HIV-related risk behaviors and HIV testing among people with sensory disabilities in the United States

Abstract

People with disabilities are an important target population for HIV prevention and treatment programs. In this study, we examined the prevalence of HIV-related risk behaviors and HIV testing among people with visual and/or hearing impairments in the United States, and compared with people without any impairments. The study was a secondary data analysis of the 2016 Behavioral Risk Factor Surveillance System. We performed weighted descriptive statistics and logistic regression analyses to determine the association between ever testing for HIV and sociodemographic characteristics, healthcare access, and HIV-related risk behaviors. The prevalence of HIV-related risk behaviors was 7.1% (95%CI = 5.4–8.8), 3.9% (95%CI = 3.0–4.9), 3.5% (95%CI = 1.5–5.4), and 5.9% (95%CI = 5.7–6.1) among those with visual, hearing, both visual and hearing, and no impairments, respectively. HIV testing among those with visual impairment was 39.7% (95%CI = 37.0–42.3) and 28.9% (95%CI = 27.3–30.5) among those with hearing impairment. Approximately 26.8% (95%CI = 21.4–32.2) of the respondents with both impairments and 38.0% (95%CI = 37.6–38.3) of those with no impairments had ever tested for HIV. In the adjusted models, the factors associated with HIV testing varied across the subgroups, with only age, race/ethnicity, and HIV-related risk behaviors common to all the four subgroups. Compared with those without any impairments, the odds of ever testing for HIV was significantly higher among respondents with hearing impairment (aOR = 1.3, 95%CI = 1.14–1.38), after controlling for sociodemographic characteristics, healthcare access, and HIV-related risk behaviors. Targeted interventions that will meet the unique needs of people with visual and/or hearing impairments are required to reduce HIV-related risk behaviors and improve uptake of HIV testing.

Keywords

Disability hearing HIV risk behaviors sensory testing visual

Introduction

Although there has been an increase in the number of people who are aware of their HIV status globally, gaps still exist in many high-income countries.¹ Of the 1.1 million people estimated to be living with HIV in the United States (U.S.), 14% are undiagnosed,² and they are estimated to transmit up to 30% of new HIV infections.² In ending the HIV epidemic in the U.S., it is imperative that the coverage of HIV testing is increased, particularly among those who may be at risk for HIV.³

People with disabilities are an important target population for HIV prevention and treatment programs.^4,5 Not only are they susceptible to sexual violence,^6,7 but they also face greater difficulties in accessing HIV prevention information and services.^4,8–10 In addition to their vulnerability, people with disabilities are found in all at-risk populations such as men who have sex with men, injection drug users, and female sex workers.¹¹ In the U.S., gay and bisexual men are significantly more likely to have a disability (any limitation or special equipment use) compared with heterosexual men.¹²

Recent estimates indicate that about 61 million adults are living with a disability in the U.S.¹³ However, the majority of the recent research on HIV risk behaviors and testing among people with disability in the U.S. has focused largely on mental impairment,^14–17 resulting in paucity of literature on people with sensory disabilities. In this study, we assessed the (i) prevalence of HIV-related risk behaviors and testing among people with visual and/or hearing impairments in the U.S., (ii) factors associated with HIV testing among people with visual and/or hearing impairments in the U.S., and (iii) differences in HIV testing among people with visual and/or hearing impairments in the U.S. compared with people without any impairments.

Methods

We conducted a secondary data analysis of the 2016 Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS survey is an annual health-related, population-based, random-digit-dialed telephone survey that assesses health status and health behaviors among non-institutionalized adults (18 years and older) residing in the U.S.¹⁸ In 2016, a total of 486,303 people were successfully interviewed across the 50 states, the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands.¹⁹ Among other things, the 2016 BRFSS survey collected data on six types of impairments (hearing, vision, cognition, mobility, self-care, and independent living).¹⁹ The question on hearing impairment was included for the first time in the 2016 BRFSS. For the purpose of this study, we categorized respondents into four subgroups. Those with (i) visual, (ii) hearing, (iii) visual and hearing, and (iv) no impairments. We classified those who responded ‘yes’ to ‘Are you blind or do you have serious difficulty seeing, even when wearing glasses?’ and ‘no’ to all other types of impairments (hearing, cognition, mobility, self-care, and independent living) as having visual impairment. We classified those who responded ‘yes’ to ‘Are you deaf or do you have serious difficulty hearing?’ and ‘no’ to all other types of impairments as having hearing impairment. Those who responded ‘yes’ to both questions on visual and hearing impairments and ‘no’ to other impairments were classified as having both visual and hearing impairments, while we classified those who responded ‘no’ to all the six impairments as having no impairments.

