Federal and State Efforts to Identify Infected Individuals and Connect Them to Care
GAO-09-985, Sep 23, 2009
Of the estimated 1.1 million Americans living with HIV, not all are aware of their HIV-positive status. Timely testing of HIV-positive individuals is important to improve health outcomes and to slow the disease's transmission. It is also important that individuals have access to HIV care after being diagnosed, but not all diagnosed individuals are receiving such care. The Centers for Disease Control and Prevention (CDC) provides grants to state and local health departments for HIV prevention and collects data on HIV. In 2006, CDC recommended routine HIV testing for all individuals ages 13-64. The Health Resources and Services Administration (HRSA) provides grants to states and localities for HIV care and services. GAO was asked to examine issues related to identifying individuals with HIV and connecting them to care. This report examines: 1) CDC and HRSA's coordination on HIV activities and steps they have taken to encourage routine HIV testing; 2) implementation of routine HIV testing by select state and local health departments; 3) available information on CDC funding for HIV testing; and 4) available data on the number of HIV-positive individuals not receiving care for HIV. GAO reviewed reports and agency documents and analyzed CDC, HRSA, and national survey data. GAO interviewed federal officials, officials from nine state and five local health departments chosen by geographic location and number of HIV cases, and others knowledgeable about HIV.
The Secretary of Health and Human Services (HHS) is required to ensure that HHS agencies, including CDC and HRSA, coordinate HIV programs to enhance the continuity of prevention and care services. CDC and HRSA have coordinated to assist health care professionals who provide HIV-related services. For example, in 2007 and 2008, CDC provided funding to HRSA to expand consultation services at the National HIV/AIDS Clinicians' Consultation Center. Both CDC and HRSA have taken steps to encourage routine HIV testing--that is, testing all individuals in a health care setting without regard to risk. For example, CDC has funded initiatives on routine HIV testing and HRSA has provided for training as part of these initiatives. Officials from over half of the 14 selected state and local health departments in GAO's review reported implementing routine HIV testing in their jurisdictions. However, according to officials we interviewed, those that implemented it generally did so at a limited number of sites. Officials from most of the selected health departments and other sources knowledgeable about HIV have identified barriers that exist to implementing routine HIV testing, including lack of funding and legal barriers. CDC officials estimated that approximately 30 percent of the agency's annual HIV prevention funding is spent on HIV testing. For example, according to CDC officials, in fiscal 2008, this would make the total amount spent on HIV testing about $200 million out of the $652.8 million CDC allocated for domestic HIV prevention to its Division of HIV/AIDS Prevention. However, CDC officials said that they could not provide the exact amount the Division spends on HIV testing, because they do not routinely aggregate how much all grantees spend on a given activity, including HIV testing. CDC estimated that 232,700 individuals with HIV were undiagnosed--that is, unaware that they were HIV positive--in 2006, and were therefore not receiving care for HIV. CDC has not estimated the total number of diagnosed HIV-positive individuals not receiving care, but has estimated that 32.4 percent, or approximately 12,000, of HIV-positive individuals diagnosed in 2003 did not receive care for HIV within a year of diagnosis. State-level estimates of the number of undiagnosed and diagnosed HIV-positive individuals not receiving care for HIV are not available from CDC. HRSA collects states' estimates of the number of diagnosed individuals not receiving care, but data are not consistently collected or reported by states, and therefore estimates are not available for comparison across all states. HHS provided technical comments on a draft of this report, which GAO incorporated as appropriate.