Early diagnosis of Human Immunodeficiency Virus (HIV) is critical to achieving the U.S. Department of Health and Human Services’ (HHS) initiative, Ending the HIV Epidemic: A Plan for America (EHE). This initiative aims to end the HIV epidemic in the United States by 2030 through strategies including early HIV diagnosis, prevention of new transmissions, effective treatment, and rapid response to outbreaks (1). HIV testing serves as the crucial first step in identifying individuals who require immediate treatment and care, and also those who are at high risk and could benefit from Pre-exposure Prophylaxis (PrEP) and other preventive measures. Unfortunately, opportunities for HIV testing are frequently missed within ambulatory care settings, particularly in primary care, representing a significant gap in addressing Estimated Missed Hiv Diagnosis In Primary Care Setting (2).
This analysis, drawing upon data from the National Ambulatory Medical Care Survey (NAMCS) (2009–2016) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) (2009–2017), examines trends in HIV testing rates across physician offices, community health centers (CHCs), and emergency departments (EDs) for males and nonpregnant females in the United States. The data reveals that HIV testing was conducted at a low percentage of visits across these settings: 0.63% of 516 million physician office visits, 2.65% of 37 million CHC visits, and 0.55% of 87 million ED visits. Notably, while HIV testing rates remained stagnant in physician offices between 2009 and 2016, CHCs showed a marked increase from 2009 to 2014, and EDs experienced a slight increase from 2009 to 2017. Public health guidelines recommend that all adolescents and adults undergo HIV testing at least once in their lifetime (3). To improve early HIV diagnosis rates and reduce estimated missed HIV diagnosis in primary care setting, it is imperative to implement strategies that overcome barriers to HIV testing in ambulatory care, such as integrating clinical decision support systems within electronic health records (EHRs) and establishing standing orders for routine opt-out testing.
The EHE initiative sets ambitious targets for 2025, aiming to diagnose at least 95% of HIV infections and prescribe PrEP to at least 50% of individuals with PrEP indications (4). In 2018, approximately 86% of people living with HIV were aware of their status, and an estimated 18% of those who could benefit from PrEP were receiving it (4). Routine opt-out HIV testing has been a CDC recommendation since 2006 (3) and has been endorsed by the U.S. Preventive Services Task Force (USPSTF) as an “A-graded” preventive service since 2013, with the most recent reaffirmation in 2019.* Furthermore, since 2014, the Patient Protection and Affordable Care Act mandates that most health insurance plans cover HIV testing without patient cost-sharing due to its USPSTF A grade.†
To further understand the landscape of estimated missed HIV diagnosis in primary care setting, this analysis utilizes the most recent NAMCS and NHAMCS data to estimate annual visit volumes and HIV testing percentages for males and nonpregnant females aged 13–64 years across physician offices, CHCs, and EDs. The NAMCS employed different sampling methodologies during the study period, including samples of office-based physicians (2009-2011 and 2016), state-based sampling (2012-2015), and a separate sample for CHCs using grantee-based (2009-2011) and delivery site designs (2012-2014). NHAMCS data was based on ED visits. Both surveys used multi-stage probability designs, sampling from primary sampling units, healthcare venues within those units, and patient visits within those venues. Data abstraction from medical records included checkboxes for HIV testing, venipuncture for other lab tests, preventive care visits, nonurgent visits, and diagnoses of HIV and pregnancy. Visits related to pre-diagnosed HIV and pregnancy were excluded. Weighted estimates were generated to represent national trends, stratified by patient demographics and visit characteristics, with 95% confidence intervals. Temporal trends in HIV testing were assessed using Cochran-Mantel-Haenszel tests, and subgroup differences were analyzed using Chi-squared tests, all performed using SAS-callable SUDAAN.
Low HIV Testing Rates Highlight Missed Opportunities in Primary Care
The study revealed that across the study periods, there were approximately 516 million annual visits to physician offices, 37 million to CHCs, and 87 million to EDs by males and nonpregnant females aged 13–64 years. However, HIV testing rates remained low overall: 0.63% in physician offices, 2.65% in CHCs, and 0.55% in EDs (Table). These low rates, particularly in physician offices, underscore the issue of estimated missed HIV diagnosis in primary care setting.
HIV testing rates varied across demographic groups and visit characteristics. Individuals aged 20–29 years had higher testing rates in both physician offices and CHCs compared to younger and older age groups. Non-Hispanic Black/African American (Black) and Hispanic/Latino (Hispanic) individuals experienced higher testing rates than non-Hispanic White individuals across all three settings. Visits to healthcare facilities in metropolitan statistical areas (MSAs) showed higher testing rates compared to non-MSA locations.
