Community-wide initiative boosts HIV testing rates in the Bronx and cuts late diagnosis

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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.

Glossary

adjusted odds ratio (AOR)

Comparing one group with another, expresses differences in the odds of something happening. An odds ratio above 1 means something is more likely to happen in the group of interest; an odds ratio below 1 means it is less likely to happen. Similar to ‘relative risk’. 

linkage to care

Refers to an individual’s entry into specialist HIV care after being diagnosed with HIV. 

immune system

The body's mechanisms for fighting infections and eradicating dysfunctional cells.

epidemiology

The study of the causes of a disease, its distribution within a population, and measures for control and prevention. Epidemiology focuses on groups rather than individuals.

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.

Despite these 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 diagnosis.

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 <0.001).

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).

Factors associated 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.

“Community-wide testing in the Bronx increased the proportion of people with known HIV status and reduced the proportion with delayed diagnosis,” conclude the investigators.

References

Myers JE et al. Assessing the impact of a community-wide HIV testing scale-up initiative in a major urban epidemic. J Acquir Immune Defic Syndr, online edition, 2012.