LA health vol 1 web

Since the AIDS epidemic was first recognized in 1981, more than 38,000 Los Angeles County residents have developed AIDS and, of these, more than 24,000 have died. Los Angeles County accounts for 35% of AIDS cases reported in California and nearly 6% of all cases reported nationally. By 1989, HIV infection and AIDS had become the leading cause of death among Los Angeles County men aged 25-44 years and, by 1994, the fourth leading cause of death among women in this age group. An estimated 32,000–45,000 county residents are currently living with HIV infection.1, 2 The number of persons who become infected each year is unknown. Despite widespread HIV prevention efforts, however, there is evidence that HIV is continuing to spread at alarmingly high rates in some communities in the county.3

Recent advances in the medical treatment of HIV infection and AIDS resulted in more than a 50% drop in AIDS-related deaths in Los Angeles County from 1996 to 1997. A similar trend has also been reported nationally. The availability of more effective treatment has made it increasingly important that HIV-infected persons be diagnosed and linked to medical care and other support services as soon as possible after infection. In addition, early HIV diagnosis provides several other potential benefits. Knowledge of one’s infection can provide an incentive to take precautions to prevent transmission of the virus to others, allows for informed decision making regarding childbearing, and can be used as an opportunity to notify at-risk sexual and needle/syringe-sharing partners of their need to be tested.

This report provides information on HIV testing among adults (aged >–18 years) in Los Angeles County. The data were collected in the Los Angeles County Health Survey, a population-based telephone survey of 8,004 county households conducted for the Department of Health Services in the spring of 1997 by Field Research Corporation. Fifty-two percent of adults who were contacted and were eligible to participate completed an interview. Participants were asked:

‹ If they had been tested for HIV in the past two years.

‹ The number of sexual partners they had in the past 12 months.

‹ The gender of these partners.

‹ How often condoms were used.

The results are weighted to the gender, age, and racial/ethnic distribution of the county adult population to correct for differential levels of participation.

Approximately One-Third Of Adults In Los Angeles County Were Tested For HIV During The Past Two Years.

An estimated 36% of the adult population, or nearly 2.4 million persons, were tested for HIV in the past two years. The percentage tested was similar for men (36%) and women (36%) but was higher among African-Americans (47%) and Latinos (43%) than among whites (30%) and Asians (26%) (Figure 1).

‹ Among Latinos, 39% of those born in the United States and 45% of those born outside the country were tested for HIV in the past two years.

‹ Among Latinos born outside the country, 48% of those who are naturalized citizens and 44% who are non-citizens were HIV-tested.

‹ The percentage tested for HIV was higher among persons 18-24 years old (42%), 25-29 years old (45%), and 30-39 years old (40%) than among those 40 years and older (30%).

The percentage tested during the past two years varied across the service planning areas (SPAs) and health districts (Table 1).

‹ The highest percentage was in the South (45%) and Metro (41%) SPAs and the lowest in the San Gabriel Valley SPA (29%).

HIV testing was inversely related to education level and family income. Forty-two percent of those with family incomes below the federal poverty level had been HIV-tested in the past two years compared to 34% of those with family incomes above 200% of the federal poverty level.4 Likewise, 42% of those with less than a high school education had been tested compared to 33% of college graduates.

HIV testing also varied by health insurance status. Forty-nine percent of those on Medi-Cal had been tested compared to 37% with private insurance and 35% without insurance.

Among Persons At Increased Risk For HIV Infection, Only 52% Had Taken An HIV Test In The Past Two Years.

An estimated 372,000 adults, or 6% of all adults in Los Angeles County, were at increased risk for HIV infection based on having had more than one sexual partner in the past 12 months and not always using a condom. Of these, only 52% had taken an HIV test in the past two years. Among those at increased risk, the percentage tested was 55% in whites, 53% in African-Americans, 49% in Latinos, and 44% in Asians. The percentage tested was higher among women (58%) than men (50%). The percentage tested among those at increased risk also varied by health insurance status (Figure 2). Seventy-three percent of those covered by Medi-Cal had been HIV-tested compared to 52% with private insurance and 47% without insurance.

‹ An estimated 149,000 men, or 5% of all men in Los Angeles County, had sex with a male partner in the past 12 months. Of these, 62% had taken an HIV test in the past two years.

‹ Among those men who had sex with men in the past 12 months, 34% had more than one sex partner and did not always use a condom. Of these, 73% had been HIV-tested in the past two years (Figure 3).

‹ An estimated 237,000 heterosexual5 men, or 7% of all men in the county, had sex with more than one female partner in the past 12 months and did not always use a condom. Of these, 45% had been HIV-tested in the past two years.

‹ An estimated 86,000 heterosexual women, or 3% of all women in the county, had sex with more than one male partner in the past 12 months and did not always use a condom. Of these, 56% had been HIV-tested in the past two years.

‹ An estimated 57,000 women, or 2% of all women in the county, had sex with a female partner in the past 12 months. Of these, 46% had been HIV-tested in the past two years.

