing, 2005 Versus 2009
For Bronx adults aged 18–64 years, decreases in concurrent HIV/AIDS diagnoses generally occurred in the same distribution as the temporal increases in HIV testing (Table 4). This phenomenon was seen among those aged 25–44 and 45–64 years, both sexes, non-Hispanic blacks, Hispanics, heterosexuals, and MSM. However, we did not see an association between increased HIV testing and decreased concurrent diagnoses among those aged 18—24 years, whites, and Asian/Pacific Islanders or other race individuals.
The findings of this analysis support that efforts to increase testing in the Bronx during this period were effective. Although increases in testing in the past 12 months were seen across a broad range of demographic groups, there were a few subpopulations that remained unaffected. Significant increases in testing percentages were not seen, for example, among the youngest survey participants (aged 18—24 years) or among those with gay/lesbian sexual identities or MSM behavior (although an increase was observed among those who self-described as bisexual). It is worth noting that these groups already had some of the highest testing percentages in 2005 (18–24 years, 54.2%; gay/lesbian identify, 69.4%; MSM behavior, 46.2%); additionally, sample sizes for all of these groups were relatively small (n < 150) in the 2005 and 2009 Bronx CHS samples, which decreased statistical power to detect an increase in testing rates. In this context, it was relatively more difficult to both affect and measure a significant change in testing among these groups. Another unexpected finding was the decrease in testing among non-Hispanic whites from 2005 to 2009. This trend may have been an unintended consequence of the media messaging during this period that prioritized images of non-whites getting tested for HIV (because they are both the predominant population group within the borough and because non-whites are more heavily affected by HIV in NYC).35–42
According to national estimates, the percentage of persons ever tested for HIV is increasing,21,43 but the proportion of Bronx residents reporting ever having been HIV tested in 2009 (79.1%) was still substantially higher than the 2008 national estimates (44.6% and 39.9% from the NHIS and the Behavioral Risk Factor Surveillance System, respectively).21,43 Although derived from somewhat different survey methodologies, the higher Bronx testing percentage likely reflects efforts to increase knowledge of HIV serostatus in NYC as a whole and, in particular, in the Bronx.
In this analysis, self-report of health-insurance coverage was independently associated with self-report of recent testing. Although type of insurance (publicly funded vs. privately funded) was not analyzed here, it is likely that a substantial proportion of the insured had some form of publicly funded, means-tested, health-care coverage (eg, Medicaid) given that 28.3% of Bronx residents are living below the poverty line, Medicaid in NYC covers individuals reporting income up to 200% of the federal poverty line, and persons below the federal poverty level had an increase in testing. Furthermore, in the NHIS in 2009,44 60% of adults who had Medicaid coverage had ever been tested for HIV, compared with only 46% who were uninsured and 43% of those who had private health insurance. Thus, it seems that lack of health insurance (affecting 16% of the Bronx population in 200745) may be a formidable obstacle to achieving higher percentages of HIV testing. However, if the Patient Protection and Affordable Care Act brings about anticipated declines in the uninsured proportion, higher HIV testing percentages may follow.
This study has a number of limitations. Most importantly, this is an ecological analysis; we can neither confirm that the increased HIV testing prevalence caused the decrease in concurrent HIV/AIDS diagnoses in the Bronx nor can increases in HIV testing prevalence or other improvements be attributed to a single NYC initiative. However, it is plausible that these favorable changes are linked.
There are several methodological features of the CHS that could have impacted the results of this analysis. A number of important additional correlates of testing (eg, substance use, recent incarceration, or hospitalization) could not be considered in this analysis because the 2009 CHS lacked questions on those subjects. Additionally, as this is a population-based ecologic analysis, certain subpopulations had relatively few representatives in the CHS sample, including some subpopulations at high risk for HIV infection (eg, MSM).
Potential biases in the CHS data are noted. As CHS is a telephone survey, information bias may have arisen, possibly favoring overreporting of testing behavior (ie, social response bias). Alternatively, recall bias or individuals' discomfort discussing sensitive matters such as HIV risk behaviors and HIV testing may have led to underreporting of testing history.
Furthermore, the characteristics of persons excluded from the CHS sample may have changed over time. For example, the sampling frame of the CHS changed between 2005 and 2009 (from landline households only, to landline and cell phone households), although only a small proportion (5.9%) of the final sample were adults who could only be contacted by cell phone.29 Despite some demographic differences between cell phone only and landline New Yorkers, in a cell phone pilot study conducted by the NYC DOHMH in 2008, health-status indicators, including HIV testing, and risk behaviors in these groups were very similar, suggesting that the previous omission of cell phone–only New Yorkers has had little impact on estimates from earlier surveys.46 Additionally, inclusion of individuals with NYC area codes may bias the CHS sample toward those living in NYC for longer periods (ie, more recent NYC arrivals may not have yet acquired a local cell phone number), however, the impact of this phenomenon on HIV testing rates is unclear. The exclusion of institutionalized adults and those without telephones from the sample may also limit the findings' representativeness. However, the proportion of adults without any phone is likely to be low, as it has been ≤2% nationally since mid 2008 (including on the January–June 2011 NHIS).47 Regardless, exclusions or lack of representation of such persons would presumably be somewhat constant over the 5-year period of this analysis, so would not likely impact dynamic changes. Furthermore, earlier work on telephone surveys suggests that they are generally quite representative28; even some vulnerable subpopulations, such as persons with disabilities, were not underrepresented in one study based on several different surveys.48
There are also several limitations related to HIV surveillance data. For example, 2005 was the first year when all CD4 counts were reportable in NYC, and so 2009 CD4 count data are likely somewhat more complete than 2005 data. Additionally, some individuals reported to the registry may not have had a CD4 test in the month following HIV diagnosis, but did have sufficient immunological suppression to qualify for an AIDS diagnosis, leading to a possible underestimate of the proportion with concurrent HIV/AIDS diagnoses.
Despite the inherent difficulty of assessing the impact of an initiative that seeks to harness existing trends to scale-up HIV testing, the key finding of this analysis, that a decrease in the concurrent proportion co-occurred with increases in testing, underscores the potential effectiveness of large-scale efforts to impact HIV testing, care, and treatment.21,24 This finding also supports the notion that increased population-level testing may facilitate identification of individuals earlier in HIV infection (before progression to AIDS). Continued surveillance for incident HIV infections and indicators of care and treatment status among PLWHA will help determine if ongoing testing efforts result in improvement in other initiative outcomes in the Bronx, such as a reduction in HIV transmission. Specifically, the formal campaign evaluation will use surveillance data to determine diagnosis rates at The Bronx Knows testing sites and to compare primary outcomes between The Bronx Knows and non–Bronx Knows testing sites, and citywide. In the meantime, intensifying testing and linkage-to-care initiatives49 and expanding existing efforts to other jurisdictions (eg, the Brooklyn Knows initiative)50 are crucial for reducing the burden of HIV/AIDS in NYC.
The authors would like to thank Sara Bodach, Leena Gupta, and Jennifer Norton for assistance with the data analysis. Additionally, the authors would like to acknowledge the NYC DOHMH The Bronx Knows initiative team in the Bureau of HIV/AIDS Prevention and Control and all The Bronx Knows and Brooklyn Knows testing partners; a complete list of testing partners can be found at www.nyc.gov/bronxhivtesting and www.nyc.gov/brooklynhivtesting, respectively. (Testing partners can also be found on the initiative Facebook pages at www.facebook.com/NYCKnows).
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