Decreasing Trends in HIV Testing among Adults in Georgia : Analysis of the 2010-2014 BRFSS D ata

Georgia is ranked fifth highest among states for rates of HIV diagnosis. About 4% of persons living with HIV infection in the United States reside in Georgia, and almost 19% of these people do not know their HIV status. The present study examined the trends and associated factors of HIV testing among adults in Georgia between 2010 and 2014 by analyzing data of the Behavioral Risk Factor Surveillance System (BRFSS). A total of 30,791 persons aged ≥18 years were identified who responded to the question “Have you ever been tested for HIV?” Overall, there were 11,543 respondents who had been tested for HIV, with a decrease in percentage from 49.4% in 2010 to 43.7% in 2014 (p<0.001). Factors associated with HIV testing were being black (p<0.001), being younger than 55 years (p<0.001), single (p=0.02), attaining education level above high school (P<0.001), engaging in HIV high-risk behaviors (p<0.001), and not having healthcare coverage (p=0.03). Overall in Georgia, there has been a decline in the temporal trend of HIV testing, and more than half of adults have never been tested for HIV. For reducing HIV transmission in Georgia, enhancing access and utilization of HIV testing should be a public health priority.


Introduction
HIV testing contributes to the prevention and control of HIV/AIDS.Following HIV diagnosis, risk behaviors tend to decrease [1][2][3]; people diagnosed with HIV can make decisions that potentially lower HIV transmission risk by avoiding risk behaviors such as unprotected sex and needle sharing [4].Also, people who test negative for HIV can make decisions to protect themselves from HIV by engaging in safer sex behaviors and in some cases, taking pre-exposure prophylaxis [4].Enabling individuals to become diagnosed early is a public health priority [5], as late diagnosis of HIV infection can lead to increased morbidity, mortality, and healthcare costs [5].
According to the Centers for Disease Control and Prevention (CDC), an estimated 1.2 million people in the United States (U.S.) are living with HIV, and 13% (156,300) of these do not know they are infected [6].Each year, nearly 45,000 people are diagnosed with HIV, with 30% of new HIV infections being transmitted by people who are living with undiagnosed HIV [4].Geographically, the burden of HIV is not evenly distributed.In 2014, the rates (per 100,000 people) of persons diagnosed with HIV infection were the highest in the South (18.5), followed by the Northeast (14.2), the West (11.2), and the Midwest (8.2) [6].Georgia (GA) with a population of 10,214,860 is the second most populous state in the southeast of the U.S [7].The population is made up of 54% whites, 32% blacks/African Americans, 9.0% Hispanics/Latinos, and 5.0% other races/ethnicities [7].With a rate of 27 per 100,000, GA is ranked fifth highest among states in regard to rates of HIV diagnosis.According to the CDC, 1 in 51 Georgians will be diagnosed with HIV in their lifetime (compared to 1 in 670 residents of North Peer-reviewed version available at Int.J. Environ.Res.Public Health 2016, 13, 1126; doi:10.3390/ijerph13111126 Dakota) [8].Despite comprising only 3.1% of the U.S. population in 2014, 6.4% (2,640) of new HIV diagnoses and 4.4% (53,230) of persons living with HIV infection in the U.S. were recorded in GA [9].About 19% of those living with HIV are unaware of their HIV status, and almost 23% of persons in the state of GA were diagnosed with AIDS within 3 months, as a result of late testing for HIV [9,10].This means that they harbored the virus for a long period of time without receiving appropriate treatment that would have prevented further deterioration of their immune system.
In 2006, the CDC recommended that, as part of routine health care, everyone between the ages of 13 and 64 be tested for HIV at least once, with yearly HIV testing for high-risk individuals, in line with the National HIV/AIDS Strategy goal of increasing by 2015, the percentage (to 90%) of persons living with HIV who know their serostatus [11,12].The purpose of the present investigation was to evaluate the progress in HIV testing in GA by examining the temporal trends and factors associated with testing for HIV among adults residing in GA between 2010 and 2014.

Data source and study participants
The Behavioral Risk Factor Surveillance System (BRFSS) is a system of health-related telephone surveys in the U.S. that collect data on residents in all 50 states, the District of Columbia, and three U.S. territories, regarding their health-related risk behaviors, chronic health conditions, and use of preventive services [13].Since it was established in 1984, GA has been part of the system [14].BRFSS completes more than 400,000 adult interviews each year, making it the largest continuously conducted health survey system in the world; it is a useful tool for addressing and developing health promotion activities [13].Secondary analyses of the BRFSS 2010-2014 data were performed to identify, during this time period, persons in the state of GA aged ≥18 years who reported having ever been tested for HIV.

