Abstract
Dear Editor:
In the United States, over 1 million people are infected with HIV and there are approximately 50,000 new HIV infections yearly. 1 The Hispanic/Latino community carries a disproportionate burden of the HIV epidemic in the United States. Although Hispanics/Latinos represent only 16% of the U.S. population, they accounted for 20% of new infections in 2009. 2 The lifetime risk for HIV among Hispanics/Latinos is approximately three times the risk for whites. 2 Despite the high prevalence of HIV within this community, in a national survey, 44% of the Hispanic/Latino population reported never being tested for HIV. 3 In fact, it is estimated that 21.6% of Hispanics/Latinos living with HIV remain undiagnosed because they have not been tested. 4 Testing is critical for HIV prevention because those aware of their HIV positive status decrease risky behaviors that could impact further transmission of HIV. Additionally, HIV status awareness leads to earlier treatment with highly active antiretroviral therapy which significantly reduces viral load, the primary biologic factor affecting HIV transmission. Coupling HIV testing with HIV treatment reduces the transmission of HIV in the community and can therefore mitigate the ongoing epidemic. 5
To remove previously determined testing barriers, and in recognition that many HIV-positive persons are not tested for HIV until late in the course of their infection despite having visited health care settings several times before the diagnosis is made, 6 the Centers for Disease Control and Prevention (CDC) in 2006 issued recommendations for routine HIV testing in health care settings [in areas with a ≥ 0.1% undiagnosed HIV prevalence] of all persons ages 13–64. 7 Notably, in 2011, 74% of Americans in a national survey reported their health care provider had never suggested HIV testing. 3 Among Hispanics/Latinos surveyed, 62% reported their health care provider had never suggested HIV testing. 3 Considering that studies have shown health care providers' recommendations for HIV testing significantly impact patient's decision to test, 8 providers may play a critical role in improving HIV testing and reducing the ongoing transmission of HIV in the community. However, the limited research of testing in community health centers after the 2006 routine HIV testing recommendations suggests there are barriers to testing even when health care providers offer it routinely. In an urban community health center that implemented routine HIV testing, 65% of patients refused HIV testing even when it was offered by health care providers. 9
Due to the high HIV prevalence in Houston, Texas, the City of Houston and the CDC have targeted Harris County Hospital District (HCHD) community health centers for routine opt-out HIV testing. HCHD provides publicly funded health care for the nation's third most populous county; over 90% of the HIV/AIDS cases in the Houston metropolitan area are in Harris County. In a recent study evaluating the prevalence of late HIV diagnoses of Houston/Harris County residents, Hispanics/Latinos made up nearly one third of the late diagnoses despite accounting for only one-fifth of the study population. 10 The objectives of our study were to determine if primary healthcare providers were offering HIV testing to patients at a predominantly Hispanic/Latino HCHD community health center with a routine opt-out HIV testing program and whether patients accepted testing. To our knowledge, there has not been a study in a predominantly Hispanic/Latino patient population that queries patients on the HIV testing practices of their providers.
Our study was conducted in a HCHD community health center from October 2010 to March 2011. Over 50% of patients in this health center are Hispanic/Latino. Eligible participants were patients between the ages of 18–64 and had completed their visit with their health care provider. Participants were given an anonymous questionnaire regarding sociodemographics, reason for health center visit, HIV testing discussions, and HIV testing acceptance. A Spanish translation of the questionnaire was also offered. A nominal incentive of an ink pen was given to participants as compensation. The study was approved by the Baylor College of Medicine Institutional Review Board and the HCHD Office of Research.
Fisher's Exact Test was employed to examine whether sociodemographics or reason for the visit were associated with whether a health care provider discussed HIV testing. Statistical tests were two-sided with an α of 0.05. Analyses were performed with SAS version 9.2 (SAS Institute, Cary, NC).
Of the 200 patients approached, 127 (63.5%) patients completed the questionnaire. Nineteen patients were ineligible due to age criteria (n=3) or because they were not seeing their primary care provider (n=16), leaving 108 patients as the final study population. See Table 1 for the population's sociodemographic characteristics. Most patients were female (73.2%) and Hispanic/Latino (69.1%). The mean age was 44.6 years (standard deviation [SD]=12.5 years). Their education levels were comparably distributed among those with some high school education (32.2%), a high school diploma/GED (37.8%), and at least some college education (30.0%). The majority of patients (66.7%) completed the survey in English.