The dependent variable in our study was ever testing for HIV. The survey assessed if respondents had ever been tested for HIV (excluding tests they might have had as part of a blood donation), as well as the month and year of the last HIV test. The following factors relating to sociodemographic characteristics, access to healthcare, and HIV-related risk behaviors were included as the independent variables:

Gender: gender of respondent (male/female).

Age: age of respondent in years at the time of the survey (18–24/25–44/45–64/≥65).

Race/ethnicity: Hispanic origin and race of respondent (non-Hispanic white/non-Hispanic black/Hispanic/multiracial and others).

Education: level of education completed (did not graduate high school/graduated high school/attended college/graduated from college).

Household income: annual household income from all sources (<$25,000/$25,000–$49,999/$50,000–74,999/≥$75,000).

Marital status: formal marital status (married/formerly married [separated, divorced, and widowed] /never married [including a member of an unmarried couple]).

Employment: labor force status of the respondent (employed/unemployed/out of labor force/unable to work).

Personal healthcare provider: if respondent had one person he/she thought of as his/her personal doctor or healthcare provider (Yes/No).

Health insurance: possession of any kind of healthcare coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare, or Indian Health Service (Yes/No).

HIV-related risk behaviors: use of intravenous drugs, or treatment for a sexually transmitted infection, or given or received money or drugs in exchange for sex, or anal sex without a condom, or four or more sex partners by the respondent in the past year (Yes/No).

We performed the data analysis with SAS software Version 9.4 (SAS Institute Inc., Cary, NC, USA), using the procedures for complex survey design. We reported weighted proportion of those who had ever tested for HIV and the proportion of those who tested for HIV in the last one year before the survey. We examined the association between HIV testing and the independent factors using bivariate and multivariate logistic regression analyses. Factors that were statistically significant in the bivariate analyses were included in the adjusted models. Multivariate regression model was also used to determine the differences in HIV testing among those with visual and/or hearing impairments and those without any impairments. We considered p < 0.05 as significant. We classified responses such as ‘don’t know/not sure’ or ‘refused’ and missing values as missing, and they were excluded from our analyses.

Ethical considerations

The data used in this study were publicly available and de-identified. An exempt was granted by the University of Nevada, Las Vegas Institutional Review Board.

Results

Table 1 shows the sociodemographic characteristics, healthcare access, HIV-related risk behaviors, and HIV testing by subgroup. Among those with visual impairment, 7.1% (95%CI = 5.4–8.8) engaged in HIV-related risk behaviors, while in those with hearing impairment it was 3.9% (95%CI = 3.0–4.9), 3.5% (95%CI = 1.5–5.4) in those with both visual and hearing impairments, and 5.9% (95%CI = 5.7–6.1) in those without impairments (Table 1). Approximately 39.7% (95%CI = 37.0–42.3) of those who had visual impairment had ever tested for HIV and 28.9% (95%CI = 27.3–30.5) of those who had hearing impairment had ever tested for HIV (Table 1). Among those who had both visual and hearing impairments, 26.8% (95%CI = 21.4–32.2) had ever tested for HIV, while 38.0% (95%CI = 37.6–38.3) of those who had no impairments had ever tested for HIV (Table 1). In all the four subgroups, of those who had ever tested for HIV, less than 50% tested in the last one year (Table 1).

Table 1.

Sociodemographic characteristics, healthcare access, HIV-related risk behaviors, and HIV testing among people with visual and/or hearing and no impairments, BRFSS, 2016.

