Improvement needed in early HIV diagnosis and linkage to care

New data show improved diagnostic rates in areas that have focused on increasing testing.

Issue: August 2007

With as many as one-quarter of the million people with HIV in the United States unaware of their serostatus, and another 25% diagnosed but not yet in care, it is clear that there are still strides to be made regarding testing to care. Kevin Fenton, MD, PhD, director of the National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention at the CDC, discussed the challenges and opportunities involved in diagnosing and treating those with HIV at the American Conference for the Treatment of HIV, held recently in Dallas.

“The undiagnosed are more likely to be people of color,” said Fenton, who is also a member of the Infectious Disease News editorial advisory board. Researchers from a recent study found that among blacks and Hispanics, there are higher proportions of undiagnosed people with HIV than among whites. Furthermore, undiagnosed people are more likely to have been infected sexually than via IV drug use.

Researchers of another study conducted in five American cities in 2004 and 2005 found that 48% of those infected by male-to-male sexual contact were unaware of their HIV status. Although 18% of white people were unaware in this cohort, 48% of Hispanics and 67% of black people were unaware of their serostatus.

Late HIV testing

Another problem still faced is late HIV testing, Fenton said. In one study of 4,127 people with AIDS, 45% were first diagnosed with HIV within 12 months of AIDS diagnosis. “Late testers, compared with those who tested earlier in the course of HIV, were far more likely to be younger, heterosexual, less educated and they were far more likely to be either African-American or Hispanic,” Fenton said.

Some of these issues with HIV/AIDS in the United States led the CDC to revise its HIV testing recommendations in 2006. For adolescents and adults aged 13 to 64 years, it is now recommended that all people are routinely screened in health care settings, regardless of risk. For those with known risk, it is recommended to have repeat HIV screenings at least annually. Opt-out screening is now recommended as well; patients must have the opportunity to ask questions and an option to decline, and it is recommended that HIV consent be included when obtaining general consent for care.

“Patients who test HIV–positive should be linked to clinical care and counseling, and of course to support and prevention services,” Fenton said. He noted that in low prevalence settings, screening should be initiated, but if the prevalence is shown to be below one per 1,000 then screening may no longer be warranted.

The CDC also now recommends universal opt-out screening for pregnant women, with a second test in the third trimester for women known to be at risk for HIV, women in key jurisdictions and those in high-prevalence health care facilities.

Progress being made

Data have begun to emerge in areas that have focused on increasing testing and improving linkage to care with promising results. Fenton said that an initiative in the NYC Health and Hospitals Corp. system that serves 1.3 million New Yorkers aimed to expand its HIV testing to 100,000 individuals per year. In fiscal year 2006, they tested 92,123 people, up 57% from the fiscal year 2005 level of 58,785. “The number of new diagnoses nearly doubled; 76% of new HIV–positive patients received and actually kept their first appointment for primary HIV care. This was a substantial improvement,” Fenton said.

There is still much room for improvement when it comes to directing newly diagnosed individuals toward treatment. According to Fenton, the CDC estimates that only approximately 50% of newly diagnosed people are linked to care within 12 months of diagnosis. There are researchers from current studies, including the Antiretroviral Treatment Access Studies (ARTAS), working on methods to improve this statistic. In preliminary results from ARTAS II, 87.6% of newly diagnosed patients were linked to care in the target period.

“Increasing opportunities for HIV testing is a key prevention strategy,” Fenton said. “However, not only determining who is infected, but ensuring their linkage to care is critical as well.” – by Dave Levitan

For more information:

Fenton K. The challenges and opportunities associated with identifying those with HIV infection and linking them to care. Presented at: The American Conference for the Treatment of HIV; May 31–June 3, 2007; Dallas.