AIDS PATIENT CARE and STDs

Volume 18, Number 1, 2004

Mary Ann Liebert, Inc.

Race/Ethnic Disparities in HIV Testing and Knowledge

About Treatment for HIV/AIDS: United States, 2001
SHAHUL H. EBRAHIM, M.D., Ph.D., JOHN E. ANDERSON, Ph.D.,
PAUL WEIDLE, Ph.D., and DAVID W. PURCELL, Ph.D.

ABSTRACT
In the United States, access to HIV care has remained suboptimal for people of color. To assess racial disparities in HIV testing and knowledge about treatment for HIV/AIDS in the
United States, we analyzed the 2001 Behavioral Risk Factor Surveillance System. We obtained
the percentage of respondents aged 18 to 64 years who: (1) were tested for HIV ever and recently (in the past 12 months) excluding for blood donations and (2) responded true to the
statement, There are medical treatments available that are intended to help a person who is
infected with HIV to live longer. We calculated the difference in rates of HIV testing and
knowledge about treatment between blacks or Latinos compared to whites. Overall, of the
162,962 respondents, 44.7% had been tested for HIV and 12.8% were tested in the past year.
Overall, 86.4% answered true to the statement on treatment for HIV/AIDS. HIV testing rates
were significantly lower among whites (ever, 42.4%; recent, 10.8%) than blacks (ever, 59.7%;
recent, 23.4%) or Latinos (ever 45.6%, recent 14.8%). Compared to knowledge among whites
(89.6%), knowledge level was, lower among blacks (odds ratio [OR] 5 0.58, 95% confidence
interval [CI] 5 0.52, 0.64) and Latinos (OR 5 0.67, 95%CI 5 0.59, 0.75) even after adjusting for
sociodemographics and HIV testing status. The knowledge gap among blacks compared to
whites decreased with increasing income and education. We conclude that knowledge about
the availability of antiretroviral treatment was high overall. Compared to whites, blacks, and
latinos had significantly higher HIV testing rates but significantly lower knowledge about
antiretrovirals.

ence to antiretroviral drugs.3,4 While access to

HIV care is good for many adults and improving for others, it has remained suboptimal for
blacks and Latinos, women, and heterosexuals.2,46 In recognition of the importance of these
racial and ethnic differences, the Federal government has made elimination of these disparities a major focus of its prevention efforts as described in the National HIV Prevention Strategic
Plan through 2005.7

INTRODUCTION

UNITED STATES , since 1996, overall AIDSrelated deaths have declined and the number
of people living with HIV/AIDS has increased
largely because of the availability and use of antiretroviral drugs.1,2 The probability of survival
of patients who have AIDS varies by access to a
knowledgeable AIDS physician, manifestation of
disease, age, race, transmission risk, and adherN THE

Centers for Disease Control and Prevention, Atlanta, Georgia.

27

28

EBRAHIM ET AL.

Many HIV-infected people are unaware of

their infection status.7 Among asymptomatic
HIV-infected individuals who are unaware of
their infection, embarking on antiretroviral
treatment is dependent on access to HIV testing. One reason to avoid HIV testing is the fear
of a positive HIV test result, and the knowledge about availability of treatment may decrease such fear. 5,8,9 In addition to knowledge
about personal risk for HIV acquisition, the belief that HIV testing is beneficial as an entry
point to care and knowledge that treatment is
available may contribute to a persons motivation for getting tested for HIV.
While information is available about the
rates of HIV testing among the US population,10 there is little information on knowledge
about treatment for HIV/AIDS. To assess the
knowledge of the population of the United
States on the availability of antiretroviral treatment, questions on knowledge about HIV treatment were included in the 2001 Behavioral Risk
Factor Surveillance System, 11 providing for the
first time, national and state-level data on the
extent of knowledge about HIV treatments. In
this report, we focus on racial and ethnic
disparities in the knowledge about the availability of treatment to prolong life of people infected with HIV and compared it with information on HIV testing.

