More than 1,100,000 people in the United States (US) are living with HIV/AIDS, and an estimated 20% of these infections remain undiagnosed [1, 2]. As of 2008, over 77,000 cases of HIV/AIDS have been reported in Texas, the 4th highest number of cumulative cases reported by state [3]. Knowledge of HIV status is critical for reducing the rates of HIV/AIDS transmission, and HIV testing has been an important part of HIV prevention efforts with improvements in test accuracy and availability [4]. In 2009, an estimated 45% of persons aged 18-64 reported ever having received an HIV test in the US [1].

Poor rates of routine testing and late diagnosis of HIV, which are common in the US, represent missed opportunities for linkage to care, treatment of HIV positive persons, and prevention of new infections. Of incident HIV diagnoses in 2008, one-third progressed to AIDS within 1 year, indicating these persons had likely been infected for the decade prior to diagnosis [1, 5]. In Texas, over one-third of all HIV diagnoses between 2003-2009 were late stage diagnoses, and an estimated one-third of Texans with known HIV diagnoses were not receiving care [6].

Various demographic, healthcare, and behavioral characteristics have been associated with ever having been tested for HIV including gender, age, and race. As of 2008, of those living with HIV/AIDS over the age of 13 in the US, roughly 21% of males and 18% of females had undiagnosed infections. By age, an estimated 58.9% of HIV positive persons aged 13-24 are living with undiagnosed HIV infections; this percentage is lower for other age groups [5].

HIV disproportionally affects blacks and Hispanics in the US relative to whites, with rates of infection nine and three times higher, respectively (112.1/100,000 for blacks and 40.5/100,000 for Hispanics versus 12.6/100,000 for whites) [1]. By race/ethnicity, undiagnosed HIV infection is more common among Asians/Pacific Islanders (26.0%), and American Indians/Alaska Natives (25.0%) relative to blacks/African Americans (21.4%), whites (18.5%), and Hispanic/Latinos (18.9%) [5]. According to the CDC, over 30% of US men living with AIDS are black, and almost 20% are Hispanic. Among women living with AIDS, almost 60% are black and 20% are Hispanic. In addition, those who are tested late in the course of the disease are more likely to be black or Hispanic [7].

Whites have been reported to be less likely to receive an HIV test than blacks or Latinos [8]. The CDC estimates that 61.8% of blacks, 47.6% of Latinos, and 40.9% of whites have ever been tested for HIV. However, despite higher rates of ever testing among blacks and Hispanics, the disproportionately high rates of HIV/AIDS diagnoses among these subpopulations indicate that blacks and Hispanics would benefit from increased testing frequency to increase early diagnoses [1]. This is a particularly relevant issue in Texas due to its large Hispanic population. According to the 2010 US Census, over 9.4 million Hispanics live in Texas, representing 37.6% of the population [9]. Of AIDS diagnoses in Texas, 45% were among whites, 32% were among blacks, and 22% were among Hispanics [3].

Other factors including area of residence, education, marital status, employment, income, and insurance status also influence rates of HIV testing. In a secondary analysis of 2005 and 2009 Behavioral Risk Factor Surveillance System (BRFSS) data, the relationship between metropolitan statistical area (MSA) and HIV testing was examined. Persons residing in urban areas were significantly more likely to have been ever tested for HIV relative to those residing in rural areas (43.6% vs 32.2) [10]. Research also indicates that individuals who have not graduated from high school are less likely than those with higher levels of education to be tested, and those who are tested late in the course of the disease are likely to be less educated than those tested earlier [7, 11].

Findings from 2008 BRFSS data indicated that a relatively higher proportion of those never married/divorced/widowed/separated had ever been tested relative to those who were married/a member of an unmarried couple (40.2% vs 36.8%) [12]. The 2008 BRFSS data indicate that relatively equal proportions of those who were employed versus unemployed had ever been tested. A higher proportion of those making an annual household income <$15,000 had ever been tested relative to those earning $15,000-$50,000 or over $50,000 (43.2% versus 40.1% and 37.6%, respectively) in the 2008 BRFSS [12].

