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Based on the steady trend in HIV incidence (new cases), CDC issued guidelines for adults and adolescents in 2006 recommending that HIV testing be integrated into routine primary care regardless of the presence or absence of possible risk factors (in the same way that providers routinely recommend screening for colon cancer and diabetes) and that every person between the ages of 13 and 64 should be tested at least once in their lifetime (more regular screening is recommended for persons demonstrating high risk behaviors).
Streamlining of scripted pre and post HIV test counseling and eliminating the requirement for written informed consent was also recommended. Since these are recommendations, not laws or mandates, states responded in various ways from adopting the new recommendations in their entirety to adopting only a portion of the recommendations. For that reason, laws for HIV testing vary from state to state. Specific laws related to HIV testing and counseling in the state of Florida are covered in a later section of this course.
While some progress has been made to increase testing, CDC estimates that roughly 20% of the 1.2 million persons living with HIV/AIDS in the US are still not aware that they are infected. These estimates are supported by surveillance data showing that almost 28% of all new infections in 2010 already met the CDC criteria for AIDS at time of diagnosis (CDC, 2012a, CDC, 2012b).
Racial Inequality
In the US, disparity continues between genders and races infected. Minority populations continue to report the greatest rate of people living with HIV/AIDS and cases of new infections, with Blacks/African Americans disproportionally infected. Black/African Americans made up just 14% of the total US population in 2009, but accounted for 48% of all people living with HIV/AIDS (CDC, 2012a, CDC, 2012b).
New cases of HIV/AIDS among males in this population were 6.5 times greater than among Whites and 2.5 times greater than among Hispanic/Latino males or Black/African Females. Black/African American female rates of HIV/AIDS were 15 times greater than among White women and 3 times greater than among Hispanic/Latino women. In 2010, the number of new cases of AIDS among Black/African Americas (16,188) remained almost double those among Whites (8,875) (CDC, 2012a). MSM remains the predominant risk category, while heterosexual sex now ranks second. The most significant rise of infections is among young Black/African American MSM. CDC estimates that one out of 16 Black/African American males and one out of 32 Black/African American females living in the US will be infected with HIV/AIDS during their lifetime (CDC, 2012a, CDC, 2012b).
HIV Prevention Efforts
Despite millions of dollars spent on HIV prevention, the yearly prevalence remains stable at 56,000 cases. Health and governmental agencies are looking for new ways to approach the problem. Treatment optimism has been blamed in part for the failure to change risky behaviors among some people. Media reports of major breakthroughs in HIV treatment and a national change in focus from HIV to other newer problems (for example, drug resistant organisms such as methacillin resistant staphylococcus aureus [MRSA], new strains of influenza, etc.) may have resulted in a false sense that HIV is no longer a major health problem since it can be managed with daily medications. Another factor contributing to new infections may be that sexually active young adults did not experience the fear and loss when HIV was first reported and may underestimate the impact of the virus.
Despite the dramatic increase in sexually transmitted infections and 30 years of HIV prevention messages, the use of barriers remains inconsistent among all age groups, thus contributing to the steady rate of new infections. Hock-Long et al. (2012) recently examined a sample of African American and Puerto Rican males and females ages 18- 25 years (N= 380) asking if the subjects had used condoms at their last sexual encounter. Subjects reported using condoms more frequently with casual partners (77.9%) than with serious partners (38.7%). The most common reason for use among causal partners was prevention of sexually transmitted infections (STIs) and to prevent pregnancy. Among serious partners the most common reason was to prevent pregnancy. In older age groups where pregnancy prevention is not a concern, condoms were used less frequently. Foster et al. (2012) reported that 67.9% of study participants ages 50 to 74 responded that they did not use condoms at every sexual encounter. In addition, more than one third of the adults in their study had multiple sexual partners.
| Table 2. HIV/AIDS by Risk Category (CDC, 2012a) |
Risk Category |
New HIV/AIDS Infections |
Living with HIV/AIDS |
Cumulative HIV/AIDS Related Deaths |
HIV/ADIS Related Deaths (2009) |
MSM |
61% |
49% |
300,000 |
6863 |
|
|
|
|
|
Heterosexual |
27% |
28% |
80,000 |
4434 |
|
|
|
|
|
IVDU |
9% |
17% |
175,000 |
4759 |
HIV and Persons 50+
Due in part to pharmaceutical advancements in antiretroviral treatments, the HIV population is aging. People who are infected are often able to return to productive lifestyles and be relatively healthy for years after their diagnosis with effective therapy and health care. In addition, people are aging better in general. Many people remain mentally and physically active into their 70s and 80s. They travel, work, and engage in sexual relationships. Unfortunately, they are often not aware of HIV risk factors. NYS estimates that by 2015 more than one-half or persons infected with HIV living in the state will be age 50+. For these reasons, this is an important population to target with HIV prevention programs and testing. Although providers are becoming more aware of risk factors among the elderly, the majority is tested at a later stage of the disease and often has AIDS at the time of diagnosis.
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