METHODS
The Behavioral Risk Factor Surveillance
System (BRFSS), established in 1984, is an ongoing, state-based telephone survey that gathers information about modifiable risk behaviors.11 Designed to produce risk factor estimates
for the noninstituitionalized civilian population 18 years of age or older in each state and
the United States, it provides baseline data for
setting national and state health promotion and
disease prevention objectives. All information
collected in the BRFSS is self-reported. The
questions are asked in English or Spanish. The
estimates from the BRFSS are computed using
sample weighting factors that adjust for differences in the probability of selection and nonresponse. This method is designed to produce
unbiased estimates for the adult population of

each state, and when aggregated, of the United

States.
For this study, we analyzed the responses of
all men and women 1864 years of age to the
questions on lifetime (ever tested) and recent
HIV testing (tested in the past 12 months) and
on the availability of treatment for HIV/AIDS.
BRFSS questions on HIV testing have been
published.10,11 Consistent with the definitions
used in an earlier report on HIV testing,10 in
this paper both ever and recent HIV testing excludes testing done exclusively for blood donations. To elicit knowledge about antiretrovirals, a true/false question was read to the
respondents as a statement: There are medical
treatments available that are intended to help
a person who is infected with HIV to live
longer. In this paper, people who respond
true to the above statement are considered to
have correct knowledge about the availability
of treatment for HIV/AIDS.
The outcome measures of interest were rates
of HIV testing and knowledge about treatment
for HIV/AIDS. First, we computed the weighted
percentage of people 18 to 64 years of age who
reported having been tested for HIV ever and
recently. Then we obtained the weighted percentage of people who responded to the statement on HIV treatment true, false, do not
know/ not sure, and refused. We conducted
stratified analyses for the two outcome measures by selected sociodemographic variables,
self-reported HIV test status, and states. To identify variables that are independently associated
with the likelihood of people 18 to 64 years of
age who knew about the availability of treatment for HIV/AIDS, we developed a multiple
logistic regression model in which all the sociodemographic variables and HIV testing status were the dependent variables.
Because we found lower levels of knowledge
about HIV/AIDS treatment among blacks and
Latinos compared to whites, we calculated the
knowledge gap between these races; actual differences in percentage of blacks and Latinos
who knew about treatment for HIV/AIDS
compared to whites stratified by the previously
mentioned variables. We conducted parallel
analyses to assess the gap in HIV testing. We
also obtained state-specific rates of knowledge
for whites, blacks, and Latinos, for the states,

29

DISPARITIES IN HIV TESTING

that had at least 50 respondents in each race category. We used SUDAAN (SUDAAN, Research
Triangle Park, NC) to obtain estimates of standard errors adjusted for the complex sample design. A p value less than 0.05 was considered
statistically significant for all analyses.

RESULTS
The results are based on 162,892 U.S. resident
men and women 18 to 64 years of age (representative of 172 million people) who responded
to the survey in 2001; 1489 respondents for
whom data on knowledge about HIV treatments were missing have been excluded from

TABLE 1.

HIV TESTING

AND

the analysis. The sociodemographic distribution of the respondents (Table 1) is comparable

to that of the U.S. population.12
HIV testing
Of the total sample, excluding the HIV tests
conducted during blood donation, 44.7% reported that they have been tested for HIV, and
12.8% reported that they were tested recently.
Ever-testing and recent testing rates varied significantly by age, race, and marital status (Table
1). Compared to whites, both ever and recent
testing rates were significantly higher in all
population groups for blacks and in some population subgroups for Latinos (Tables 1 and 2).