The HIV testing results are in Table 2. Patients came to the clinic for a routine health check-up (49.0%), a specific health problem (27.9%), or other reason that was not provided by the patient (23.1%). Only 25.5% of patients reported that a health care provider discussed HIV testing. Therefore, the vast majority (73.6%) reported that no one discussed HIV testing during their visit, while the remaining 0.9% did not remember having a discussion.
There was a significant association between reason for visit and whether a healthcare provider discussed HIV testing (Fisher's exact p<0.02). Among those who came to the clinic for a routine health check-up, 38.8% reported that a health care provider discussed HIV testing. In contrast, among those who came to the clinic for a specific health problem or some other reason, 13.8% and 12.5%, respectively, reported that a health care provider discussed HIV testing. Further, Hispanic/Latino individuals (33.3%) were significantly more likely to report that a healthcare provider discussed HIV testing relative to non-Hispanic/Latino individuals (6.9%; Fisher's exact p<0.01). There were no significant associations between the patients' age, gender, race, or education and whether one reported that a healthcare provider discussed HIV testing with them (all p>0.05).
Of the 27 patients that reported that a health care provider discussed HIV testing, only 7 patients (25.9%) accepted an HIV test. The majority of patients declined an HIV test (59.3%) or did not respond to the question regarding acceptance of HIV testing (14.8%).
To our knowledge, this is the first study done in a predominantly Hispanic/Latino-serving community health center in a high HIV prevalence area to assess if patients are being offered HIV testing in accordance with recent CDC recommendations. Almost three fourths of the patients reported that no one discussed HIV testing with them. Notably, Hispanics/Latinos were more likely than non-Hispanics/Latinos to report that an HIV testing discussion occurred; nevertheless, the prevalence of this discussion still remained low, at 33% for Hispanics/Latinos.
There could be several reasons for the low prevalence of HIV testing discussions. While less than 1% of patients reported “not remembering” if a discussion took place, it is possible that more patients did not remember and responded that no discussion took place. It is also possible that no discussion took place because health care providers were unaware of the recommendation to offer routine opt-out HIV testing to all patients age 13–64. Our study was unable to verify whether health care providers offered HIV testing in accordance with CDC recommendations. Notably, providers could have offered testing at a different clinic visit; our questionnaire did not ask if patients had ever had a HIV testing discussion with their provider. Limitations of our study include a small sample size from a single community health center that may not be representative of the HIV testing practices of the greater Hispanic/Latino community.
Health care providers can have a significant impact on improving HIV testing. While there are several barriers to HIV testing, national data indicate among those who do report in 2011 ever having been tested, 40% of Hispanic/Latinos report being tested because a healthcare provider suggested testing. 3 In fact, studies have found that intent to test for HIV is associated with physician recommendation of the HIV test. 8 Similarly, delays in testing also may be impacted by health care providers. In a study of late HIV diagnoses (study population 33% Hispanic), 42% of the study's participants reported not having been tested for HIV the year prior to their HIV diagnosis because no one offered them the HIV test. 11 Finally, a 2011 survey found that 62% of Latinos wanted to know who should get tested for HIV 3 ; health care providers could be a key source of this information for their patients. Because community health centers serve predominantly minority patient populations and often those at highest risk for HIV, it is particularly important that community health center health care providers be engaged in improving HIV testing rates for their patients.
Notably, health care provider testing behaviors is only one barrier to overcome in the efforts to make HIV testing routine. Similar to other studies done in community health centers, 9 we found that even when HIV testing was offered, many patients declined to be tested. The 2006 CDC HIV testing recommendations were intended to allay previously determined barriers to patients' acceptance of HIV testing; further research is needed on how to overcome ongoing HIV testing barriers. Notably, a recent study of Hispanics/Latinos found that HIV testing at home or in the community is preferred more than HIV testing in a clinic setting. 12
It is encouraging that the CDC has expanded HIV testing initiatives for the Hispanic/Latino community. 2 Given the disproportionate affect HIV is having on Hispanic/Latino communities and the role HIV testing can have in mitigating the epidemic, further research is needed on how to improve the rate of HIV testing—both by providers and patients—for this population.
Footnotes
Acknowledgments
This research was supported by the Baylor-UT Houston Center for AIDS Research (CFAR), an NIH-funded program (AI036211). This article was, in part, the result of statistical analysis support provided by the Design and Analysis Core of the Baylor-UT Houston Center for AIDS Research, an NIH funded program (AI036211). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
Author Disclosure Statement
No competing financial interests exist.