Ask an Expert: HIV Testing with Travis Sanchez

By Shelby Crosier

There were over 36,000 new HIV diagnoses in the U.S. in 2021. The majority of those new infections were in men who have sex with men, and over half were in the South. In the same year, there were more than 1 million people living with HIV in the U.S., but 13% of them were not aware of their HIV status.

Getting tested for HIV is the only way to know your HIV status and begin treatment. Ahead of National HIV Testing Day on June 27, Travis Sanchez, DVM, research professor of epidemiology, shared insights about the importance of HIV testing, why some people don’t get tested, and how Together TakeMeHome (a program that sends free HIV self-testing kits through the mail) is making testing more accessible.

Tell me about the HIV testing landscape. Who needs to be getting tested, how many people are actually doing it, and who are we missing?

We look to the CDC for guidance regarding HIV testing, and there is an existing recommendation for screening of every later adolescent and adult at least once in their lifetime for HIV. For disproportionately impacted populations, those that are at increased risk of HIV acquisition, they should be tested at least annually, or in some cases even more frequently than annually.

The folks that are being missed kind of varies. We have groups of people who aren't even meeting the once-in-a-lifetime HIV test recommendation. There are some that may not be in the highest HIV acquisition risk group, but still could benefit from additional services like sexually transmitted infection (STI) screening or other follow up.

We also have a substantial proportion of people who are in the higher risk groups that are not getting tested frequently enough. Maybe they've had one HIV test in their life, but they're not doing testing as routinely as they should be.

Who are the disproportionately impacted populations that should be tested for HIV more often?

The CDC’s recommendations for testing more than once in a lifetime are based on behaviors that people engage in that place them at increased risk of acquiring HIV infection.

In addition to those recommendations, we also know that there are populations disproportionately impacted by HIV who should consider testing annually or even more frequently. Those include sexually active gay, bisexual, and other cisgender men who have sex with men; transgender women; and cisgender African American women. These are also priority populations for our new HIV self-testing program.

What barriers do people face to being tested for HIV?

Some barriers come from having to access HIV testing solely through clinic-based testing, and those are access issues. So maybe someone has transportation concerns, maybe they live in a rural area and can't get to a clinic easily, or maybe the place where they could access HIV testing has other concerns around privacy or confidentiality or stigma, particularly for marginalized populations.

That's where HIV self-testing has really come to the forefront more recently, particularly for mailed testing where we can send tests directly to people's homes.

How does Together TakeMeHome address barriers to and disparities in HIV testing?

With Together TakeMeHome, we are reaching a high proportion of people who are taking an HIV test for the very first time. A quarter of the people who are ordering from us have never had an HIV test before, and about another quarter haven't had an HIV test in the past year. I think that emphasizes what we suspected the value of the program was, which was reaching people who are having access issues.

Another thing that I want to emphasize is the geographic reach of this program. We've distributed thousands of tests to every state, and Puerto Rico, in the first year, and more than 400,000 total tests have been distributed. That gives us some idea of what people are asking for, and of where the need lies. There are hundreds of thousands of people that wanted this that weren't getting HIV tested until it was offered to them.

To me, that means that people aren't resistant to the idea of HIV testing. It's more about structure and barriers than it is about intent and interest. I think that is encouraging because for a while we just didn't know why people were not getting HIV tested.

Why is it important for people to have access to HIV testing?​

There is still a substantial number of people who are living with HIV infection but have never had a test, or have not had a recent test, and therefore have not had the opportunity to be diagnosed and then linked into HIV care. We want to get as many people as possible through those systems and into effective HIV care.

The other aspect is that there's evidence that for people who are aware of their HIV status and engaged with care, they have a substantially reduced risk of transmitting HIV infection to their partners. So, there's also a broader public health prevention goal around identifying people early in the course of their infection and ensuring that they get into care.

There are also a whole host of additional prevention activities that can be recommended for people who are not currently living with HIV when they get tested. There are services like STI screening, as well as new prevention tools like taking daily or injectable medications to prevent HIV infection, what we call pre-exposure prophylaxis. Part of that first step into starting those additional prevention activities is to understand your HIV status by having an HIV test.

What more can be done, programmatically or in research, to improve HIV testing efforts?

I think that we see the mailed HIV self-testing as the first step down the whole sexual health pathway for people. So, we hope to be able to strengthen the connections that we can make to those extra steps that we want people to take after they've gotten the HIV self-testing result. We want to think about ways to reconnect them into their local communities and prevention resources. The next phase of the program is going to be thinking about how to strengthen those connections.

At the same time, we have to acknowledge that there is a reason why some people specifically sought out mailed HIV self-testing. We need to think about how we could deliver other care and prevention resources through telehealth or mail, or how we could improve the care environments in their communities to make things more accessible. That could mean making the resources more physically accessible, financially accessible, or improving the culture or privacy protections so that people feel more comfortable going to the places they can access.