Insurance status may affect HIV testing as insured individuals likely have more contact with health providers or health clinics and therefore more opportunities to get an HIV test. Data from the 2008 BRFSS indicated that a similar proportion of insured and uninsured had ever received an HIV test (37.5% and 39.7%, respectively) [12]. Barriers to HIV testing may represent unique challenges in Texas because of the large numbers of uninsured residents, which the US Census estimated to be 24.6% of the population for 2003-2005 [13].

An individual’s relationship with a healthcare provider can also be an important factor in deciding whether to be tested for HIV. Physician endorsement of HIV testing is one of the most consistent predictors of HIV testing. Attitude toward the person providing the test is a factor that HIV test recipients have identified as important in their attitudes toward HIV testing [14]. In the 2008 BRFSS, a similar proportion of those with or without a primary healthcare provider had ever been tested (37.8% and 38.7%) and a higher proportion of those having not seen a doctor in the past year because of cost had ever been tested for HIV (46.3% and 36.4%) [12].

HIV risk behaviors may also be related to ever receiving an HIV test – roughly 28% of persons with any HIV risk factor had ever been tested using 2001-2009 NHIS data for those aged 18-64 [1]. A stronger predictor of HIV testing than actual behavior may be perception of risk for HIV, and research suggests that perceiving no risk for HIV is a barrier to testing [15].

During recent years, HIV transmission and progression prevention strategies have emerged, including early diagnosis of the infection. A delay in diagnosis until later stages may be associated with irreversible immune damage and related complications. Accordingly, the Joint United Nations Program on HIV/ADIS has developed a strategy to reduce infections in young people by half with a primary objective of increased access to HIV testing [16].

Given the high prevalence of HIV infections in Texas, many of which are undiagnosed, the relatively high rates of uninsured persons, and inconsistent research findings regarding HIV testing among Hispanics, more research is needed to understand how these and other factors influence HIV testing in Texas. This study investigated the association between demographic characteristics (gender, race/ethnicity, age, area of residence, education, marital status, employment status, and income), health care characteristics (insurance status, having a primary provider, and access to health care), and HIV risk behaviors with ever having received an HIV test using 2010 Texas BRFSS data.

Of the 18,077 respondents in the 2010 Texas BRFSS, 11,518 were under the age of 65 and were asked whether they had ever received an HIV test, of which 9,744 had complete exposure information. Of those, 3,575 (36.69%; weighted 39.99%) had ever received an HIV test, 5,933 (60.89%; weighted 57.62%) had never received an HIV test, and 236 (2.42%; weighted 2.40%) responded ‘don’t know/not sure’ or ‘refused to answer’.

The final analysis was restricted to the 9,744 respondents with complete exposure information answering ‘yes’ or ‘no’ to have been ever tested for HIV. The 236 respondents answering ‘don’t know/not sure’ or ‘refused’ were excluded from modeling analyses. These respondents were significantly (p<0.05) different from those that answered the HIV testing history question as either ‘yes’ or ‘no’ by race/ethnicity (more likely to be white or multiracial/other and less likely to be black or Hispanic), education (more likely to have attained a higher level of education), and marital status (more likely to be married and less likely to be separated or a member of an unmarried couple).