K NOWLEDGE ABOUT HIV/AIDS TREATMENT : U NITED STATES, 2001

HIV testing (%)

Gender
Male
Female
Race
White
Black
Hispanic
Other
Marital status
Never married
Married
Divorced/widow
Age (years)
1824
2544
4564
Income
,$25K
$2550K
$50K1
Do not know/refused
Education
,High School
High school
Some college
College
Employment
Not employed
Employed
a People

Know that treatment existsa

Distribution
respondents (%)

Ever

Recent

aOR (95% CI)

50.2
49.8

42.5
46.9

12.6b
13.0

85.6
87.2

Referent
1.16 (1.06, 1.28)

69.9
10.2
13.2
6.6

42.4
59.7
45.6
43.8

10.8
23.4
14.8
13.0

89.6
80.9
78.0
77.4

Referent
0.58 (0.51, 0.66)
0.60 (0.52, 0.70)
0.36 (0.30, 0.43)

34.5
58.4
21.1

45.1
43.2
50.2

17.3
10.6
15.3

85.6
87.2
84.4

Referent
0.90 (0.79, 1.02)
0.89 (0.75, 1.06)

15.4
47.5
37.1

44.0
55.7
30.9

20.0
14.8
7.2

84.2
87.5
85.9

Referent
1.05 (0.91, 1.20)
1.05 (0.91, 1.22)

22.8
31.0
34.3
11.9

46.5
45.9
45.2
36.5

15.9
13.5
11.0
10.6

79.6
87.0
93.2
76.4

Referent
1.27 (1.12, 1.44)
1.91 (1.64, 2.22)
0.65 (0.56, 0.76)

8.8
30.6
28.4
32.1

40.7
41.3
47.2
47.5

13.1
12.6
13.9
11.9

71.1
82.1
90.1
93.3

Referent
1.38 (1.20, 1.60)
2.57 (2.19, 3.02)
3.53 (2.96, 4.21)

25.0
74.8

42.8
45.5

13.3
12.6

83.5
87.6

Referent
0.99 (0.88, 1.11)

who responded True to the statement Treatment is available to help people with HIV/AIDS live longer.
Differences in ever and recent HIV testing rates among population groups were significant (p , 0.05)
except for recent testing by sex.
OR, adjusted odds ratios; adjusted for all the variables in the table and HIV testing; 95% CI 5 95% confidence
intervals.
b Note:

30

EBRAHIM ET AL.
TABLE 2.

RACE/ETHNIC DIFFERENCES

Gender
Male
Female
Marital status
Married
Divorced/widowed
Never married
Age (years)
1824
2544
4564
Income
,$25K
$2550K
$50K1
Do not know/refused
Education
,High School
High school
Some college
College
Employment
Employed
Not employed
Geographic region
Northeast
Midwest
South
West
History of HIV testing
Never
Ever
Tested recently

IN

HIV TESTING

AND

KNOWLEDGE ABOUT HIV/AIDS TREATMENT , 2001

Ever tested for HIV (%)

Knew that treatment exists (%)

