Ann Do is a research associate professor in the Department of Epidemiology at Emory University and previously served as a medical epidemiologist in the Division of HIV/AIDS Prevention (DHAP) at Centers for Disease Control and Surveillance (CDC).
Q: You started your professional career working with the CDC’s Epidemic Intelligence Service and were a founding member of CDC’s DHAP Mental Health and Substance Use Working Group. How did you become interested in working on HIV/AIDS policy and how have you seen it evolve over the last two decades?
HIV is a condition that cuts across health and society. I began working in HIV after starting my residency in the nineties. When I got into the Epidemic Intelligence Service at CDC, I was originally assigned to the Hospital Infections Program, where we were seeing a lot of tuberculosis (TB) outbreaks in hospital settings because HIV patients were susceptible to TB. When AIDS was first recognized, the focus was primarily on preventing deaths, but we’ve come so far since then. If you said 20 years ago that we could even think about working towards a cure, no one would take you seriously, but now researchers are actually working toward potential cures, which is an amazing shift.
In HIV surveillance, where I came to work for most of my public health career, the big transition was from AIDS surveillance to HIV surveillance. Before there was an HIV test, we could only rely on clinical signs of AIDS for case detection, and much of the initial epidemic response involved clinical issues – preventing AIDS opportunistic illness and death. Then, when we had an HIV test, the focus shifted to detecting new infections and conducting behavioral surveillance to guide primary prevention efforts. We’ve come a long way in the last two decades, but I think there’s still a lot more work to be done. Although the rate of new HIV infection has decreased overall, we know that HIV still disproportionately affecting communities of color. Until we find a way to address that disparity effectively, we’re not going to be able to make any substantial gain in terms of fighting HIV.
Q: The Behavioral Risk Factor Surveillance System (BRFSS) is a series of health-related telephone surveys that collect state data about U.S. residents regarding their health-related risk behaviors, chronic health conditions, and use of preventive services. The most recent available BRFSS data suggests that there has been a slight increase in the number of people who report having been tested for HIV, currently around 40% of respondents. What is causing this increase and how can we continue to drive this number up?
BRFSS is such a valuable source of data that allows us to look at HIV testing, not just nationally, but also at the state level and in large metropolitan areas. Regarding the data on the prevalence of ever having tested for HIV, the slight annual increase is a natural pattern that is expected over time, and not really indicative of a true increase in recent testing. If there were a spike in the prevalence of ever having tested for HIV, that may be more indicative of an increase in recent HIV testing, but data on past-year HIV testing would be a more direct measure of recent testing patterns
In terms of how we can continue to drive up HIV testing, the biggest thing would be to normalize testing. We all think about getting our cholesterol or blood sugar checked, but I think there is still a lot of stigma associated with HIV testing. Therefore, the more that we can normalize HIV testing, the better. One way to do this is to include a prompt in electronic health records, just like there is for cholesterol testing so that people don’t even think about it; doctors just do the test as part of routine testing for other conditions.
Another way we can increase testing is to normalize it among the health care providers. I think health care providers need to look at HIV testing just like other kinds of health maintenance issues. Most importantly, I think we just need to provide HIV testing everywhere. In recent years, we have an increase in pharmacists doing HIV testing in pharmacies. I think that’s helpful and something that we can build on. It is also another way of making HIV tests more widely available in non-traditional settings.
Q: The BRFSS data on HIV testing by age shows that young people aged 18-24 are among those least likely to report having ever been tested for HIV, along with individuals 65 and older. So many HIV awareness campaigns and interventions target young people. Why are we still seeing such a low rate of testing among these communities?
Lower rates of testing in youth populations is not just a phenomenon in the U.S.; it’s occurring worldwide. This trend suggests that there are not only age-related factors but also ways we can improve our outreach strategies. My background is in pediatrics, and from experience, I know that young people, especially adolescents, have a sense of invulnerability where they don’t think bad things can happen to them. Plus, at that stage of life, there is a need to really belong, so I think they are more sensitive to HIV stigma. There may also be a lack of knowledge and awareness at play. For those in this field, we hear about HIV all the time, but we forget that younger generations may not have been exposed to HIV messages in the same way. Overall, I think the messages need to be more directed at younger persons.
I think it’s good that there’s a lot of focus on youth, but despite this, we still don’t know a lot about what is effective in terms of getting young people to get tested and more research that needs to be done to see what works. I’m involved in iTech, which is part of the Adolescent Trials Network and focuses on looking at technology-based interventions for young people. Phone applications can make it easier for young people to find HIV prevention services, testing, and PrEP services. We need to look for more services that are designed for youth and that are youth-friendly. I think a lot more outreach needs to happen because young people don’t generally seek out HIV testing on their own and need to be encouraged to do so.
Q: Routine testing is one of the most important ways to detect new HIV infections as early as possible. Why is this such an important tool and how can we ensure people have access to routine screening, especially in a time of disruption like COVID-19?
HIV testing is truly the gateway to HIV care. You can only be linked to care if you receive an HIV diagnosis. In addition, for those who test HIV negative, it’s an opportunity to deliver HIV prevention messages and referrals to PrEP. However, because we are in the COVID-19 pandemic, it’s trickier to continue to encourage people to get testing because testing accessibility is a problem. I think that in the healthcare sector some clinics may start to open up soon. In the lab setting, there are precautions that can be taken to prevent COVID-19 transmission, and patients can get tested in brief lab visits and leave without a lot of exposure. It’s the in-person clinical visits that would be lengthier and can be more problematic.
As we eventually move past this pandemic, people should increasingly be able to go and get in-person testing. However, there is also an opportunity to promote home testing as well since that’s available now. More people do seem to like doing rapid home testing for many reasons, including privacy and ease of accessibility. While I do hear that the rapid home test tends to be not as sensitive as the lab test, it’s a good way to start if our goal is to get people to do HIV testing. CDC has put out guidance about HIV testing during COVID-19, and they recommend lab only visits or home testing.
Q: What value does mapping this data have and why is AIDSVu adding these maps on HIV testing to our site?
I think anything that can bring attention to HIV testing can help. It’s great that we’re able to look at HIV testing by state, but mapping the data makes it a lot more accessible, easier to interpret, and helps to drive the point home. Maps help us visualize where we still need to do a lot more work in terms of getting people tested.
I see the HIV testing maps on AIDSVu as just the beginning. I think eventually we’ll want to be able to drill down to below the state level. All in all, I think displaying data on maps is a great way for people to visualize the data and just be able to interpret it quickly. I think AIDSVu continues to be a great tool for other HIV-related data and now the new HIV testing data just adds to that.