Date: Fri, 10 Mar 1995 09:02:15 +0500
From: ghmcleaf{CONTRACTOR/ASPEN/ghmcleaf}%NAC-GATEWAY.ASPEN@ace.aspensys.com
Subject: MMWR 03/10/95


MORBIDITY AND MORTALITY WEEKLY REPORT
Centers for Disease Control and Prevention
March 10, 1995
Vol. 44, No. 9

HIV Counseling and Testing -- United States, 1993
     Counseling and testing (CT) are important components of state
and local human immunodeficiency virus (HIV)-prevention programs
(1). Analysis of national data sources indicates that HIV-antibody
tests are obtained from a variety of testing sites, including
private physicians, hospitals, and outpatient clinics (66.7%), and
publicly funded sites (33.1%) (2). This report uses data from CDC's
1993 Behavioral Risk Factor Surveillance System (BRFSS) to examine
variations in rates of use of private and public HIV CT sites by
state.
     In 1993, a total of 49 states and the District of Columbia
participated in the BRFSS, a state-specific population-based,
random-digit-dialed telephone survey that collects information
monthly from U.S. adults aged greater than or equal to 18 years.
Thirteen questions about HIV/AIDS-related knowledge and attitudes
and HIV-antibody testing history during the preceding year were
asked only to respondents aged less than or equal to 65 years. In
1993, a total of 84,039 persons responded to these questions
(state-specific range: 993 to 3667). The state-specific median
percentage of 82% of eligible respondents completed interviews (3).
Data for each state were weighted by demographic characteristics
and by selection probability; results are representative of persons
aged 18-65 years in each state. Confidence intervals for
percentages and estimated numbers of persons tested were based on
standard errors that accounted for complex survey design (4).
     A median of 25.5% of persons (range: 14.4% [Iowa] to 37.5%
[Alaska]) answered yes to the question: "Except for donating or
giving blood, have you ever had your blood tested for the AIDS
virus infection?" (Table 1). The number (weighted estimate) of
adults who had ever been tested for HIV was highest in California
(6.3 million).
     A median of 9.6% of persons (range: 4.1% [Maine and South
Dakota] to 16.9% [District of Columbia]) reported obtaining
HIV-antibody tests primarily for diagnostic reasons* (Table 1).
Persons categorized as having obtained diagnostic HIV-antibody
tests were identified by one of three responses to the question
"What was the main reason you had your last AIDS blood test?": "to
find out if infected," "because of referral by a doctor or health
department or sex partner," or "for routine checkup**."
     In 43 states and the District of Columbia, at least 50.0%
(median: 60.9%) of respondents had obtained their last diagnostic
test from a private physician, health maintenance organization, or
private outpatient clinic (Table 2). A median of 16.2% of persons
(range: 5.0% [North Dakota] to 37.6% [Mississippi]) had obtained
their last diagnostic test at a publicly funded prevention site
(including health departments; AIDS, sexually transmitted disease
[STD], or tuberculosis clinics; and drug-treatment programs).
     The estimated number of persons who obtained a diagnostic test
at a publicly funded site during the preceding year correlated with
the number of tests reported to CDC's HIV Counseling and Testing
System by publicly funded sites in each state (5) (correlation
coefficient=0.96; p less than 0.01).
     A median of 60.7% of persons who had obtained their most
recent diagnostic HIV-antibody test at a publicly funded site
(range: 30.8% [New Jersey] to 95.7% [Oklahoma]) received counseling
with their test results (Table 2). In comparison, a median of 28.2%
of persons who had obtained their tests from a private site (range:
7.7% [Kentucky] to 77.3% [Oklahoma]) also received counseling. In
most (90%) of the reporting areas, the number of persons who
received counseling with their HIV test results was greater than or
equal to 1.5 times greater for persons tested at publicly funded
sites than those tested at private sites.
Reported by the following BRFSS coordinators: S Jackson, MPA,
Alabama; P Owen, Alaska; B Bender, Arizona; J Senner, PhD,
Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M
Adams, MS, Connecticut; F Breukelman, Delaware; C Mitchell,
District of Columbia; D McTague, MS, Florida; E Pledger, MPA,
Georgia; F Newfield, MPH, Hawaii; C Johnson, MPH, Idaho; B Steiner,
MS, Illinois; R Guest, MPH, Indiana; P Busick, Iowa; M Perry,
Kansas; K Bramblett, Kentucky; D Hargrove-Roberson, MSW, Louisiana;
D Maines, Maine; A Weinstein, MA, Maryland; R Lederman, MPH,
Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; E
Jones, MS, Mississippi; J Jackson-Thompson, PhD, Missouri; P Smith,
Montana; S Huffman, Nebraska; E DeJan, Nevada; K Zaso, MPH, New
Hampshire; G Boeselager, MS, New Jersey; P Jaramillo, MPA, New
Mexico; C Maylahn, MPH, New York; G Lengerich, MD, North Carolina;
D Young, MS, North Dakota; E Capwell, PhD, Ohio; N Hann, MPH,
Oklahoma; J Grant-Worley, MS, Oregon; J Romano, MPH, Pennsylvania;
J Hesser, PhD, Rhode Island; M Lane, MPH, South Carolina; B Miller,
South Dakota; D Ridings, Tennessee; R Diamond, MPH, Texas; R Giles,
Utah; R McIntyre, PhD, Vermont; S Carswell, MA, Virginia; K Holm,
MPH, Washington; F King, West Virginia; E Cautley, MS, Wisconsin.
Behavioral and Prevention Research Br, Div of Sexually Transmitted
Diseases and HIV Prevention, National Center for Prevention Svcs;
Behavioral Risk Factor Surveillance Br, Office of Surveillance and
Analysis, National Center for Chronic Disease Prevention and Health
Promotion, CDC.
Editorial Note: The findings from the 1993 BRFSS document a high
degree of state-specific variability in self-reported HIV-antibody
tests in the United States. This variability may reflect
state-specific differences in such factors as the prevalence of HIV
infection and HIV testing in high-risk groups, the presence and
impact of HIV-prevention programs, and age distribution. The BRFSS
estimates of the number of persons last tested for voluntary or
diagnostic reasons at a publicly funded clinic correlated highly
with estimates from CDC's HIV Counseling and Testing System, and
the median percentage of respondents ever tested for HIV (25%) is
consistent with estimates based on CDC's National Health Interview
Survey (22%).
     Health-care visits to seek and obtain HIV tests are important
opportunities to counsel persons about the risk for HIV infection
and methods to reduce such risk (1). The data in this report
indicate that, in most states, approximately threefold more persons
reported having obtained their HIV test from a private provider
than from a public site; however, persons who had obtained their
test from a private provider were substantially less likely to have
reported receiving counseling than those who obtained tests at a
public site. This finding underscores the need for physicians and
other health-care providers in private settings to offer HIV
counseling at the time patients receive their HIV test results.
     The findings in this report are subject to at least two
limitations. First, the sample size of persons who reported having
had an HIV-antibody test in individual states did not enable
stratification by other respondent characteristics. For example,
state-specific sample sizes precluded analysis to determine whether
specific high-risk populations that obtained HIV-antibody testing
also received counseling. Second, because the BRFSS is a
telephone-based system, some persons at high risk for HIV infection
most likely were excluded from the survey.
     The BRFSS is a unique source for information about
HIV-antibody testing behaviors of U.S. adults--particularly
patterns of HIV testing outside of public clinics--and can be used
both at the federal and state levels to improve HIV-prevention and
intervention programs. Questions about CT in the 1993 BRFSS were
developed based on input from state health departments; subsequent
BRFSS surveys may incorporate additional HIV-related behavioral
questions.
References
1. Hinman AR. Strategies to prevent HIV infection in the United
States. Am J Public Health 1991;81:1557-9.
2. CDC. HIV counseling and testing services from public and private
providers--United States, 1990. MMWR 1992;41:743,749-52.
3. CDC. 1993 BRFSS quality control report. Atlanta: US Department
of Health and Human Services, Public Health Service, CDC, 1994.
4. Shah BV. Software for Survey Data Analysis (SUDAAN) version 5.30
[Software documentation]. Research Triangle Park, North Carolina:
Research Triangle Institute, 1989.
5. CDC. HIV counseling and testing data system: national profile,
1993. Atlanta: US Department of Health and Human Services, Public
Health Service, CDC, 1994.