Actual difference
compared to whites

Actual difference
compared to whites

Whites

Blacks

Latinos

Whites

Blacks

Latinos

40.9
43.8

17.7
16.8

20.9a
7.7

88.9
90.3

28.6
28.8

211.9
211.2

41.3
48.1
41.9

17.7
9.6
20.0

4.5
2.2a
0.7a

90.0
87.6
89.6

27.0
28.3
29.9

211.6
29.2
212.2

42.5
54.9
28.0

18.5
14.1
18.3

20.2a
23.4
8.3

88.2
91.1
88.4

29.2
28.8
28.4

213.6
211.5
210.8

44.5
43.1
43.5
32.8

14.7
18.2
20.6
17.3

21.6a
3.2
9.5
10.8

84.3
89.2
94.2
80.9

27.1
25.6
23.2
213.2

211.1
26.9
22.9
212.7

41.4
37.7
43.6
45.9

11.6
19.1
20.6
17.7

25.2
9.1
9.3
11.3

75.1
84.5
91.9
95.3

29.6
28.9
24.6
23.8

26.1
25.8
26.1
26.4

43.2
39.9

18.6
15.3

1.9a
7.5

90.5
87.1

27.4
210.3

211.5
210.7

39.8
37.6
44.9
46.7

22.5
21.2
14.7
10.9

13.8
9.0
0.8a
24.5

90.4
89.9
87.3
92.2

24.3
26.6
28.5
211.3

214.7
27.2
28.7
214.4

87.1
93.0
92.1

214.6
26.4
26.1

216.0
26.7
27.1

a Actual differences compared to whites for blacks or Latinos within each population group were significant
( p , 0.05) both for HIV testing and knowledge, except when marked.
(2) indicates lower rates among blacks and Latinos compared to whites. Other rates are higher than whites.

Overall knowledge and its determinants

Of the total sample, 86.4% of respondents
stated correctly that it was true that treatment
existed to help HIV-infected people live longer;
3.3% stated that treatments did not exist. The
majority of those who did not provide the correct answer stated that they did not know or
were not sure (7.7% of the total) that treatment
existed to help HIV-infected people live longer.
An additional 2.7% refused to answer the question. Knowledge increased with increasing
educational level and average annual household income. Statistically significant differ-

ences were found in the percentage of people

who knew about treatment for HIV/AIDS by
race, marital status, income, and education after adjusting for sociodemographics and HIV
test status of the respondent (Table 1).
Knowledge gap
By race, blacks and Latinos had the lowest
percentage of people who knew about treatment for HIV/AIDS, 8.6 to 11.6 percentage
points, respectively, less than the rate for
whites (89.6%) and this trend was statistically
significant for all population groups (Table 2).

31

DISPARITIES IN HIV TESTING

Knowledge gap compared to whites was generally similar for men and women both among
blacks and Latinos; thus only aggregate data
for men and women are presented in Table 2.
Among sociodemographic subgroups, both
among blacks and Latinos, knowledge gap
about treatment for HIV/AIDS compared to
whites was the smallest among people who had
an annual household income above $50,000
and highest among those who never had an
HIV test (Table 2). Among blacks, knowledge
gap compared to whites narrowed with increasing education and income. However,
among Latinos, such a pattern was noted only
for income.

FIG. 1.

Of note, even among blacks and Latinos who

had been tested for HIV, knowledge level was
not higher than that among whites who had
not been tested for HIV (Table 2). Whites in
most states had knowledge rates above 85%
(highest rate, 95.0% Washington, D.C.) and in
few states in the 81%85% range (Louisiana,
Kentucky, Mississippi, Tennessee, Nebraska).
Among blacks, among the 38 states with adequate sample size, knowledge rates varied
from 66.0% in Mississippi to 91.0% in Hawaii
(Fig. 1). Among Latinos, among the 43 states
with adequate sample size, knowledge rates
varied from 65.0% in Arkansas to 92.5% in
Delaware (Fig. 1).

Percentage of blacks and Latinos who knew that treatment exists for HIV/AIDS, 2001.

32

EBRAHIM ET AL.