Discussion

The results of the survey indicate that about one-third of adults in Los Angeles County have been tested for HIV infection in the past two years. In comparison, a 1989 survey conducted in the county found that only 23% of adults had ever been tested for HIV,6 indicating that HIV testing among county residents has increased substantially during the intervening period. Nearly two-thirds of men who had sex with men had been HIV-tested in the past two years, suggesting that efforts to target HIV counseling and testing services in the

county to this high-risk population have achieved some success. The percentage tested

was also higher in nonwhite and lower income populations, coinciding with where

the epidemic appears to be spreading most rapidly.7

These data highlight the importance of continued efforts to direct HIV

counseling and testing services most intensively to those areas and

subpopulations in the county where the epidemic is most heavily

concentrated. Because many of those at greatest risk for HIV are

living in poverty, addicted to drugs, members of stigmatized groups,

or in other ways disadvantaged, they may not actively seek or have

access to testing services provided in traditional health care settings.

For this reason, the Los Angeles County Department of Health

Services directs and supports both confidential and anonymous HIV

counseling and testing services in a wide range of settings including

community-based organizations, mobile van testing units, and in a variety

of other outreach settings (see sidebar on page 7). Efforts are also

being made to incorporate new testing modalities into local

programs as they become available. For example, a more

user-friendly HIV test that uses oral secretions rather than

blood is now available at many counseling and testing

sites. A study is also underway in the county to assess

the accuracy and acceptability of several “rapid”

HIV tests that provide results in as little as 10

minutes, thereby obviating the need to return

for results on another day.

The survey was limited in that it did not include

questions about condom use in relation to

specific sexual practices (e.g., vaginal, oral,

or anal intercourse) and specific types of

sexual partners (e.g., spouse, other primary

partner, or casual partner). In addition, the

number of persons reporting injection drug use was

too low to allow for meaningful analysis of this risk behavior.

The ability to define each respondent’s HIV risk profile was

therefore limited.

Despite these limitations, the finding that nearly 50% of

persons who reported multiple partners and not always using

a condom had not been HIV-tested in the past two years

suggests a need for enhanced efforts to reach this at-risk

population. Reasons for not receiving HIV counseling and testing services among at-risk persons are varied and complex. For example, many at-risk persons refuse HIV-testing when offered because they don’t want to know their status or do not perceive themselves to be at risk.8 Others may not access services for logistical reasons such as long waiting times in clinics or inconvenient clinic locations. Others may take the test but not return for their results.9 In the present survey, the finding that those without health insurance were less likely to have been HIV-tested suggests that lack of insurance may also be an important barrier.

One-third of the men in the survey who reported sex with men also reported two or more partners in the past year and not always using a condom. This finding highlights the need for more effective HIV prevention strategies for self-identified gay and bisexual men and other men who have sex with men, particularly for those in their teens and early twenties among whom infection rates remain high.10

The estimates presented in this report may not accurately reflect current levels of testing given that more than a year has elapsed since the data were collected. It is possible that recent widespread publicity regarding advances in medical treatment and improved quality of life among many living with HIV has resulted in increased numbers of persons seeking testing. The County Department of Health Services is planning a follow-up survey in 1999 that will provide comparison data to assess temporal trends in testing.

The survey findings should also be viewed with caution given the very personal nature of the questions that were asked. Some respondents may have elected not to disclose information about their sexual behavior or past HIV testing. A recent national survey found that as many as 29% of respondents who reported in an initial interview having had an HIV test later reported not having been tested, suggesting the potential for significant underreporting.11

In conclusion, the survey results indicate that many adults in Los Angeles County are accessing HIV testing services. Unfortunately, a substantial number of adults who may be at risk for HIV based on their sexual practices have not utilized these services in the recent past. The findings highlight the importance of continued efforts to target HIV counseling and testing services to these and other at-risk persons. In addition, the findings underscore the need for more effective strategies to ensure that counseling and testing services are received by hard-to-reach populations known to be at increased risk for infection.

HIV Counseling & Testing Services

Los Angeles County Department of Health Service’s HIV Counseling and Testing Unit, Office of AIDS Programs and Policy coordinates publicly funded HIV counseling, testing, and partner notification services in Los Angeles County. The Unit also provides technical assistance, assists in monitoring the quality of these services, and ensures that appropriate referral mechanisms are in place to link those who test positive to treatment facilities. Counseling and testing services are provided in 22 county public health facilities; 12 community-based organizations (CBOs) contracted by the county that provide services at more than 25 locations; six mobile testing units; four street outreach programs; the Drug Expansion (DREX) Program for substance abusers that provides services at 23 locations; and the Court/Custody Program providing services at three locations. Overall, testing services are provided confidentially at 47 sites and anonymously (client is not required to provide a name) at 33 sites throughout the county. Anonymous testing is provided primarily by the county-contracted CBOs and mobile testing units while confidential testing is offered at all sites.

Publicly funded HIV counseling and testing services are provided to approximately 55,000 Los Angeles County residents each year. As reflected in the findings presented in this report, many additional persons receive these services in the private sector. In order to maximize the overall public health impact of counseling and testing services provided at publicly funded sites, services are directed most intensively to populations at greatest risk of infection and to those who may not have access to services in traditional health care settings.

The HIV Counseling and Testing Unit is also responsible for collecting data on services provided at publicly funded sites and distributing these data in aggregate form to the California State Office of AIDS, the Centers for Disease Control and Prevention, and to local community planning groups. The Unit is committed to improving counseling and testing services in the county through analysis and dissemination of these data. If you would like more information on HIV counseling and testing services available in the county, call the Office of AIDS Programs and Policy at (213) 351-8000.