Dr. Eugene McCrayNational HIV Testing Day, held every June 27, was established in 1995 to encourage people to get tested for HIV, know their status, and get linked to care and treatment. This year’s theme, “Doing It My Way,” emphasizes that while there are different ways to be tested for HIV—at home, or in a doctor’s office or clinic—the important thing is to get tested. According to the U.S. Centers for Disease Control and Prevention (CDC), of the approximately 1.1 million people with HIV in the United States, about 15%, don’t know it. Almost 40% of new HIV infections are transmitted by people who do not know they are infected. We spoke with Dr. Eugene McCray, Director of the CDC’s Division of HIV/AIDS Prevention, about what should be done to increase HIV testing rates. For more resources and information on where to be tested, see the National HIV Testing Day website.
amfAR: In February, the CDC reported that annual rates of new HIV infections in the U.S. have leveled off since 2013 and that progress in HIV prevention has stalled. Since HIV testing is essential to prevention efforts, what is being done or planned to increase testing rates?
Dr. Eugene McCray: As part of the recently proposed Ending the HIV Epidemic: A Plan for America, we are committed to reducing the number of new HIV infections in the United States by 75 percent within five years, and then by at least 90 percent within 10 years.
A major part of the Ending the HIV Epidemic initiative is to diagnose all individuals with HIV as early as possible. We know approximately 165,000 Americans have HIV but don’t know it. Early detection is critical and can lead to quicker treatment and suppression of the virus to an undetectable levels in the blood. We know that people with HIV who achieve and maintain an undetectable viral load remain healthy and have effectively no risk of transmitting the virus.
CDC focuses on making HIV testing simple, accessible, and routine. HIV testing is a core component of all CDC funding to health departments and community-based organizations (CBOs). CDC works with health departments, the clinical community, and community organizations to bring HIV testing to everyone who needs it and diagnose infections as early as possible.
A portion of that work includes using innovative approaches to increase testing in clinical settings and developing strategies to make HIV testing more accessible in nontraditional settings (i.e., mobile clinics, syringe services programs, jail/prisons, etc.).
amfAR: What strategies have been found to be most effective in increasing HIV testing among members of high-risk communities?
Dr. McCray: Targeted testing in nonclinical settings has been useful to reach people who might not be willing, or able, to regularly access medical services. In cities that were part of CDC’s Expanded Testing Initiative, focused HIV testing activities resulted in increased testing among black men who have sex with men (MSM); a population disproportionately affected by HIV. The data suggest that our efforts to increase HIV testing among key populations at high risk for HIV might be having a measurable population-level impact. As part of the initiative to end the epidemic, CDC will continue to prioritize targeted and expanded testing efforts. CDC will continue researching promising interventions like self-testing, partnering HIV testing and couples testing, and offering testing in nontraditional venues such as pharmacies. CDC will also work to take proven testing interventions to scale across the country, including in Ending the HIV Epidemic jurisdictions.
We know we have a lot of room to improve. Many HIV infections in MSM and people who inject drugs (PWID) could be diagnosed sooner if HIV testing were more frequently offered during clinical visits. Data from the National HIV Behavioral Surveillance (NHBS) show substantial numbers of MSM and PWID who learned of their HIV status reported “missed opportunities” for earlier diagnosis. Approximately half of these individuals reported seeing a health care provider in the past year and not being offered an HIV test. As physicians and medical providers, we have to do a better job at making HIV testing a routine part of preventative medical care.
amfAR: What has been the effect, if there has been any effect, of the availability of PrEP in motivating some people to be tested for HIV?
Dr. McCray: We don’t know if the availability of pre-exposure prophylaxis, or PrEP (a daily pill to prevent HIV infection),is linked to motivating people to test for HIV. Indirectly, since all persons seeking or being referred for PrEP require an HIV test, and will have repeated tests while taking PrEP, expanded PrEP access and use would be expected to increase the frequency of HIV testing.
