June 27th is National HIV Testing Day, an annual day to promote HIV testing. To get the full benefits of HIV testing and knowing one's status, we have to pair testing with other interventions, as test results alone are not adequate to halt the epidemic.
Let's put the HIV epidemic into context. Approximately 1.2 million people in the United States currently live with HIV infection, with an additional 50,000 new cases of HIV every year. These are only the identified cases, meaning more people untested are living with HIV. Indeed, 20 percent of people who have the virus don't know they are infected. Since they are not receiving HIV treatment, they may be inadvertently transmitting HIV to others.
The Centers for Disease Control and Prevention (CDC), the nation's health protection agency, recommends everyone 13 to 64 years old should get tested for HIV at least once in life as part of routine health care. This is a wonderful recommendation, but in practice there are several barriers to HIV testing due to the stigma that still surrounds HIV. Many still write it off as a "gay disease," and providers are often unwilling to recommend a test due to how patients will receive the recommendation thought to be for those at high-risk. Further, patients may be unwilling to request a test because they fear being judged by clinicians as irresponsible in their sex life.
One way to break the testing barrier, and address the stigma of requesting or recommending a test is to move to a recommendation of annual HIV testing for every sexually active person. This is already recommended for patients who: (a) have more than one sex partner; (b) have a sexually transmitted infection (STI); and (c) inject drugs.
One group often overlooked in HIV testing outreach is seniors. The US population is aging, with over 40 percent of all people over age 45. This is reflected in HIV statistics also, with half of all people infected being over age 50. Most people don't think about seniors as being at risk for HIV infection, but seniors are sexually active! People over 50 may have similar risk factors (unprotected sex, multiple sex partners) to those under 50, but may be less aware of their risk or not perceive themselves to be at risk due to a historical association of HIV with anal sex. Health care professionals, too, may underestimate older patients' risk for HIV, leading to missed opportunities for HIV prevention. This means that people over 50 are more likely to be diagnosed with HIV later in the course of the disease, with missed opportunities for early linkage to HIV care. Some older adults may actually be at an increased risk for getting HIV; for example, vaginal thinning and dryness in older women can make HIV transmission easier
Fortunately, new methods for HIV testing have emerged. Gone are the times when we needed to get a blood draw in the arm and wait two weeks for the test result. Now, we have options for rapid (20 minutes) HIV testing through a simple finger prick or an even less invasive oral swab. An HIV test which can be done entirely at home is also available, with the test ordered online.
But testing itself is not sufficient to halt the epidemic. Testing needs to be linked to instant HIV care for those who test positive so they walk out of the clinic with a months-worth of HIV medications, including the first dose of medications, taken in the clinic itself. Those who test negative but don't use condoms should also receive preventive medications, such as pre-exposure prophylaxis. And while the patients are engaged in the clinical setting, we should think about integrating sexual health for both men and women.
It is imperative that we think hard of how best to engage people in HIV testing and, integrating those who get a positive result into the continuum of care. A simple but often overlooked option is community based participatory research (CBPR). Why not ask HIV positive and HIV negative patients and clinicians how we can reach people for HIV testing, and how we can best integrate HIV prevention and care services in the healthcare setting? Unfortunately little CBPR work has been done to date to promote HIV prevention.
Despite CDC recommendations, significant barriers to HIV testing remain. We need new and better ways to reach older adults with HIV testing, and to integrate the continuum of care into HIV testing. National HIV Testing Day is the ideal time to get started on this.
Brandon Brown has published over 30 papers on the topic of HIV after obtaining his PhD in International Health from the Johns Hopkins Bloomberg School of Public Health. As an Assistant Professor of Medicine at the University of California, Riverside, he has over 10 years of experience in HIV research, and has conducted HIV projects in Peru, Mexico, Nigeria, and the United States. Jeff Taylor, a 30-plus year HIV positive long-term survivor, co-wrote the blog. Taylor has been active in HIV research advocacy for 20 years.
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