Measures
Respondents were categorized under socio-demographic variables of gender (male or female); age in years (18-24, 25-34, 35-44, 45-54, 55-64, or 65+); race (non-Hispanic (NH) white, NH black, Hispanic, NH other, or NH multiracial); education (<high school, high school/GED, some post high school, or college graduate); annual income in USD (<15,000, 15,000 -<25,000, 25,000 -<35,000, 35,000 -<50,000, or 50,000+); marital status (married, divorced, widowed, separated, never married, or a member of an unmarried couple); healthcare coverage (yes/no); and HIV high-risk situations (yes/no).HIV high-risk situations included engaging in any of the following behaviors for the past year: use of intravenous drugs, treatment for sexually transmitted disease, giving or receiving money or drugs for sex, or having anal sex without a condom.The type of health coverage was assessed for the year 2014, for which data were available.The outcome variable was participants' response to the question "Have you ever been tested for HIV?" (Yes/no).

Statistical analyses
Descriptive statistics of socio-demographic variables and HIV high-risk situations related to HIV testing were generated for each year, using frequencies and proportions.Weighted percentages of respondents who had ever been tested for HIV were calculated for each variable category for each year.Joinpoint Trend Analysis software [15] was used to calculate the annual percent change (APC) over time.Logistic regression analyses were conducted to examine the association of socio-demographic variables, HIV high-risk situations and HIV testing.The model included data for the 3 years (2010-2012) in which HIV high-risk situations were recorded, and data were adjusted for gender, age, race, education, income, marital status, healthcare coverage, and HIV high-risk situations.Some of the variables were re-categorized to fit in the model.Odds ratios and related 95% confidence intervals were derived from regression analysis.The significance level was set at p<0.05, and all tests were two-sided.Unweighted counts, weighted percentages, and logistic regression analyses were performed using the IBM SPSS Complex Samples version 24 [16].

BRFSS datasets are publicly accessible and do not contain personally identifiable
Peer-reviewed version available at Int.J. Environ.Res.Public Health 2016, 13, 1126; doi:10.3390/ijerph13111126information.CDC ensures that the process of data collection and release are governed by appropriate rules, regulations, and legislative authorizations [17].

Socio-demographic characteristics and HIV risk situations of respondents
In the BRFSS database, 30,791 adults in GA responded to the question "Have you ever been tested for HIV?"The respondents were ≥18 years old, predominantly female (63.3%, n=19,481), white (66.6%, n=20,511), college graduates (35.0%, n=10,781), married (52.7%, n=16,219), with an annual income of ≥ $50,000 (36.5%, n=11,231) and with some form of healthcare coverage (84.9%, n=26,156) (Table 1).In addition, for the years data were available (2010-2012), 97.5% (n= 17,734) of respondents did not engage in HIV high-risk behaviors.For all the years under review, the results of the descriptive analyses of socio-demographic categories and having been tested for HIV were statistically significant (p <0.001).In GA, there were 11,543 respondents who had ever been tested for HIV.The weighted population estimates of those, by year of interview, and the APC for each variable are shown in Table 2.There was a decrease in the percentages of respondents who had ever been tested for HIV, from 49.4% in 2010 to 43.7% in 2014 (p<0.001);however, the APC of -2.86 was not significantly different from zero.During this time, the annual percentages of those tested were higher for GA than nationally (US [38.8% in 2010, 34.4% in 2014).Also for GA, APCs over time were significant for the decreasing number of HIV testers among respondents who were males (APC= -3.27), attained high school education (APC= -2.92) or less (APC= -7.28), earned less than $25,000 annually (APC= -4.53 and -4.51 for <$15,000 and $15,000 -<$25,000, respectively), and never married (APC= -2.88).
Peer-reviewed version available at Int.J. Environ.Res.Public Health 2016, 13, 1126; doi:10.3390/ijerph13111126Acronyms: Unwt.N -unweighted counts, Wt. % -weighted population estimates, CI -confidence interval, APC -Annual Percent Change, NH -non-Hispanic, GED -General Educational Development, N/A -data not available.Note: p-values were significant for the association between all the socio-demographic categories and having ever been tested for HIV.* APC is significantly different from zero at alpha=0.05. a APC calculated for years with available data.(-) APC was not calculated for respondents who don't know or refused to respond to questions asked.
Peer-reviewed version available at Int.J. Environ.Res.Public Health 2016, 13, 1126; doi:10.3390/ijerph13111126 There was a decrease in the numbers of males being tested for HIV (testers) from 48.7% in 2010 to 41.9% in 2014, compared to female testers, 50.1% in 2010, and 45.4% in 2014 (p<0.001).The number of respondents who had been tested for HIV with less than high school education decreased from 47.9% in 2010 to 34.6% in 2014 (p<0.001), and those with a high school education also decreased from 45.1% in 2010 to 40.1% in 2014 (p<0.001).Similarly, there was a decline in the number of testers among earners of less than $25,000 annual income, from 52.0% in 2010 to 42.6% in 2014 (p<0.001) and those who were never married, from 56.4% in 2010 to 50.4% in 2014 (p<0.001).For the other socio-demographic categories, the trends in HIV testing were stable, and the APCs were not significant.Overall, approximately 60% of persons between the ages of 25 and 44 had been tested for HIV, compared to <50% of those aged 18-24 and greater than 45 years of age.There was a slight increase of 0.04 in APC (not significant) among NH multiracial group and a significant decrease in the number of testers, though with stable APC, was noted among the different racial/ethnic groups.
Over the period of 2010-2014, (results not shown in table 2), the highest numbers of testers were NH black respondents (66.4% vs. 37.6% white and 44.5% Hispanic (p<0.001).Fewer persons with healthcare coverage compared with those with no coverage (44% and 54.8% respectively, p<0.001); and almost 50% of respondents with greater than high school education, earning annual income of <$15,000 (53%), separated (65%), or in an unmarried couple relationship (57%) had been tested for HIV.More persons engaged in high-risk behaviors had been tested for HIV than those who had not (71.4% vs. 45.2%;p<0.001).Data for HIV high-risk activities and for the type of healthcare coverage were available for only 2010-2012 and 2014 respectively.As shown in Figure 1, respondents on the military (Tricare) plan were the highest testers (68.2% [95% C.I=58.9-76.2%]),followed by those on Medicaid (66.9% [95% C.I=56.1-76.1%]).