These findings suggest that there are important relationships between gender, age, area of residence, marital and employment status, and HIV risk behaviors and HIV testing in a Texas population by race/ethnicity. Whites and Hispanics shared many significant predictors of ever receiving an HIV test that were not observed among blacks. White and Hispanic women were significantly more likely to have been tested relative to men of the same racial/ethnic group, and whites and Hispanic in the 25-44 year age group were also significantly more like to have ever been tested for HIV relative to members of the same racial/ethnic group ages 18-24. Additionally, white and Hispanic respondents who were divorced versus married and those reporting at least one HIV risk behavior were more likely to be tested. Similarly, BRFSS data from four states found that 19% of respondents reported at least one risk behavior, which was different by gender (men 23%; women 15%), and that among this subgroup, younger age groups also had a higher likelihood of having received a recent HIV test; perception of risk also influenced HIV testing behaviors [18]. These findings are consistent with our study for white and Hispanic populations, and emphasize the need to further explore racial/ethnic differences in HIV testing behaviors. Another study using 2005 BRFSS data to evaluate testing rates and predictors of testing among racial/ethnic groups found that, similar to our study, gender was not a significant predictor among blacks; in contrast to our findings, this study showed that marital status was not a significant predictor among Hispanics [19].

MSA was a significant predictor among whites and blacks. Whites who lived outside the central city of a MSA and those who did not live in a MSA were significantly less likely to have been ever tested relative to those who lived in the central city of a MSA. In contrast, blacks not living in a MSA were more likely to have been ever tested relative to those residing in the central city of a MSA. Studies have shown that persons residing in rural areas are less likely to report ever receiving an HIV test, possibly contributing to relatively high rates of late-stage HIV diagnoses in rural areas [10]. Findings from this study indicate that area of residence needs to be further explored in relation to HIV testing by racial/ethnic groups with the goal of planning interventions and allocating resources targeted to high risk groups. The implications for these differences may be compounded by disparities in HIV diagnoses by race/ethnicity between urban and rural areas [20]. Additionally, employment status was a significant predictor among whites but not the other racial/ethnic groups – whites who were unable to work were more than twice as likely to have been ever tested for HIV relative to those who were employed for wages. Also, blacks that were widowed or separated were significantly less likely to have been tested relative to those who were married.

Overall, higher rates of testing were observed among blacks relative to other racial/ethnic groups. The higher rates of lifetime testing for blacks may be a result of increased perception of risk [21]. The lower rates of testing among Hispanics could be associated with a reluctance to discuss sexual issues in the Hispanic culture, a barrier to visiting clinics or medical centers for an HIV test, and possibly differential risk perception [22, 23]. Additionally, the relationship between risk perceptions/behaviors and HIV testing may be more important for some ethnic groups than others. Fernandez et al., reported that Hispanic men who engaged in HIV risk behaviors were more likely to have been tested and to have been tested recently than men who had not engaged in such behaviors [24]. Perceptions of risk may be a better predictor of HIV testing than actual riskbehavior, and a measurement of such perceptions may be a valuable addition to the BRFSS. Since perception of risk is cited as an important predictor of HIV testing, the CDC emphasizes the need for counselors involved in HIV prevention to assist clients in developing a more accurate perception of risk [25].

Limitations of the study include those inherent to the BRFSS, namely the cross-sectional nature of the data, self-reported data which may lead to information bias, potentially ambiguous question structures, and lack of inclusion of persons without telephones [17]. Further limitations to this analysis include the inability to evaluate the association between respondent knowledge of HIV and HIV treatments and HIV testing. Knowledge about treatments for HIV may be an important predictor since knowledge about treatments may reduce the fear of receiving a positive HIV test. Additional research should examine differences in knowledge about HIV among different racial/ethnic groups in order to develop strategies for improving differential knowledge and increasing rates of HIV testing for those most at risk. Studies reported that the level of awareness of HIV and HIV treatments varies by age, race, ethnicity, and education [26].

Our findings have implications for future studies and may aid healthcare professionals working with various racial/ethnic groups at-risk for HIV/AIDS in Texas. Because there were significant differences in the rates of HIV testing by demographic characteristics, more research is needed to investigate whether men and women or individuals from different ethnic groups need specialized interventions to promote HIV testing. Finding interventions that promote increased testing among Hispanics and blacks is especially important because of their increased risk for HIV/AIDS. Since the findings indicated that Hispanics were less likely to be tested than blacks, there is a critical need for more research studying the predictors of HIV testing for this population and interventions that may improve their rate of testing.