* For this study, diagnostic HIV-antibody tests were defined as
those administered primarily to learn infection status rather than
voluntary tests to qualify for insurance, military induction,
immigration, marriage license application, or employment.
** This response was included in "diagnostic" reasons to avoid
excluding respondents who initiated a routine examination to
determine whether they were infected with HIV.


Clarification: Vol. 43, Nos. 51 & 52
     The notice to readers "Recommended Childhood Immunization
Schedule--United States, January 1995" (pages 959-960) stated that
infants born to hepatitis B surface antigen (HBsAg)-positive
mothers should receive immunoprophylaxis with 0.5 mL of hepatitis
B immune globulin (HBIG) and 0.5 mL of hepatitis B vaccine
administered at separate sites. Hepatitis B vaccines licensed in
the United States are produced by Merck and Co., Inc. (Rahway, New
Jersey), and SmithKline Beecham (Philadelphia) and are available in
various concentrations. The recommended dose of hepatitis B vaccine
for infants varies by manufacturer and HBsAg status of the mother
(Table 1). Merck and Co., Inc., recommends 2.5 ug of Recombivax HB
(registered) for infants of HBsAg-negative mothers and 5.0 ug for
infants of HBsAg-positive mothers; SmithKline Beecham recommends 10
ug of Engerix-B (registered) regardless of the mother's HBsAg
status. Providers should know the HBsAg status of an infant's
mother and consult the product package insert for the recommended
vaccine dose.
     Providers also should be aware that the Food and Drug
Administration recently lowered the age-appropriate dose of
Engerix-B (registered) from 20 ug to 10 ug for adolescents 11-19
years of age (Table 1) (1).
Reference
1. Smithkline Beecham Pharmaceuticals. Brief summary of prescribing
information: Engerix-B (registered) [Package insert]. Philadelphia:
Smithkline Beecham Pharmaceuticals, 1995.


Addendum: Vol. 44, No. 8
     In the article, "Exposure of Passengers and Flight Crew to
Mycobacterium tuberculosis on Commercial Aircraft, 1992-1995," the
following names should be added to the credits ("reported by") on
the sixth line on page 139: A Ignacio, MD, D Morishige, RL Vogt,
MD, State Epidemiologist, Communicable Disease Div, Hawaii Dept of
Health.


Errata: Vol. 44, No. 8
     In the article, "Exposure of Passengers and Flight Crew to
Mycobacterium tuberculosis on Commercial Aircraft, 1992-1995," on
page 138 in the first sentence under investigation 3, the length of
flight is incorrect. The sentence should read, "In March 1993, a
foreign-born passenger with pulmonary TB traveled on a 4 1/2-hour
flight from Mexico to San Francisco."
     In the article, "Use of Safety Belts--Madrid, Spain, 1994,"
the first sentence on page 151 should read, "Of 1063 phone numbers
called to identify eligible households, 294 (27.7%) could not be
contacted (no one answered or the line was busy), and 185 were
excluded (because the phone number was commercial, no one aged
greater than or equal to 18 years was in the home at the time of
the call, or respondents never traveled by vehicle)."