While physician offices showed no significant increase in HIV testing rates from 2009 to 2016 (p = 0.0534), CHCs demonstrated a significant increase from 0.76% in 2009 to 2.41% in 2014 (p<0.0001) (Figure 1). EDs also showed a slight but significant increase over time (p<0.0001).
HIV testing was significantly more frequent during preventive care visits in physician offices and CHCs compared to other visit types. Moreover, visits involving venipuncture were also associated with higher HIV testing rates in physician offices, CHCs, and EDs (Figure 2). Among individuals with private insurance, HIV testing rates increased in CHCs from 2009–2012 to 2013–2014 (p = 0.0482). For those with Medicaid, testing rates increased in physician offices and CHCs over similar periods (p = 0.0352 and p = 0.0287, respectively). However, no increase was observed for privately insured individuals in physician offices or for either privately insured or Medicaid recipients in EDs.
Discussion: Addressing Barriers to Increase HIV Testing and Reduce Missed Diagnoses
Despite the large volume of annual ambulatory care visits, HIV testing rates remained notably low, highlighting a critical area for improvement in public health practice and a significant contributor to estimated missed HIV diagnosis in primary care setting. The observed increase in HIV testing within CHCs can be partially attributed to Health Resources and Services Administration (HRSA) initiatives. HRSA has been collecting HIV testing data since 1999 and incorporated it as a quality measure for federally qualified health centers and look-alike health centers in 2014.†† §§ ¶¶ Furthermore, some CHCs have proactively implemented clinical decision support algorithms to enhance HIV testing rates (5,6).
The lack of increase in HIV testing in physician offices from 2014–2016, even after the elimination of patient cost-sharing, suggests that factors beyond cost are hindering testing efforts. These barriers may include reliance on providers to initiate testing in busy clinical settings. The higher prevalence of HIV testing during preventive care visits underscores the importance of these visits for risk assessment and identifying individuals needing routine or more frequent testing, as well as PrEP. The correlation between venipuncture visits and higher HIV testing rates indicates a convenient opportunity to integrate HIV testing when blood is already being drawn for other purposes.
However, individuals at higher risk for HIV, such as young Black and Hispanic males and people who inject drugs, may not frequently utilize preventive care services but do access healthcare for other needs (7). These non-preventive care visits represent crucial, and often missed, opportunities for HIV testing. A modeling study estimated that tripling HIV testing rates in ambulatory care settings for Black and Hispanic men aged 18–39 years could achieve near-universal testing coverage by age 39 (8). Given the simplicity of HIV blood tests, implementing clinical decision support systems within EHRs to prompt HIV testing for eligible patients (9) and adopting standing orders for routine opt-out testing (10) are essential strategies to reduce clinical barriers and increase testing rates in ambulatory care. Addressing these barriers is critical to reducing estimated missed HIV diagnosis in primary care setting.
This study’s findings are subject to limitations. Firstly, it estimates visit-based testing rates, not the number of individuals tested annually, as some individuals may be tested across multiple visits. Secondly, smaller recent sample sizes limited detailed analyses by patient and visit characteristics. Thirdly, changes in NAMCS and CHC sampling designs might affect the trend estimates. Finally, the lack of recent CHC data beyond 2014 limits the ability to monitor current trends in this important setting.
Conclusion: Leveraging Primary Care to Enhance HIV Diagnosis and Prevention
Increasing HIV testing rates is paramount to achieving the EHE initiative’s goals. Ambulatory healthcare encounters, particularly within primary care settings, offer valuable opportunities to expand HIV testing and reduce estimated missed HIV diagnosis in primary care setting. Jurisdictions participating in the initial phase of the EHE initiative, which have the highest HIV diagnosis rates, should be prioritized for interventions to increase testing. Routine, lifetime HIV testing for all individuals, and annual or more frequent testing for those at increased risk due to sexual behavior or injection drug use, are crucial for identifying infections, linking individuals to care, and expanding PrEP access. To effectively end the HIV epidemic, leveraging testing opportunities within ambulatory health care, especially primary care, is essential to improve diagnosis rates and ultimately curb HIV transmission.
References
1. https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/ending-the-hiv-epidemic.
2. Singh S, Song R, Bradley H, et al. HIV testing in অ্যাম্বুলatory care settings in the United States, 2009–2014. J Acquir Immune Defic Syndr. 2017;75(2):228-235.
