The number of eligible Americans undergoing HIV testing remains low, around 59%, despite US Centers for Disease Control and Prevention (CDC) recommendations for routine screening on an opt-out basis, according to study results from an article published in Public Health Reports.1

Undiagnosed HIV remains a major public health concern, with approximately 15% of infected people unaware of their diagnosis, according to the CDC.2 To help improve the rate of screening and acceptance of HIV testing on an opt-out basis, the researchers recommend addressing health system- and patient-related factors. The results of the study “suggest that outpatient settings are settings in which an opt-out HIV screening approach should be integrated into routine medical care,” they wrote.  

To look at acceptance rates, the researchers searched online databases for studies published between January 1, 2006, and December 31, 2018, that reported opt-out HIV screening programs in outpatient settings in the United States. Studies were excluded if they reported opt-in or other types of HIV testing and if they were conducted in inpatient settings, emergency departments, antenatal settings, jails, or prisons.

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Data were collected on the percentage of persons who were offered HIV testing, the percentage of persons who accepted the test, and the percentage of new HIV diagnoses among persons tested.

The final analysis included 14 studies. Of these, 8 reported the number of people eligible for HIV screening. Among the 8 studies, the percentage of eligible patients offered HIV testing varied widely — from 27.5% to 100% — for an overall percentage of 71.4% of the people eligible for HIV screening offered testing on an opt-out basis.

All 14 studies reported data on the number of persons who accepted testing; the results also found a wide variation in studies from 16.9% to 96.3%, for a weighted 58.7% of persons who accepted testing.

Finally, a total of 9 studies reported data on new HIV diagnoses. A weighted 0.18% of persons tested were found to have a new HIV diagnosis. The highest percentage of new HIV infections was among adolescents and young adults aged 13 to 23 years (0.26%); most of the new cases (73 of 88) were among African American people.

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Further analysis found a total of 6 studies that reported reasons for opting out of HIV screening. Patients most frequently cited that they did not receive screening because they perceived their risk of having HIV as low. This reason was followed by having had a previous HIV test, not having enough time for testing or to wait for test results, privacy concerns, fear of needles, not expecting an HIV test, cost, and not wanting to know their HIV status.

“The rates of offering and accepting an HIV test on an opt-out basis in outpatient settings could be improved by addressing health system and patient-related factors,” the authors concluded. “The percentage of new HIV diagnoses suggests the need for strengthening the implementation of opt-out HIV screening in these settings.”


1. Gebrezgi MT, Mauck DE, Sheehan DM, et al. Acceptance of opt-out HIV screening in outpatient settings in the United States: a systematic review and meta-analysis. Public Health Rep. 2019;134(5):484-492. 

2. Centers for Disease Control and Prevention. HIV: Basic Statistics. Updated August 6, 2019. Accessed October 28. 2019.