Characteristics	Visual		Hearing		Visual and hearing		No impairments
Characteristics	N^a	% (95% CI)^b	N^a	% (95% CI)^b	N^a	% (95% CI)^b	N^a	% (95% CI)^b
Total	6365	1.9 (1.8–2.0)	17,509	3.2 (3.1–3.3)	1349	0.3 (0.2–0.3)	327,817	94.6 (94.5–94.8)
Gender
Male	2800	49.1 (46.4–51.8)	10,694	66.3 (64.8–67.7)	764	56.9 (49.8–63.9)	145,981	49.8 (49.5–50.2)
Female	3564	50.9 (48.2–53.6)	6809	33.7 (32.3–35.2)	585	43.1 (36.1–50.2)	181,811	50.2 (49.8–50.5)
Age (years)
18–24	376	12.2 (10.2–14.1)	205	3.5 (2.9–4.2)	25	5.8 (2.5–9.0)	21,221	14.4 (14.1–14.7)
25–44	1153	29.0 (26.4–31.6)	1079	12.8 (11.5–14.1)	91	10.7 (7.3–14.1)	81,932	37.8 (37.5–38.2)
45–64	2444	37.9 (35.3–40.6)	4538	31.3 (29.9–32.8)	357	32.9 (25.1–40.6)	123,700	31.9 (31.6–32.2)
≥65	2324	20.9 (19.1–22.6)	11,503	52.4 (50.7–54.0)	865	50.7 (43.4–57.9)	96,461	15.9 (15.6–16.1)
Race/Ethnicity
Non-Hispanic white	4322	52.3 (49.5–55.1)	15,534	82.2 (80.5–83.9)	1077	67.7 (59.7–75.7)	264,050	70.6 (70.3–71.0)
Non-Hispanic black	736	15.4 (13.3–17.4)	562	6.0 (4.8–7.1)	79	8.2 (5.4–11.1)	24,975	11.3 (11.0–11.5)
Hispanic	984	30.6 (27.7–33.4)	723	10.1 (8.7–11.6)	118	22.3 (13.8–30.8)	25,785	16.5 (16.2–16.8)
Multiracial and others	187	1.8 (1.3–2.2)	336	1.6 (1.3–2.0)	42	1.8 (1.0–2.6)	6941	1.6 (1.5–1.7)
Education
Did not graduate high school	816	22.1 (19.6–24.7)	1227	13.5 (11.9–15.1)	172	24.1 (16.3–31.9)	16,910	10.5 (10.2–10.7)
Graduated high school	2135	33.4 (30.9–35.8)	5323	30.6 (29.2–32.0)	493	37.8 (30.8–44.8)	82,956	26.7 (26.4–27.0)
Attended college	1752	28.2 (25.7–30.7)	4948	32.3 (30.8–33.7)	356	24.2 (19.4–29.1)	88,310	31.5 (31.1–31.8)
Graduated from college	1644	16.3 (14.7–17.9)	5968	23.7 (22.5–24.8)	326	13.8 (10.7–16.9)	138,734	31.4 (31.1–31.6)
Marital status
Married	2737	41.3 (38.7–43.9)	9946	59.2 (57.6–60.8)	635	48.1 (40.8–55.3)	187,364	53.6 (53.2–53.9)
Formerly married	2190	26.1 (23.8–28.3)	6070	28.1 (26.7–29.5)	550	33.9 (27.3–40.5)	73,476	15.8 (15.7–16.0)
Never married	1407	32.7 (29.9–35.4)	1431	12.7 (11.5–13.8)	158	18.0 (13.4–22.7)	64,998	30.6 (30.3–31.0)
Employment
Employed	2814	53.7 (51.0–56.3)	6024	43.4 (41.8–45.1)	383	35.3 (27.6–43.0)	194,504	65.8 (65.4–66.1)
Unemployed	384	8.1 (6.5–9.7)	391	3.5 (2.8–4.3)	49	4.2 (1.8–6.7)	11,413	4.6 (4.5–4.9)
Out of labor force	2659	30.9 (28.6–33.2)	10,555	50.5 (48.9–52.1)	798	50.6 (43.4–57.9)	114,400	28.0 (27.7–28.3)
Unable to work	468	7.3 (5.8–8.7)	451	2.5 (2.1–2.9)	109	9.8 (6.9–12.8)	5318	1.6 (1.5–1.7)
Income
<$25,000	2215	41.2 (38.4–44.1)	3464	25.3 (23.8–26.9)	466	43.2 (35.2–51.2)	52,966	21.4 (21.1–21.7)
$25,000–$49,999	1538	30.5 (27.5–33.5)	4408	28.2 (26.7–29.8)	361	35.7 (26.9–44.5)	69,181	23.4 (23.1–23.7)
$50,000–$74,999	669	11.0 (9.3–12.6)	2607	16.7 (15.6–17.8)	144	9.5 (6.5–12.5)	50,188	16.3 (16.0–16.5)
≥$75,000	925	17.3 (15.3–19.3)	4077	29.7 (28.1–31.2)	145	11.6 (7.7–15.5)	108,371	38.9 (38.6–39.3)
Personal healthcare provider
Yes	5130	74.1 (71.7–76.5)	15,737	86.9 (85.8–88.0)	1159	79.1 (71.3–87.0)	272,181	76.7 (76.3–77.0)
No	1212	25.9 (23.5–28.3)	1706	13.1 (12.0–14.2)	185	20.9 (13.0–28.7)	54,502	23.3 (23.0–23.7)
Insurance
Yes	5599	81.6 (79.2–83.9)	16,709	92.6 (91.5–93.8)	1235	82.3 (73.8–90.9)	303,428	88.8 (88.5–89.1)
No	740	18.4 (16.1–20.8)	772	7.4 (6.2–8.5)	108	17.7 (9.1–26.2)	23,207	11.2 (10.9–11.5)
HIV-related risk behaviors
Yes	271	7.1 (5.4–8.8)	304	3.9 (3.0–4.9)	31	3.5 (1.5–5.4)	11,233	5.9 (5.7–6.1)
No	5787	92.9 (91.2–94.6)	16,373	96.1 (95.1–97.0)	1242	96.5 (94.6–98.4)	301,912	94.1 (93.9–94.3)
HIV test ever
Yes	1971	39.7 (37.0–42.3)	3406	28.9 (27.3–30.5)	316	26.8 (21.4–32.2)	94,351	38.0 (37.6–38.3)
No	3932	60.3 (57.7–63.0)	12,594	71.1 (69.5–72.7)	905	73.2 (67.8–78.6)	210,462	62.0 (61.7–62.4)
HIV test within one year
Yes	593	44.6 (39.6–49.6)	733	35.5 (31.5–39.5)	72	46.3 (34.0–58.6)	24,767	41.7 (41.0–42.4)
No	902	55.4 (50.4–60.4)	1508	64.5 (60.5–68.5)	126	53.7 (41.4–66.0)	48,596	58.3 (57.6–59.0)