DISCUSSION
This first population-based U.S. data on
knowledge about treatment for AIDS indicates
high knowledge level in the general population.
This rate is about the same as that reported for
Sweden, the only other developed country that
has reported such data.13 Despite higher rates of
HIV testing among blacks and Hispanics compared to whites shown by this study and in previous reports, we found that knowledge about
the availability of antiretroviral treatment was
significantly lower among blacks and Latinos,
compared to whites. The reported increase in the
percentage of people who were ever tested, from
the mid-1980s (1987; 5%) through the mid-1990s
(19951996; 38%42%),10 appears to have leveled
off (44.7% in 2001 in our study). The low percentage of people ever tested for HIV for 1998
(30%) reported based on the National Health Interview Survey could be caused by inclusion of
responses from older people in that analysis
(39% of the respondents were aged 50 years or
older).14 The percentage of people who have
been tested in the past year is within the 9%17%
rates reported by various national surveys in the
1990s.10
The populations groups identified in our
study as having low rates of knowledge about
treatment for HIV/AIDS (people of color, low
socioeconomic status) are also known to have
less knowledge and utilization of many other
health services including influenza vaccination, cancer screening, cardiovascular care, sexually transmitted disease (STD) services, and
prenatal care.15,16 The differences between socially disadvantaged and advantaged population groups may have been even wider if the
BRFSS data collection methods had allowed for
inclusion of population groups such as people
without telephones and people who are instituitionalized. The data from the BRFSS are subject to social desirability bias, coverage, and reporting errors that affect survey data. People
who exhibit HIV risk behaviors may be more
knowledgeable about HIV/AIDS treatment
than the general population and such risk information is not collected by the BRFSS. Notwithstanding these examples of sampling bias,
our data shed light on a fundamental aspect of
HIV/AIDS care utilization: knowledge that
treatment for HIV/AIDS exists.

We had expected that nearly all people who

were tested for HIV, irrespective of color, would
know about treatment for HIV. Knowledge gap
among people of color, however, existed even
among people who had been tested for HIV. Although the BRFSS data cannot be used to assess
the quality and content of counseling during HIV
testing, the results from this study underscore
the need to ensure that the contact of people with
the health care system during a testing encounter
be used to educate them about fundamental aspects of HIV/AIDS prevention and care. It is a
challenge for health care providers and public
health departments to communicate information
about emerging treatment options to diverse
population groups that traditionally had poor
uptake of health-related messages. It has been reported that even among people who had a
known health care provider or health insurance
coverage, those who belong to minority populations groups are less likely to hear about antiretroviral drugs than others.4,17 Physicians may
communicate less effectively with people of
lower socioeconomic status and disadvantaged
minority populations, and some population
groups may lack trust in the medical care system, both of which adversely affect uptake of information by patients.18
While it is debatable whether knowledge
about the availability of treatment is a necessary factor in peoples motivation to access a
particular treatment, according to the theory of
reasoned action,19 individuals attitudes toward particular drugs would be expected to
contribute to their decisions to use or not use
the drug or making attempts to access such
drugs. HIV treatment can reduce both the
transmission of infection and disability and the
need to close the gap in racial disparities with
respect to knowledge about HIV/AIDS treatment is clear. The United States has succeeded
in closing racial disparities in access to and utilization of care with respect to some health issues. For example, adequate utilization gap in
prenatal care services between whites and
blacks narrowed steadily through the 1980s
and moved toward unity in the 1990s.16
Targeted HIV testing may have resulted in
the higher testing noted for people of color
compared to whites in our study and in previous reports which used national data.14 Population groups with lower level of HIV preva-

33

DISPARITIES IN HIV TESTING

lence may not perceive themselves to be at increased risk for HIV, and therefore are not inclined to seek HIV testing. However, low levels of education, associated with low levels of
HIV testing in our study and other studies,14 is
also associated with low levels of and knowledge about treatment for HIV. Drawing from
these findings and experiences in advancing
HIV prevention among most affected population groups, initiatives aimed at increasing access to antiretrovirals should make greater efforts to inform blacks, Latinos, and people with
low level of education about the availability of
antiretroviral treatments through innovative,
varied, and culturally sensitive educational
strategies. Current national policy emphasis on
and commitment to the reduction of racial disparities in access to HIV/AIDS treatment, including existing efforts to remove economic
barriers to HIV/AIDS treatment, can help narrow the knowledge gap.

ACKNOWLEDGMENTS

9.

10.

11.

12.

13.

14.

M.T. McKenna is thanked for his suggestions

on the analysis and comments on the draft.
15.

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Address reprint requests to:

Shahul H. Ebrahim, M.D., Ph.D.
Mail Stop E37
Centers for Disease Control
1600 Clifton Road
Atlanta, GA 30333
E-mail: Sbe@cdc.gov

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