Identifying Missed Opportunities for HIV Testing in Clinical Settings

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Pinpointing and eliminating missed opportunities for HIV testing and diagnosis in healthcare settings has the potential to reduce HIV transmission, especially among high-risk groups.

Despite the CDC’s recommendation that people at a higher risk of contracting HIV be screened annually, many are not offered or do not receive HIV testing. The CDC estimates that 1 in 7 people living with HIV do not know they are infected, and many live with HIV for years before their infection is diagnosed.

With the importance of early detection and linkage to treatment for patient outcomes and viral suppression, clinical settings play a crucial role in identifying undiagnosed HIV cases. As men who have sex with men (MSM) and people who inject drugs (PWID) are at high risk of being HIV-positive, researchers estimated the percentages of these groups who are unaware of their HIV infection to pinpoint missed opportunities for testing and diagnosis in the clinical setting.

The researchers used data from high-risk populations in rotating annual cycles in cities with high HIV burden from the CDC’s National HIV Behavioral Surveillance (NHBS). Data from 9105 MSM were collected in 2014, and data from 19,357 men and women who reported injecting drugs in the past year from 2012 to 2015 were collected. Participants completed an anonymous interview and HIV test. They were considered unaware of their HIV infection if they reported no previous HIV-positive test result or no previous HIV test, had a confirmed HIV-positive NHBS test result, and had no detectable antiretroviral drugs in their blood sample.


Of the MSM, 22% had a positive test result, and 8% of PWID had a positive test result. Of those who were HIV-positive, 8% of MSM and 12% of PWID were unaware of their infection.

Notably, the majority of MSM and PWID who were unaware of their infection reported having visited a clinician in the past year (81% and 65%, respectively). However, a lower proportion reported being offered an HIV test by the clinician at the time (43% and 24%, respectively).

Of unaware MSM, 44% reported not having an HIV test in the past year, whereas 77% of PWID who were unaware of their infection reported not having a test in the past year. Among those not tested in the past year, 52% of MSM and 45% of PWID indicated that they had not been offered a test, despite a visit to their clinician.

Reviewing the data, the authors noted, “Many HIV infections among MSM and PWID could be diagnosed sooner if HIV testing were more frequently offered during clinical visits.” They recommend that clinicians routinely screen patients for HIV and identify those with ongoing risk to ensure that they are screened annually.

They concluded that eliminating missed opportunities for HIV testing and subsequent diagnoses in healthcare settings may reduce HIV transmission, especially among high-risk groups, such as MSM and PWID.


Wejnert C, Prejean J, Hoots B, et al. Prevalence of missed opportunities for HIV testing among persons unaware of their infection [published online June 26, 2018]. JAMA. doi: 10.1001/jama.2018.7611.