Older Women Don't Want HIV Tests

PITTSBURGH, Aug. 9 -- Most women age 50 or older were not interested in HIV testing when it was offered, even if they had risk factors for infection, researchers here found.
Only 22% of older women in an area with high HIV prevalence were interested in testing although more than half had risk factors for exposure, reported Aletha Akers, M.D., M.P.H., of the University of Pittsburgh, and colleagues, in the July/August issue of the Journal of Women's Health.
The CDC revised its guidelines in September 2006 to recommend routine HIV testing for all adults ages 13 to 64 seen in healthcare settings unless the patient declines and at least annual screening for those at high risk.
But, the findings suggest "it may not be right to simply exclude women over age 64 in high risk communities," Dr. Akers said. "Providers shouldn't just take the CDC recommendations by the letter."
Older adults, particularly older women, have been largely ignored by HIV prevention campaigns, the researchers noted, which "is a concern, given that this is one of the fastest growing segments of the U.S. population as baby boomers age."
To help nail down the size of the problem, the researchers analyzed data from a cross-sectional study conducted in the general internal medicine clinic of a large inner-city hospital in Atlanta. The city had a 1.9% cumulative AIDS prevalence during the study period from June 2001 to July 2002.
A total of 514 women ages 50 or older completed the 68-item questionnaire in a face-to-face interview. They ranged in age up to 95, but 64% were younger than 64. Most participants were African-American (73%), not sexually active (73%), and had low HIV knowledge (65%).
Although 74% perceived themselves at low HIV risk, all would have been considered high risk using the CDC's definition at the time of the study because of the prevalence of HIV in the area where they lived.
Furthermore, 55% had moderate-risk or high-risk factors for exposure over their lifetime. For moderate-risk women, the most common factors were having two to five sexual partners since 1978 (82%).
For high-risk women, the most common factors were sex with an intravenous drug user (39%), a blood transfusion between 1979 and 1985 (34%), and prostitution (24%).
However, just 22% of the women expressed interest in HIV testing when it was offered during the interview.
Notably, women who were not interested in HIV testing were more likely to have moderate-risk or high-risk factors for lifetime exposure to HIV than women who were interested in testing (63% versus 37%, P<0.001).
In multivariate analysis, women who had no interest in HIV screening but had never been tested were more likely to be older (P=0.038), be African-American (P=0.023), and perceive themselves at low risk (P=0.020).
Likewise, the third of all women who were uninterested despite having moderate- or high-risk factors were more likely to be older (P=0.006) and African-American (P=0.004).
The most commonly cited reasons for disinterest in HIV testing were:
29% believed that testing was unnecessary.
17% did not perceive herself at risk, such as "I don't mess around."
17% had been tested before.
Those who were interested were more likely to be at moderate or high risk than at low risk (14% versus 27%, P<0.001). The most common reasons given for interest were:
39% curiosity, such as "Just to make sure I'm O.K."
23% safety, such as "Because you never know what someone has left behind."
10% concerns about a partner's behaviors, such as "Why not, my husband has them [sexually transmitted infections] all the time."
"The findings in this study underscore the fact that older women's motivation for obtaining HIV testing is influenced by their knowledge about HIV, perceived risk of contracting the virus, and actual risk status," Dr. Askers and colleagues said.
This should come as no surprise because similar factors influence younger adults, they noted.
But, "unlike younger women, older women have been largely ignored by HIV education, prevention, and testing programs," they wrote.
"As a consequence, they appear to be less capable of accurately assessing their lifetime risk … even when they have significant risk factors and reside in communities with high rates of HIV infection," they added.
Physicians and public health providers need to recognize the danger of this situation, the investigators said.
"This requires that health providers perform HIV risk assessments and recommend HIV testing for at-risk older women, especially those residing in high-risk communities," they concluded.
The study was supported by the Emory Medical Care Foundation. Dr. Akers received funding from the Robert Wood Johnson Clinical Foundation during the study but reported no conflicts of interest. Primary source: Journal of Women's HealthSource reference: Akers A, et al "Factors Associated with Lack of Interest in HIV Testing in Older At-Risk Women" J Womens Health 2007;16:842-858.