BRFSS: Behavioral Risk Factor Surveillance System.

^aUnweighted frequency.

^bWeighted percentage and confidence interval.

The results of the binary and multivariate logistic regression analyses are shown in Tables 2 and 3. In the adjusted analyses, in respondents with visual impairment, gender, age, race/ethnicity, and HIV-related risk behaviors were significantly associated with ever testing for HIV (Table 3). Those who were between 25 and 64 years, who belonged to non-Hispanic black race/ethnic group, who engaged in HIV-related risk behaviors, and females had significantly higher odds of ever testing for HIV (Table 3). However, those aged 65 years and older had lower odds of ever testing for HIV (Table 3). Among those with hearing impairment, the odds of ever testing for HIV was significantly higher in those aged 25–44 years, non-Hispanic black, Hispanic, formerly and never married, and those who engaged in HIV-related risk behaviors. Whereas, females, people aged 65 years and older, both those who graduated and did not graduate high schools, and those who earned $50,000–$74,999 had significantly lower odds of ever testing for HIV (Table 3). Among respondents with both visual and hearing impairments, non-Hispanic black had significantly higher odds of ever testing for HIV, as well as those who were unemployed, and respondents who engaged in HIV-related risk behaviors (Table 3). Among those with no impairments, gender, age, race/ethnicity, education, marital status, having a personal healthcare provider, employment status, and HIV-related risk behaviors were significantly associated with ever testing for HIV (Table 3).

Table 2.

Bivariate logistic regression analysis for ever testing for HIV among people with visual and/or hearing and no impairments, BRFSS, 2016.

