HIV testing rates are suboptimal in the United States, according to a study published in the Morbidity and Mortality Weekly Report. There is significant regional variation in testing rates, with rural areas displaying lower rates of testing and diagnosis than urban areas.

The study included data collected through the telephone-based Behavioral Risk Factor Surveillance System (BRFSS), which examined the rates of US adult HIV testing nationwide, in 7 states with disproportionately high rural diagnoses, and in 50 local jurisdictions accounting for the majority of incident HIV diagnoses. In this survey, respondents were asked about prior HIV testing, as well as about high-risk behaviors. The percentages of lifetime history of testing and testing within the previous year were estimated using pooled data from 2016 to 2017. Counties were categorized as mostly urban, mostly rural, or completely rural. Testing percentages were compared between urban and rural counties using Rao-Scott chi-squared tests. The complex multistage sampling design was accounted for through weighting. HIV diagnosis rates among people aged >13 years were reported per 100,000 population.

Among those surveyed, 38.9% of those aged >18 years had ever received an HIV test. Among the 15,701 participants who reported a recent risk for HIV exposure, 29.2% had received a test in the past year, and 64.8% had ever been tested. Adults within the 50 high-diagnosis jurisdictions had a higher rate of lifetime testing (46.9%) compared with those in the 7 states with disproportionate rural HIV (35.5%). The percentage of testing in the past year among at-risk individuals was 34.3% in the 50 jurisdictions, compared with 26.2% in the 7 states.

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Generally, the 50 jurisdictions had higher rates of testing and diagnosis compared with the 7 states. However, 32.1% of adults living in 1 of the 7 states resided in mostly rural areas, compared with 37.2% who resided in mostly urban areas had ever been tested for HIV. Lifetime testing varied widely between jurisdictions (36.5%-70.7%), as did testing within the past year (8.1%-31.3%). The percentage of lifetime testing among adults in the 50 jurisdictions and 7 states was positively associated with a rising rate of HIV diagnosis among individuals aged >13 years (r=0.71; P<.01).

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Limitations to this study included a small proportion of individuals reporting recent HIV risk, potential bias within self-reported data, low BRFSS response rates, the lack of inclusion of every HIV risk-increasing behavior, disparate age ranges among participants, and the inclusion of data from 2016 to 2017 surveys and concurrent HIV diagnoses.

Study researchers concluded that less than “Ever testing for HIV was lower in rural areas of the seven states with disproportionate rural HIV occurrence, compared with that in urban areas of these states, the 50 local jurisdictions with the majority of diagnoses of HIV infection, and the United States nationally.”


Pitasi MA, Delaney KP, Brooks JT, DiNenno EA, Johnson SD, Prejean J. HIV testing in 50 local jurisdictions accounting for the majority of new HIV diagnoses and seven states with disproportionate occurrence of HIV in rural areas, 2016–2017. MMWR Morb Mortal Wkly Rep. 2019;68(25):561–567.