Occult HIV Infections Unmasked by Rapid Tests

ATLANTA, June 22 -- Rapid HIV testing with on-the-spot results during emergency room visits or at community events appears to be a feasible way to identify people who are infected with the virus and don't know it. So it would seem on the basis of a pair of studies published in the June 22 issue of Morbidity and Mortality Weekly Report. One covered free rapid testing in emergency rooms, and the other involved gay pride events at such sites as tents, mobile testing units, community centers, churches, and bars.
Yearlong pilot programs in three urban emergency departments found that more than half of the patients offered a rapid HIV agreed to be tested, according to Edward Telzak, M.D., of the Bronx Lebanon Hospital Center in New York, and colleagues.
And of those who were actually tested, Dr. Telzak and colleagues found, 1% proved to be HIV-positive and nearly 90% of those were linked to HIV care and treatment.
The three pilot projects -- in New York, Los Angeles, and Oakland -- were intended to see how acceptable offering such testing would be to patients arriving for emergency treatment.
The reports come as the CDC is recommending a so-called opt-out approach to HIV testing, in which it would become a routine part of medical care, without the need for separate consent and pre-test counseling.
The pilot projects, however, followed the standard form, in which patients were given pre-test information, specific written consent was required, and HIV counselors were present to provide more information in the event the test was positive.
Signs and brochures advertised the free tests, which used the OraQuick Advance test, and patients were offered the test if they said they were HIV-negative or did not know their status.
Patients whose rapid test was positive were given risk-reduction counseling and asked to give a second specimen for confirmatory testing by Western blot.
An HIV test was offered to 34,627 (18.6%) of the 186,415 people who sought care, although the proportions varied from 2.1% in New York to at 47.7% in Oakland.
Overall, 19,556 (56.5%) of those offered testing agreed to be tested and 9,365 actually got the tests, but the proportion of those were tested varied by site -- 99.8% in Los Angeles, 99.4% in New York, and 38.5% in Oakland.
The testing identified 97 people with newly diagnosed HIV infection, of whom 85 (or 88%) then had at least one follow-up visit for HIV treatment, the researchers found.
In an accompanying editorial comment, the CDC said the test program -- although not in the same format as proposed by the agency -- shows that routine testing "is a feasible strategy for identifying persons with previously undiagnosed HIV infection."
In a companion article, researchers from several states and cities reported on using rapid HIV testing during 11 gay pride events in nine U.S. cities during 2004 through 2006.
The testing took place in "diverse settings, including tents, mobile testing units, community centers, churches, bars, and hotel rooms," the researchers said.
During the events, 627 men older than 18 took part in a behavioral assessment and 543 reported that they were HIV-negative or did not know their HIV status.
Of those, 133 were given a rapid HIV test (also using the OraQuick system) and eight (or 6%) tested positive. Two of those could not be located for later follow-up.
The report suggests that such events can be "an important strategy" to reach gay men who might not otherwise get tested, the CDC said in an accompanying editorial comment.
But the agency noted that in several cases, the demand for the testing outstripped available resources, which limited the effectiveness of the program.
As well, follow-up was difficult, since 25% of those who tested positive could not be located later for confirmatory testing and possible HIV care, the agency said. Additional source: Morbidity and Mortality Weekly ReportSource reference: Telzak EE et al. "Rapid HIV Testing in Emergency Departments -- Three U.S. Sites, January 2005-March 2006." MMWR 2007;56(24):597-601. Additional source: Morbidity and Mortality Weekly ReportSource reference: "Rapid HIV Testing Among Racial/Ethnic Minority Men at Gay Pride Events -- Nine U.S. Cities, 2004-2006." MMWR 2007;56(24):602-04.