PrEP is a major focus of the proposed End the HIV Epidemic initiative. We know that not enough people who could benefit from PrEP are using it. CDC is working on multiple fronts to increase PrEP awareness and use. We are working to increase provider awareness and competency to prescribe PrEP, to increase PrEP awareness and use among people who could benefit from it, and to reduce the stigma surrounding its use. Many of our programmatic activities focus on identifying communities and individuals who could benefit from PrEP and linking them to PrEP-related services.
amfAR: The CDC has for years tried to make HIV testing routine for everyone aged 13 to 64. How can HIV testing be further normalized so it is indeed as routine as other health screenings?
Dr. McCray: We know that CDC guidelines for HIV testing are not fully implemented in clinical settings. CDC is working on several fronts to increase screening in clinical settings. A part of that is working to make HIV testing (ever and after an STD diagnosis) a part of the core set of clinical quality measures used by Centers for Medicare and Medicaid Services and other payers.
We are also working to maximize the use of electronic medical records (EMRs) for integrating HIV testing into standards of care and standard operating procedures. That means including testing for HIV any time blood is drawn if there’s no record of an HIV test in a patient’s electronic medical record. We will make HIV testing guidelines more accessible and convenient to clinicians by providing new digitized formats, clinical decision support tools, and apps that can be integrated within electronic medical records systems to prompt staff to offer HIV testing.
In addition, we will continue our efforts toward increasing provider and patient awareness of routine HIV testing as well as providing testing in diverse settings—clinical and nonclinical.
amfAR: After all these years, stigma continues to play a role in deterring people from getting tested and seeking treatment if they are HIV positive. Are we just not doing enough in general to combat stigma or are there particular strategies that haven’t been tried or are underutilized?
Dr. McCray: CDC’s Director Dr. Robert Redfield recently said, “Stigma is the enemy of public health.” Stigma and other social and structural barriers prevent people from getting tested, getting in and staying in care, and accessing services that prevent them from getting HIV. There are things we can continue to do to reduce HIV-related stigma. We must start by changing how we talk about HIV. We can do our part to stop HIV stigma by being intentional and thoughtful when choosing our words and choosing to use supportive—rather than stigmatizing—language.
Our social marketing campaign, Let’s Stop HIV Together, raises awareness that we all have a role to play in stopping HIV stigma. Many of the campaign materials are available online for use by any organization or individual working to reduce the stigma around HIV.
We have come so far in the fight against HIV. What it means to live with HIV has changed drastically. With better treatment options, people with HIV live nearly normal life expectancies. Staying in treatment keeps people with HIV healthy and also prevents HIV transmission. People with HIV who take HIV medicine as prescribed and achieve and keep an undetectable viral load (or stay virally suppressed) have effectively no risk of transmitting HIV to their HIV-negative sexual partners.
amfAR: What is the most important message you could convey to someone—a young person who is sexually active perhaps—who feels no need to get tested?
Dr. McCray: If you are sexually active, it is important for you to protect your health and the health of your sex partners by getting tested regularly for HIV and other sexually transmitted infections. Making HIV testing a part of your sexual health routine is a good habit for four reasons. First, getting an HIV test is quick, easy, and most often free. An HIV test is done by taking blood from the finger or arm, or by an oral swab. Second, testing is the only way to know if you have HIV and can help put your mind at ease if you are worried about HIV. Third, it’s important that you take control of your health by getting tested. If you test positive for HIV, being diagnosed early means you have a better chance of living a long and healthy life. With the right treatment and care, people with HIV can expect to live as long as a person without HIV. If you test negative, you can protect yourself from sexual transmission of HIV by using PrEP or condoms. Fourth, testing for HIV regularly and knowing your status means that you can look after the sexual health of you partner, too. If you test positive, you can prevent HIV from being sexually transmitted to your partner by getting on—and staying on—treatment so that the level of virus in your blood is so low that is “undetectable.” If you have an “undetectable” virus load, you can no longer pass on the virus through sex with you HIV negative partner.