Factors	VisualOR (95%CI)	HearingOR (95%CI)	Visual and hearingOR (95%CI)	No impairmentsOR (95%CI)
Gender
Male	Ref	Ref	Ref	Ref
Female	1.3 (1.00–1.57)*	0.8 (0.68–0.95)**	0.7 (0.42–1.26)	1.1 (1.09–1.16)***
Age (years)
18–24	Ref	Ref	Ref	Ref
25–44	1.7 (1.10–2.70)*	2.6 (1.62–4.22)***	1.0 (0.24–4.06)	2.8 (2.69–3.01)***
45–64	1.0 (0.68–1.58)	1.2 (0.74–1.79)	0.4 (0.09–1.34)	1.3 (1.27–1.42)***
≥65	0.3 (0.18–0.43)***	0.3 (0.21–0.51)***	0.1 (0.03–0.34)**	0.4 (0.36–0.41)***
Race/Ethnicity
Non-Hispanic white	Ref	Ref	Ref	Ref
Non-Hispanic black	3.3 (2.42–4.62)***	2.9 (2.03–4.28)***	5.3 (2.42–11.5)***	3.5 (3.35–3.72)***
Hispanic	1.9 (1.46–2.58)***	2.1 (1.50–2.98)***	2.2 (0.90–5.46)	1.7 (1.64–1.81)***
Multiracial and others	3.0 (1.76–5.02)***	2.0 (1.20–3.33)**	1.4 (0.53–3.62)	1.8 (1.64–2.01)***
Education
Graduated from college	Ref	Ref	Ref	Ref
Attended college	1.1 (0.81–1.49)	1.1 (0.88–1.28)	2.3 (1.25–4.22)**	0.9 (0.91–0.98)**
Graduated high school	0.8 (0.61–1.04)	0.7 (0.55–0.79)***	1.1 (0.57–2.15)	0.7 (0.72–0.77)***
Did not graduate high school	0.8 (0.57–1.16)	0.8 (0.56–1.15)	1.5 (0.62–3.41)	0.8 (0.79–0.89)***
Marital status
Married	Ref	Ref	Ref	Ref
Formerly married	0.9 (0.73–1.21)	1.1 (0.94–1.33)	1.1 (0.58–1.94)	1.2 (1.16–1.26)***
Never married	1.7 (1.28–2.24)**	2.4 (1.89–3.05)***	4.3 (2.11–8.60)***	1.4 (1.36–1.46)***
Employment
Employed	Ref	Ref	Ref	Ref
Unemployed	1.1 (0.72–1.78)	1.5 (0.92–2.42)	4.9 (1.46–16.26)*	1.2 (1.07–1.25)**
Out of labor force	0.4 (0.30–0.49)***	0.3 (0.29–0.41)***	0.3 (0.14–0.53)**	0.4 (0.40–0.44)***
Unable to work	1.1 (0.66–1.71)	1.0 (0.71–1.51)	1.5 (0.67–3.59)	1.0 (0.85–1.08)
Income
≥$75,000	Ref	Ref	Ref	Ref
<$25,000	1.2 (0.91–1.68)	0.8 (0.62–0.97)*	1.6 (0.68–4.01)	1.1 (1.06–1.16)***
$25,000–$49,999	1.3 (0.91–1.89)	0.7 (0.59–0.90)**	0.7 (0.26–1.77)	1.0 (0.91–1.00)*
$50,000–$74,999	1.7 (1.14–2.61)**	0.7 (0.54–0.88)**	1.3 (0.50–3.65)	0.9 (0.87–0.95)***
Personal healthcare provider
No	Ref	Ref	Ref	Ref
Yes	1.1 (0.82–1.39)	0.7 (0.53–0.82)**	0.7 (0.27–1.64)	0.9 (0.84–0.91)***
Insurance
No	Ref	Ref	Ref	Ref
Yes	1.0 (0.76–1.39)	0.4 (0.28–0.56)***	0.9 (0.34–2.56)	0.8 (0.74–0.83)***
HIV-related risk behaviors
No	Ref	Ref	Ref	Ref
Yes	3.7 (2.30–5.94)***	5.2 (3.16–8.52)***	14.4 (4.58–45.48)***	3.1 (2.87–3.29)***

BRFSS: Behavioral Risk Factor Surveillance System.

*p < 0.05, **p < 0.01, ***p < 0.001.

Table 3.

Multivariate logistic regression analysis for ever testing for HIV among people with visual and/or hearing and no impairments, BRFSS, 2016.

