Self-Reported HIV-Antibody Testing Among Persons With Selected Risk Behaviors -- Southern Los Angeles County, 1991-1992

Since 1985, the number of human immunodeficiency virus (HIV) tests provided annually through publicly funded counseling and testing (CT) programs has continued to increase, with more than 2 million tests provided in 1991 (1). However, the success of CT programs in reaching persons most at risk for infection and transmission of HIV is unclear. To ensure that resources are used as effectively as possible, CT programs must evaluate their ability to reach persons at highest risk. This report summarizes an assessment of HIV testing among street-recruited injecting-drug users (IDUs), female sex partners of male IDUs, and female prostitutes in southern Los Angeles County in 1991-1992.

From April 1991 through September 1992, anonymous street interviews were conducted in Long Beach, California, and nearby communities as part of activities sponsored by the CDC Acquired Immunodeficiency Syndrome (AIDS) Community Demonstration Projects (2). Interviews were conducted in 127 sites that had been associated with high prevalences of drug abuse, prostitution, or both. Trained interviewers familiar with the community and target groups conducted 7734 brief, preliminary risk assessments in these sites with English-speaking persons aged greater than or equal to 18 years; of these, 3097 persons were identified who met eligibility criteria for the second portion of the on-street interview that included questions about HIV risk, attitudes, and HIV-testing history. Eligibility was based on self-reported membership in one or more of four target populations (i.e., male IDU, female IDU, female sex partner of male IDUs, and female prostitute) and recent sexual or drug-use behavior (i.e., vaginal or anal intercourse in the previous 30 days or needle sharing in the previous 60 days)*. Participants received $2 in fast-food certificates for completing the brief risk assessment or $5 in cash for completing the full interview. Because the interviews were conducted anonymously on the street, repeat interviews (n=704) were identified and excluded from data analysis by using a subset of unique identifiers that retained respondent anonymity (e.g., date of birth, place of birth, ethnicity, and sex).

The statistical relation between CT service use and respondent characteristics were assessed using two methods. First, chi-square tests for general association were used to identify differences in the percentage of persons reporting use of CT services. Second, stepwise logistic regression was used to assess the unique contribution each one of the identified respondent characteristics made to the use of CT services.

Overall, 1709 (71.4%) persons reported having been tested for HIV infection, including 466 (64.9%) of 718 male IDUs and 1243 (74.2%) of 1675 high-risk females. Among male IDUs, HIV-testing history varied by race/ethnicity and sexual orientation, with black and homosexual/bisexual males less likely to have been tested than other male IDUs (Table_1). Among high-risk females, HIV-testing history was related to race/ethnicity, age, sexual orientation, and HIV risk, with females who were black, aged less than 30 years, and heterosexual less likely to have been tested (Table_2).

When analyzed using stepwise logistic regression, only nonblack race/ethnicity ** remained significantly related to previous testing of males (odds ratio {OR}=1.5; 95% confidence interval {CI}=1.1-2.1). Nonblack race/ethnicity (OR=2.1; 95% CI=1.6-2.7), history of injecting-drug use (OR=1.9; 95% CI=1.5- 2.4), history of prostitution (OR=1.8; 95% CI=1.4-2.4), and having a non-IDU sex partner (OR=1.5; 95% CI=1.1-1.9) were positively associated with females having been tested for HIV.

Overall, 1512 (88.5%) persons reported having obtained their test results, including 88.1% of male IDUs and 88.7% of high-risk females. Among male IDUs, no respondent characteristics were associated with receipt of test results (Table_1). Among females, race/ethnicity was significantly related to receipt of results (p less than 0.01) (Table_2). Stepwise logistic regression indicated that both nonblack race/ethnicity (OR=2.2; 95% CI=1.5-3.2) and not having an IDU partner (OR=1.5; 95% CI=1.1-2.1) were independently associated with women having received HIV test results. Reported by: RJ Wolitski, MA, B Radziszewska, PhD, California State Univ, Long Beach. Behavioral and Prevention Research Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Findings from CDC's 1989 National Health Interview Survey (NHIS) indicated that in the United States, 41.5% of persons at increased risk *** were tested for HIV infection and that testing rates were lower among blacks, Hispanics, and persons with less than a high school education (3). The NHIS also documented higher rates of CT among persons in metropolitan areas, the western United States, and persons at increased risk. However, because the NHIS sampling scheme targeted households, estimates for HIV testing probably underrepresented some groups of at-risk persons (e.g., those who were homeless or who lived in transitional housing). When compared with the NHIS results, the rates of self-reported testing among the high-risk populations in southern Los Angeles County were higher. In addition, these findings are consistent with information from publicly funded testing sites in Los Angeles County, which indicate comparable return rates (82%) for similar high-risk persons (CDC unpublished data, 1993), and suggest that HIV-prevention programs promoting CT in southern Los Angeles County have been effectively extended to IDUs, female sex partners of male IDUs, and street prostitutes. However, 37% of all at-risk persons interviewed in this assessment had either not been tested or failed to obtain their test results, emphasizing the need to continue to offer CT and other HIV-prevention services to populations at high risk.

One factor that may account for the lower rates of testing among female sex partners of male IDUs in southern Los Angeles County may be that a substantial proportion of these women did not perceive themselves as being at high risk for HIV infection because they did not personally inject drugs or engage in prostitution (4,5). Only 55.5% of female sex partners of male IDUs who had no history of drug injection or prostitution had been tested.

