An Evaluation of an Expanded HIV Testing Program in North Carolina Sexually-Transmitted Disease Clinics

Klein, Pamela

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March 21, 2019

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Klein, Pamela
- Affiliation: Gillings School of Global Public Health, Department of Epidemiology

Abstract

Over 20% of the 1.1 million persons infected with HIV in the United States are unaware of their HIV infection; these persons contribute to approximately 50% of new transmission events each year. To address this problem, the Centers for Disease Control and Prevention released recommendations supporting routine, opt-out HIV testing in clinical settings. We conducted a before-after intervention analysis of a routine, opt-out HIV testing program implemented in North Carolina sexually transmitted disease (STD) clinics. The study population included all adult North Carolina residents who were tested for HIV in any of the 102 North Carolina STD clinics from July 1, 2005 through June 30, 2011. Exposure was dichotomized at the date of intervention implementation on November 1, 2007. Three primary outcomes were considered: (1) HIV testing, as absolute counts and rate per 100,000 population; (2) detection of new HIV-infected persons, as absolute counts and HIV-positivity per 1000 tests; and (3) progression to AIDS within 12 months of HIV diagnosis. Interrupted time series analyses were used to examine trends in HIV testing and case detection over the study period; Poisson regression and multilevel regression models with county-specific random intercept terms were used to evaluate the overall impact of the intervention. Pre-intervention, 426 new HIV-infected cases were identified from 128,029 tests (0.33%), whereas 816 new HIV-infected cases were found from 274,745 tests post-intervention (0.30%). Pre-intervention, HIV testing increased by 55 tests per month (95% confidence interval [CI]: 41, 72), but only increased by 34 tests per month (95% CI: 26, 42) post-intervention. A slight pre-intervention decline in the monthly rate of case detection was mitigated by the intervention (mean difference in HIV-positivity=0.01; 95% CI: -0.02, 0.05). Overall, no association was observed between the introduction of the intervention and risk of progression to AIDS within 12 months of initial HIV diagnosis (risk ratio=1.05, 95% CI: 0.77, 1.43). The impact of a routine, opt-out HIV testing program in North Carolina STD clinics was minimal. Persons not traditionally targeted for HIV testing, particularly women, experienced the greatest benefit. HIV prevention interventions should be continually evaluated for program efficacy.

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