Factors	VisualaOR (95% CI)	HearingaOR (95% CI)	Visual and hearingaOR (95% CI)	No impairmentsaOR (95% CI)
Gender
Male	Ref	Ref		Ref
Female	1.4 (1.12–1.84)**	0.8 (0.65–0.97)*		1.2 (1.18–1.27)***
Age (years)
18–24	Ref	Ref	Ref	Ref
25–44	1.6 (0.91–2.72)	2.5 (1.30–4.95)**	0.8 (0.23–3.15)	3.0 (2.79–3.26)***
45–64	1.0 (0.59–1.69)	1.3 (0.66–2.49)	0.5 (0.15–1.97)	1.5 (1.39–1.63)***
≥65	0.4 (0.23–0.76)**	0.5 (0.22–0.91)*	0.2 (0.06–0.85)*	0.5 (0.46–0.56)***
Race/Ethnicity
Non-Hispanic white	Ref	Ref	Ref	Ref
Non-Hispanic black	3.0 (2.06–4.49)***	3.0 (1.91–4.86)***	3.0 (1.15–7.70)*	3.5 (3.30–3.74)***
Hispanic	1.7 (1.24–2.44)**	1.5 (1.00–2.12)*	1.3 (0.53–2.98)	1.6 (1.53–1.74)***
Multiracial and others	3.3 (1.83–5.89)***	1.0 (0.59–1.70)	0.9 (0.31–2.94)	1.7 (1.55–1.94)***
Education
Graduated from college		Ref	Ref	Ref
Attended college		1.1 (0.89–1.40)	1.4 (0.74–2.83)	1.0 (0.91–1.00)*
Graduated high school		0.7 (0.52–0.83)**	0.5 (0.24–1.01)	0.7 (0.71–0.78)***
Did not graduate high school		0.5 (0.31–0.72)**	0.8 (0.29–2.11)	0.7 (0.61–0.73)***
Marital status
Married	Ref	Ref	Ref	Ref
Formerly married	1.2 (0.89–1.70)	1.6 (1.25–1.90)***	1.6 (0.89–2.91)	1.5 (1.43–1.59)***
Never married	1.3 (0.90–1.96)	1.5 (1.09–2.17)*	2.1 (0.89–4.86)	1.2 (1.15–1.28)***
Employment
Employed	Ref	Ref	Ref	Ref
Unemployed	1.2 (0.72–1.86)	1.3 (0.69–2.31)	5.8 (1.85–18.29)**	1.2 (1.05–1.26)**
Out of labor force	0.7 (0.51–1.04)	0.8 (0.62–0.99)*	0.5 (0.22–1.04)	0.7 (0.72–0.80)***
Unable to work	1.3 (0.70–2.30)	1.6 (0.94–2.60)	1.0 (0.41–2.54)	1.0 (0.86–1.17)
Income
≥$75,000	Ref	Ref		Ref
<$25,000	0.8 (0.53–1.17)	0.8 (0.54–1.05)		1.0 (0.94–1.07)
$25,000–$49,999	1.0 (0.66–1.46)	0.8 (0.62–1.03)		0.9 (0.89–0.98)*
$50,000-$74,999	1.5 (0.93–2.29)	0.8 (0.57–0.99)*		0.9 (0.85–0.95)***
Personal healthcare provider
No		Ref		Ref
Yes		1.3 (0.95–1.69)		1.2 (1.14–1.26)***
Insurance
No		Ref		Ref
Yes		0.7 (0.46–1.01)		1.0 (0.96–1.12)
HIV-related risk behaviors
No	Ref	Ref	Ref	Ref
Yes	2.8 (1.49–5.21)**	1.9 (1.13–3.33)*	7.2 (1.92–27.00)**	2.7 (2.47–2.92)***

BRFSS: Behavioral Risk Factor Surveillance System.

*p < 0.05, **p < 0.01, ***p < 0.001.

Note: Empty cells were variables that were not statistically significant at bivariate level.

After adjusting for sociodemographic characteristics, healthcare access, and HIV-related risk behaviors, compared with those without any impairments, the odds of ever testing for HIV was significantly higher among those with hearing impairment (aOR = 1.3, 95%CI = 1.14–1.38, p < 0.001), while it was not significantly different among those with visual and both visual and hearing impairments (data not shown).

