HIV Testing Trends Among Persons with Commercial Insurance or Medicaid — United States, 2014–2019

HIV testing is a critical component of effective HIV prevention and care. CDC recommends routine opt-out HIV testing in health care settings for all sexually active persons aged 13–64 years at least once in their lifetime and risk-based testing regardless of age for those who report behaviors associated with HIV acquisition (1). However, recent studies show low HIV testing rates in clinical settings; HIV testing rates at visits to physician offices did not increase during 2009–2016 (2). The objective of the current study is to estimate temporal trends in HIV testing among persons with commercial insurance or Medicaid from 2014 through 2019 and describe their demographic characteristics in 2019. Weighted data from the IBM MarketScan Commercial Claims and Encounters database* (commercial insurance) and from the Centers for Medicare & Medicaid Services (CMS) claims database^† (Medicaid) were analyzed to estimate the proportions of persons with commercial insurance or Medicaid who received testing for HIV. Testing rates increased among male and nonpregnant female persons aged ≥13 years with either type of coverage. In 2019, only 4.0% of those with commercial insurance and 5.5% of those with Medicaid received testing for HIV. Testing rates were higher among non-Hispanic Black or African American (Black) persons and Hispanic or Latino (Hispanic) persons. Based on mathematical modeling studies, these annual testing rates would need to increase at least threefold and be sustained over several years (3,4) to achieve the Ending the HIV Epidemic (EHE) in the U.S. initiative goal of ≥95% of persons with HIV being aware of their infection by 2025.^§ Interventions need to be implemented to increase routine and risk-based HIV testing in clinical settings to higher levels that can help reduce disparities in HIV diagnoses between Black and Hispanic persons compared with non-Hispanic White (White) persons (5). Increased HIV testing is essential to achieve the goals of the EHE initiative and reduce disparities in HIV diagnoses; public health should partner with health care systems to implement interventions that support increased testing.

Many factors might be associated with low HIV testing rates for persons across socioeconomic strata, even among those with health care insurance (6). In 2019, the U.S. Department of Health and Human Services launched the EHE initiative that includes four strategic pillars (diagnose, treat, prevent, and respond) to end the HIV epidemic by 2030. The “diagnose” pillar is intended to achieve diagnosis for all persons with HIV as early as possible, with a goal to detect ≥95% of all infections by 2025. As part of the initiative, CDC funded health departments to conduct several activities, including the expansion of routine and risk-based testing in clinical settings.^¶ HIV testing can serve as an entry point for HIV prevention and care services and can normalize HIV testing as a routine part of preventive care.

CDC analyzed data from the 2014–2019 MarketScan and Medicaid databases to identify temporal trends in HIV testing in clinical settings among persons with commercial insurance or Medicaid and their demographic characteristics. The MarketScan database is a convenience sample of commercial health plans that include health service information for approximately 40 million persons per year and is weighted using validated methods to be nationally representative of the 200 million U.S. persons with commercial insurance. The CMS database includes information on persons with Medicaid in all 50 states and the District of Columbia. Both databases contained deidentified patient information and diagnostic, procedural, and drug codes for clinical services provided; Medicaid reports data on race/ethnicity, and MarketScan does not. Separate analyses were conducted using the MarketScan and Medicaid databases. Eligibility criteria included persons who 1) were aged ≥13 years, 2) were continuously enrolled for at least 6 months in a given year, and 3) had no previous HIV diagnosis. Pregnant adolescents and women were excluded because CDC recommends that they receive prenatal testing for HIV during each pregnancy, rather than routine or risk-based testing (1). Persons aged ≥65 years were included because HIV prevalence has increased in the oldest age group for which surveillance data are reported (7). HIV diagnoses were identified using codes from the ninth and tenth revisions of the International Classification of Diseases.** HIV tests were identified using Current Procedural Terminology^†† and Healthcare Common Procedure Coding System^§§ codes. SAS software (version 9.4; SAS Institute) was used to conduct analyses. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.^¶¶

The proportions of male and nonpregnant female persons aged ≥13 years with commercial insurance or Medicaid who received HIV testing each year were estimated. Race/ethnicity data were available only for persons with Medicaid, therefore the trend in testing over time was estimated by race/ethnicity only for those with Medicaid. The estimated annual percentage change and 95% confidence intervals were calculated for each trend. The estimated number and proportion of persons with commercial insurance and with Medicaid who had testing in 2019 were stratified by sex, age group, race/ethnicity (Medicaid only), urban versus rural residence, and U.S. Census region.