The findings of this report are subject to at least five limitations. First, the total population of high-risk persons from which the study sample was drawn was unknown. Second, because the level of respondents' use of CT services was based on self-reports, their reports of use of CT services may have been influenced by perceived desirability of receiving a HIV test and test results. Third, only minimal respondent characteristic information was collected and available to make comparisons; additional client and service delivery information is necessary for a comprehensive evaluation of CT service use in this geographic area. Fourth, because some of these persons may not have been tested in a publicly funded CT site, these findings cannot be directly compared with national data. Fifth, the racial/ethnic differences may have reflected differences in factors such as socioeconomic status and general use of health-care services.

High rates of AIDS cases continue to be observed in the metropolitan Los Angeles County area (6). Self-reports of testing in this assessment addressed neither how recently or how frequently tests were obtained nor the results of tests. However, the high level of self-reports of HIV testing among IDUs and high-risk women in southern Los Angeles County is encouraging when compared with what would have been predicted by findings from national surveys. In continuing to offer HIV CT programs to populations at risk, programs targeting women should emphasize that women's risk for HIV infection is in part determined by the sexual and drug-related practices of their male sex partners.

References

1. CDC. Publicly funded HIV counseling and testing -- United States, 1991. MMWR 1992;41:613-7.

2. O'Reilly KR, Higgins DL. AIDS Community Demonstration Projects for HIV prevention among hard-to-reach groups. Public Health Rep 1991;106:714-20.

3. Anderson JE, Hardy AM, Cahill K, Aral S. HIV antibody testing and posttest counseling in the United States: data from the 1989 National Health Interview Survey. Am J Public Health 1992;82:1533-

5. Cohen JB, Hauer LB, Wofsy CB. Women and IV drugs: parenteral and heterosexual transmission of human immunodeficiency virus. J Drug Iss 1989;19:39-56.

6. Worth D. Decision making and AIDS: why condom promotion among vulnerable women is likely to fail. Stud Fam Plann 1989;20:297-307.

7. CDC. HIV/AIDS surveillance report. Atlanta: US Department of Health and Human Services, Public Health Service, May 1993;5:4.

Table_1
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 1. Self-reported HIV-antibody testing and receipt of test results among male
injecting-drug users (IDUs) -- southern Los Angeles County, 1991-1992
===========================================================================================

                                         %           HIV tested         Received results
                            Sample     Total      -----------------     -----------------
Characteristic               size      sample      %     Chi-square      %     Chi-square
-----------------------------------------------------------------------------------------
Race/Ethnicity
  Black                      444        61.8      60.4      12.5*       88.0       0.6
  Hispanic                   131        18.2      68.7      --          88.6      --
  White                      125        17.4      74.4      --          88.2      --
  Other                       18         2.5      83.3      --          86.7      --

Age (yrs)
  <=29                        73        10.2      58.9       1.3        90.7       0.3
  >=30                       645        89.8      65.6      --          87.8      --

Sexual orientation
  Heterosexual               677        94.4      65.9       5.6+       88.0       0.0
  Bisexual/
    Homosexual                40         5.6      47.5      --          88.9      --

IDU sex partner
  Yes                        466        72.2       61.6      1.7        86.0       3.2
  No                         179        27.8       67.0     --          92.4      --

Lived in area for >=1 yr
  Yes                        635        88.7       65.4      0.4        87.6       0.8
  No                          81        11.3       61.7     --          92.0      --
----------------------------------------------------------------------------------------
* p<0.01.
+ p<0.05.
===========================================================================================

TABLE 2. Self-reported HIV-antibody testing and receipt of test results among high-risk
women -- southern Los Angeles County, 1991-1992
===========================================================================================

                                         %           HIV tested         Received results
                            Sample     Total      -----------------     -----------------
Characteristic               size      sample      %     Chi-square      %     Chi-square
-----------------------------------------------------------------------------------------
Race/Ethnicity
  Black                       923       55.1      68.3      42.1*       85.2      16.1*
  Hispanic                    262       15.6      77.5      --          91.1
  White                       419       25.0      83.1      --          92.8
  Other                        71        4.2      87.3      --          93.5

Age (yrs)
  <=29                        596       35.6      71.3       4.0+       88.7       0.0
  >=30                       1078       64.4      75.8      -    -      88.7

Sexual orientation
  Heterosexual               1363       81.5      72.7       9.0*       88.9       0.2
  Bisexual/
    Homosexual                310       18.5      81.0      --          88.0

Ever injected drugs
  Yes                         937       55.9      80.9      49.7*       90.0       3.0
  No                          738       44.1      65.7      --          86.8

Ever traded sex for
  money or drugs
    Yes                      1199       71.6      76.9      16.1*       88.2       1.1
    No                        475       28.4      67.4      --          90.3

Injecting-drug user
  sex partner
    Yes                      1121       68.7      71.3       9.2*       87.3       3.5
    No                        510       31.3      78.4      --          91.0

Lived in area for >=1 yr
  Yes                        1385       82.8      75.1       2.4        88.6       0.0
  No                          287       17.2      70.7      --          89.1
-----------------------------------------------------------------------------------------
* p<0.01.
+ p<0.05.
===========================================================================================

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