A community-wide HIV
testing initiative in the Bronx borough of New York City appears to be working,
results of a study published in the online edition of the Journal of Acquired Immune Deficiency Syndromes suggest. Between 2005 and 2009 the proportion
of people who reported being tested for HIV within the past year increased by
a third. There was also a big fall in the percentage of HIV infections
diagnosed late. These achievements coincided with the Bronx Knows testing campaign.
“The findings in this
analysis support that efforts to increase testing in the Bronx during this
period were effective,” write the investigtors.
It is estimated that
21% of all HIV infections in the US are undiagnosed. This is a serious public
health concern. Epidemiological data suggest that a large proportion of HIV transmissions originate in people who have undiagnosed HIV. Moreover, late
diagnosis of HIV (when CD4 count has fallen to a low level, a measure of damage to the immune system) is an important factor in the remaining HIV-related mortality
seen in the US and other richer countries.
Because of this,
opt-out HIV testing is recommended for everyone aged between 13 and 64
years as part of their routine health care. People with a high risk of HIV are
recommended to have annual tests, and gay and other men who have sex with men
who have multiple or anonymous sexual partners, or who use recreational drugs, are recommended to have a test for HIV every three to six months.
recommendations, many people in the US remain untested. Community-wide testing
campaigns have therefore been launched in a number of US urban areas with a
high prevalence of HIV. These include Bronx
Knows, a three-year initiative launched in 2011. Bronx Knows also had the aim of increasing linkage to care for people diagnosed with HIV.
Formal evaluation of
the campaign is pending. However, data on HIV testing history obtained in
surveys conducted in 2005 and 2009 provided an opportunity to see if there had
been any increase in the proportion of Bronx residents testing for HIV during
the first year of the campaign. The investigators also analysed health
surveillance data to determine if there had been any change in the proportion
of people diagnosed with HIV and AIDS at the same time – a marker of late HIV
The study population included
1224 Bronx residents who participated in the 2005 survey and 1232 residents who
were interviewed in 2009. All were aged between 18 and 64 years. Most were
black or Hispanic – only 14% were white.
The proportion of people who had ever tested for HIV increased significantly from 69% in 2005 to
79% in 2009. There was also a substantial increase in the percentage of
participants who reported having an HIV test in the previous year, from 37 to
49%. The investigators calculated that there was a 14% increase in the
proportion of individuals who reported ever testing for HIV, whereas the
percentage who said they had had a recent HIV test increased by 32%.
Increases in HIV
testing in the previous twelve months were focused in specific groups. These
included individuals aged between 24 and 44 (p < 0.001), men (p = 0.001),
black people (p < 0.001), Hispanic people (p < 0.001), those with a high school
education (p = 0.001), individuals with a heterosexual (p < 0.001) or
bisexual identify (p <0.001), as well as those with health insurance (p
The only group in
which a significant decrease in testing in the past twelve months was observed
were white people (33% to 16%; p = 0.02). The investigators suggest that this could
have been “an unintended consequence of media messaging during this period
which prioritized images of non-whites tested for HIV.” They explain that this
was because non-white groups “are both the predominate population within the
borough and because non-whites are more heavily affected by HIV in New York City.”
No increases in
testing rates were seen in men who identified as gay or in men reporting sex
with other men. However, the investigators stress that these groups already had
some of the highest reported testing rates in 2005 (69% gay identity; 46% reported
sex with another man).
with an increased likelihood of testing in the previous year included younger
age (24 to 44 vs 45 to 64 years: AOR = 2.27; 95% CI, 1.60-3.21), black race
(AOR = 8.40; 95% CI, 4.01-17.61), Hispanic race (AOR = 7.11; 95% CI,
3.39-14.94), Asia/Pacific Islander or other racial identity (AOR = 6.53; 95%
CI, 2.24-19.04), bisexual identity (AOR = 6.53; 95% CI, 2.24-19.04) and having
health insurance (AOR = 1.91; 95% CI, 1.16-3.15).
The Bronx Knows initiative also appeared to
be reducing the number of late HIV diagnoses. The proportion of people
diagnosed with HIV and AIDS at the same time fell from 30% in 2005 to 24% in
2009, a relative decrease of 22%. The fall in late diagnoses was predominantly
located in the same population who reported an increase in recent HIV testing.
testing in the Bronx increased the proportion of people with known HIV status
and reduced the proportion with delayed diagnosis,” conclude the investigators.