Discussion

In this study, we assessed HIV-related risk behaviors and HIV testing among people with visual and/or hearing impairments and compared with those without any impairments in the U.S. The prevalence of HIV-related risk behaviors ranged from 4 to 7%, with the highest among people with visual impairment. Our results showed that 27–40% of people with visual and/or hearing impairments had ever tested for HIV, with the lowest proportion among those with both visual and hearing impairments. Less than half of those who had ever tested for HIV had a test in the last one year before the survey. The factors associated with HIV testing varied across the subgroups, with only age, race/ethnicity, and HIV-related risk behaviors common to all the subgroups. Compared with people without any impairments, people with hearing impairment were more likely to have ever tested for HIV.

The magnitude of risk behaviors that we found in our study, particularly among people with visual impairment, may reflect lack of access to prevention messages that are tailored to their peculiar needs. People with sensory impairments may require HIV prevention messages disseminated in a way that they will be able to understand or produced in materials that they will be able to read.^20–22 Where these are not available, they may be less knowledgeable about HIV risks and prevention.^22,23

Even though there are no HIV screening guidelines specific to people with disabilities, the U.S. Centers for Disease Control and Prevention recommends that persons between 13 and 64 years old should have an HIV test at least once as part of regular medical care, while those most at risk of HIV, such as gay and bisexual men, should get an HIV test at least once in a year.²⁴ Given its public health importance, the routine HIV screening of adults and adolescents (15– 65 years) has also been endorsed by the U.S. Preventive Services Task Force.^25,26 Despite these recommendations, our results showed suboptimal HIV testing among those with visual and/or hearing impairments. Although lower, our finding is consistent with a previous study in the U.S. which analyzed the 2002 National Health Interview Survey, and reported that 56.9% of the people with sensory disability (hearing or visual) had ever tested for HIV.²⁷ Among those with hearing impairment, a similar study reported HIV testing prevalence of 47.5%.²⁸ While there are individual- and systems-level barriers affecting uptake of HIV testing in the U.S.,²⁹ studies have shown that low-risk perception is one of the main reasons why people do not test for HIV.^30,31 This may account for the differences in sociodemographic characteristics and risk behaviors in HIV testing in our results. Offering of HIV testing by physicians may also be risk-based, rather than routine.^32,33 For example, older people (65 years and older) with sensory disabilities may not be offered HIV testing as much as younger people who may be at higher risk.

Our findings also showed that those with hearing impairments had higher odds of testing than people without any impairment. While this observation cannot be easily explained, it is possible that people with hearing impairment, because of their condition and maybe other comorbidities, have higher health services utilization,³⁴ presenting more opportunities for HIV testing.³⁵ Similar studies in the U.S. have found higher HIV testing among people with mental disabilities^15,16 or any limitation³⁶ compared with people without these disabilities.

Of note, the majority of the respondents had a personal healthcare provider, but unlike those without any impairments, there was not enough evidence to suggest an association between personal healthcare provider and HIV testing in those with visual/and or hearing impairments. Even with access to care, poor communication with providers may result in unmet health needs for people living with disabilities.^20,21 Healthcare providers may also not have the requisite skills of providing patient-centered care to people with disability.^37,38 Communications between healthcare providers and people with visual and/or hearing disabilities can be improved through the use of methods such as American Sign Language, personal assistive listening devices, braille, large print, and speechreading.²⁰

There were limitations in our study. HIV testing in the study was self-reported, and there could also have been some misrepresentation. Social desirability bias among some of the respondents may have resulted in underreporting of HIV-related risk behaviors. We were also unable to classify the impairments by severity. Treatment for a sexually transmitted infection is not directly a risk behavior. However, sexually transmitted infections may occur as a result of sexual risk behaviors, and they also increase the risk of HIV. The assessed behaviors were in the last one year preceding the survey. There might be people who had engaged in HIV-related risk behaviors in the past and had never tested for HIV. Because of the cross-sectional nature of the survey, it was also impossible to determine if the HIV-related risk behaviors or HIV testing occurred before or after the respondents became impaired. Future studies could examine HIV epidemiology and treatment engagement among people with visual and/or hearing impairments in the U.S.

Conclusions

Despite the recommendation for routine HIV testing, it is still suboptimal, not only in the general population but also among people with visual and/or hearing impairments in the U.S. Given their vulnerability, people with sensory disabilities warrant more attention in the efforts to ending the HIV epidemic in the U.S. Targeted interventions that will meet their unique needs are required to reduce HIV-related risk behaviors and improve uptake of HIV testing.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Babayemi O Olakunde

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