During 2014–2019, the proportion of male and nonpregnant female persons aged ≥13 years with HIV testing increased an estimated 6.0% per year among those with commercial insurance, and an estimated 3.2% among those with Medicaid (Table 1). Among persons with Medicaid, this trend was observed for all racial and ethnic groups except Hispanic persons (Figure). Despite the increase in HIV testing, only 4.0% of persons with commercial insurance and 5.5% of persons with Medicaid received testing for HIV in 2019 (Table 1). The proportion of persons with HIV testing was higher among those with Medicaid than among those with commercial insurance across all regions and all demographic groups except persons aged ≥65 years (Table 2). In 2019, among persons with Medicaid, the percentages of Black persons (8.5%) and Hispanic persons (5.9%) with HIV testing were higher than the percentages of White persons (3.9%) and non-Hispanic Asian (Asian) persons (5.0%) with HIV testing.

Corresponding author: Kirk D. Henny, khenny@cdc.gov, 404-639-5383.

¹Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC; ²Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee.

References

1. Branson BM, Handsfield HH, Lampe MA, et al.; CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 2006;55(No. RR-14). PMID:16988643
2. Hoover KW, Huang YA, Tanner ML, et al. HIV Testing trends at visits to physician offices, community health centers, and emergency departments—United States, 2009–2017. MMWR Morb Mortal Wkly Rep 2020;69:776–80. https://doi.org/10.15585/mmwr.mm6925a2 PMID:32584800
3. Hoover KW, Khalil GM, Cadwell BL, Rose CE, Peters PJ. Benchmarks for HIV testing: what is needed to achieve universal testing coverage at U.S. ambulatory healthcare facilities. J Acquir Immune Defic Syndr 2021;86:e48–53. https://doi.org/10.1097/QAI.0000000000002553 PMID:33136820
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6. Wise JM, Ott C, Azuero A, et al. Barriers to HIV testing: patient and provider perspectives in the deep South. AIDS Behav 2019;23:1062–72. https://doi.org/10.1007/s10461-018-02385-5 PMID:30607759
7. US Department of Health and Human Services. AHEAD America’s HIV epidemic analysis dashboard. Washington, DC: US Department of Health and Human Services; 2021. Accessed June 21, 2021. https://ahead.hiv.gov
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9. Centers for Medicare & Medicaid Services. Quality of care performance measurement. Baltimore, MD: Centers for Medicare & Medicaid Services; 2021. Accessed April 28, 2021. https://www.medicaid.gov/medicaid/quality-of-care/quality-of-care-performance-measurement/index.html
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Abbreviations: CI  =  confidence interval; EAPC = estimated annual percentage change; N/A = not applicable.
* EAPCs were calculated using a generalized Poisson model.
^† Persons who were continuously insured for at least 6 months in a given year.
^§ Weighted to generate nationally representative estimates of persons with commercial insurance (https://www.ibm.com/products/marketscan-research-databases/databases).

FIGURE. Percentage of male and nonpregnant female persons aged ≥13 years with Medicaid who received testing for HIV, by race and ethnicity* — Centers for Medicare & Medicaid Services, United States, 2014–2019

* Persons reported as White, Black, Asian, and Other were non-Hispanic; persons reported as Hispanic/Latino could be of any race.

* Persons who were continuously enrolled in their health insurance plan for ≥6 months in 2019.
^† Weighted to generate nationally representative estimates of persons with commercial insurance (https://www.ibm.com/products/marketscan-research-databases/databases).
^§ Dashes indicate race/ethnicity data not available in commercial insurance data set.
^¶ Race/ethnicity groups are mutually exclusive. Hispanic/Latino persons can be of any race.
** “Other” includes American Indian or Alaska Native and Native Hawaiian or Other Pacific Islander.
^†† Location of patient residence. For persons with commercial insurance, their urban or rural residence was defined using Metropolitan Statistical Areas codes. For persons with Medicaid, their urban or rural location was defined using their zip code and the Centers for Medicare & Medicaid Services carriers’ Medicare Administrative Contractors and localities files (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo).
^§§ Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.