3. CDC. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings. MMWR. 2006;55(RR14):1-17.
4. https://www.cdc.gov/hiv/statistics/overview/index.html.
5. Yehia NC, Reynolds NR, Lo Re V 3rd, et al. Trends in HIV testing and diagnosis in a large urban health system, 2000-2010. J Acquir Immune Defic Syndr. 2012;60(4):411-417.
6. Beckwith CG, Wood BR, Koenig HC, et al. Optimizing HIV screening in the emergency department through provider education and electronic health record modification. Acad Emerg Med. 2014;21(5):543-551.
7. Mimiaga MJ, Biello KB,страишнс А, et al. missed opportunities for HIV testing among young black men who have sex with men. J Urban Health. 2010;87(5):773-787.
8. জুয়াখেলী এ, হার্ভে এমএ, হিলিস এসডি, এটল। HIV testing among young men in অ্যাম্বুলatory care settings: a modeling analysis. AIDS Behav. 2015;19(12):2217-2225.
9. জিউসারি এ, বোয়ার্স জে, রিড বিআর, এট আল। Clinical decision support systems for HIV screening: a systematic review. Implement Sci. 2016;11:123.
10. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-17; quiz CE1-4.
TABLE. Mean Number of Annual Visits and Percentage of Visits with HIV Test
| Characteristic | Physician offices (2009–2016) | Community health centers (2009–2014) | Emergency departments (2009–2017) |
|---|---|---|---|
| No. of visits* | HIV test, % (95% CI) | No. of visits* | |
| Total | 515,518,000 | 0.63 (0.45–0.87) | 37,374,000 |
| Sex | |||
| Female | 305,086,000 | 0.62 (0.41–0.94) | 24,349,000 |
| Male | 210,431,000 | 0.64 (0.49–0.84) | 13,024,000 |
| Age group, yrs | |||
| 13–19 | 48,606,000 | 0.56 (0.33–0.95) | 4,029,000 |
| 20–29 | 57,179,000 | 1.71 (1.37–2.12) | 5,764,000 |
| 30–39 | 77,948,000 | 1.02 (0.71–1.46) | 6,725,000 |
| 40–49 | 110,264,000 | 0.67 (0.34–1.34) | 7,864,000 |
| 50–64 | 221,520,000 | 0.21 (0.15–0.31) | 12,992,000 |
| Race/Ethnicity | |||
| White | 370,020,000 | 0.37 (0.30–0.45) | 15,929,000 |
| Black | 57,345,000 | 1.51 (1.06–2.14) | 6,116,000 |
| Hispanic† | 61,976,000 | 1.20 (0.70–2.04) | 13,292,000 |
| Other§ | 26,177,000 | 1.06 (0.42–2.65) | 2,037,000 |
| U.S. region | |||
| Northeast | 105,836,000 | 0.59 (0.43–0.81) | 6,641,000 |
| Midwest | 102,923,000 | 0.38 (0.27–0.51) | 6,266,000 |
| South | 192,637,000 | 0.80 (0.41–1.54) | 8,900,000 |
| West | 114,122,000 | 0.61 (0.45–0.83) | 15,567,000 |
| Metropolitan statistical area (MSA)¶ | |||
| MSA | 466,984,000 | 0.67 (0.47–0.94) | 30,025,000 |
| Non-MSA | 48,534,000 | 0.28 (0.15–0.52) | 7,348,000 |
| Insurance type | |||
| Private | 347,585,000 | 0.61 (0.47–0.81) | 6,612,000 |
| Medicaid | 51,315,000 | 0.79 (0.55–1.15) | 14,591,000 |
| Other** | 90,670,000 | 0.32 (0.22–0.47) | 13,626,000 |
| Provider specialty | |||
| Primary care†† | 263,192,000 | 1.09 (0.76–1.57) | 18,599,000 |
| Other | 252,326,000 | 0.15 (0.11–0.22) | 1,190,000 |
| Nonphysician | — | — | 17,585,000 |
* Weighted nationally representative estimates. † Hispanic/Latinos might be of any race. § Other races/ethnicities include Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native. ¶ Location of health care venue. ** Other insurance types include Medicare, workers compensation, self-pay, no charge/charity, and other. Insurance type was missing for 6.0% of visits to physician office, 7.3% of visits to community health centers, and 8.2% of visits to emergency departments in the analytic sample. †† Primary care specialties include general and family practices, internal medicine, obstetrics and gynecology, and pediatrics.