HIV risk situations and socio-demographic determinants of HIV testing in GA
In Table 3 are the results of logistic regression analyses for the association between socio-demographic factors, HIV high-risk situations, and the dependent variable, having ever been tested for HIV, after adjusting for all the variables in the model.The model included data for the 3 years (2010-2012) for which responses to HIV high-risk situations were recorded.Except for gender and income, all the variables entered had a significant effect.NH black/African American respondents (OR=3.26[95% C.I= 2.87, 3.69]; p<0.001), and respondents of other ethnic groups combined (OR=1.10[95% C.I=0.912, 1.32]; p=0.33) were more likely to have been tested than NH white respondents.People who were younger than 55 years were more likely to have been than older people; [18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34]

Discussion
BRFSS data from 2010 to 2014 (the year of the most current data) were analyzed to examine the temporal trends and socio-demographic factors associated with HIV testing among adults in GA.Overall in GA, there was a decrease in the percentages of respondents who had ever been tested for HIV, from 49.4% in 2010 to 43.7% in 2014, with a non-significant APC.The factors associated with HIV testing included being black/African American, single, younger than 55 years, having greater than high school education, engaging in HIV high-risk behaviors, and not having healthcare coverage.
The results show that, after 2010, less than half of the adults had been tested for HIV.Results of previous studies conducted nationally and in other parts of the U.S., show that the percentages of adults who had ever tested for HIV increased significantly between 2000 and 2010 [18,19].Barriers to HIV testing include HIV-related stigma, sexuality, religion, race, and class, Peer-reviewed version available at Int.J. Environ.Res.Public Health 2016, 13, 1126; doi:10.3390/ijerph13111126emphasizing responsibility, testing concerns, and media influences [20,21].The percentages of respondents who had been tested for HIV were highly associated with the presence of HIV risk factors and with self-reported current risks of contracting HIV.Racial minorities, younger persons, especially young black/African American (men having sex with men (MSM)), have the highest risk and prevalence of HIV/AIDS [19].A disadvantage of low HIV testing among persons who are perceived as low-risk is missing of opportunities to diagnose HIV-infected persons and linking them to care.Reasons for fewer people with healthcare coverage not being tested may be because (a) routine HIV testing is not offered in the places where most people get their health care and (b) awareness of CDC's 2006 recommendations for HIV screening has been low among primary care providers [22,23].Release of the United States Preventive Services Task Force recommendations for HIV testing in 2013, and the provision of the Affordable Care Act that both HIV screening and targeted risk-based testing are now covered without cost-sharing as part of the essential benefits package, may boost future HIV testing rates [22].
A strength of the present report is utilization of the most currently available BRFSS data.It is also among the few studies that have examined the trends of HIV testing with the APCs, and the associated socio-demographic factors of HIV testing and is the only report solely for the state of GA.There are some limitations.The BRFSS data are self-reported by respondents and are subject to recall bias.The survey is based on non-institutionalized populations and excludes persons with the same risk of exposure who are residing elsewhere, such as nursing homes or long-term-care facilities.Since data are collected by telephone, individuals who live in households without a residential telephone or cell phone are not included.Further, the sampling frame of the BRFSS is the entire state; therefore, some rural areas might be represented by relatively few interviews.Because of these limitations, the results might be either underestimated or overestimated.Despite these limitations, data from the BRFSS are reliable and generally valid because the content of the survey questions, questionnaire design, data collection, procedures, interviewing techniques, and data processing have been developed to improve data quality [24].

Conclusions
Between 2010 and 2014, there has been a decline in the percentage of adults in GA who have ever been tested for HIV with less than 50% now reporting to have been tested.A strong indicator for testing is the engagement in HIV high-risk behaviors.In GA, increasing access to and utilization of HIV testing should be a public health priority, and more programs that will increase awareness to recommendations for testing among healthcare providers are warranted.