HIV testing is a vital part of our efforts to end the HIV epidemic in the United States. A few days before National HIV Testing Day on June 27, I had the opportunity to talk about HIV testing with Dr. Vincent Guilamo-Ramos, a member of the Presidential Advisory Council on HIV/AIDS (PACHA).  We were fortunate to get some time with him as he was wrapping up his work at New York University and Montefiore Medical Center before he begins his new job on July 1 as the Dean of the Duke University School of Nursing. The following highlights of our conversation have been lightly edited for length and clarity.

Kaye Hayes: Let’s start with the big picture: what role does testing play in our efforts to end the HIV epidemic?

Vincent Guilamo-Ramos: The only way to be certain whether someone has HIV is for them to get tested. Everyone should know their HIV status. It empowers people with the knowledge to protect themselves and their partners from transmission of HIV. By getting tested, people are able to make informed decisions about their sexual and overall health. This includes starting and adhering to HIV treatment to achieve sustained viral suppression if they test HIV-positive or starting and adhering to HIV prevention methods, including pre-exposure prophylaxis (PrEP), if they test HIV-negative. That’s why “Diagnose” is one of the four key pillars of the Ending the HIV Epidemic in the U.S. initiative.

CDC reported in May that approximately 13% of people living with HIV in the United States do not know they have HIV. People with undiagnosed HIV are not receiving the care and treatment they need to protect their immune systems and prevent the transmission of HIV to their sexual partners. So, the CDC recommends everyone aged 13 to 64 be tested for HIV at least once as part of their routine health care. CDC also advises that individuals whose behavior might put them at higher risk of getting HIV benefit from more frequent testing, such as annual or biannual testing for sexually gay, bisexual, and other men who have sex with men. HIV.gov’s Who Should Get Tested? page has a good summary.

KH: HIV testing technologies have improved in recent years and now there are options for self-testing. Can you tell us about the role that self-tests can play and your thoughts on how we can make best use of them?

VGR: I always like to explain to folks that there are actually two types of HIV self-tests: 1) a rapid self-test (a home test), and 2) a mail-in self-test. As noted by its name, these self-test options enable people to administer an HIV test in the privacy of their home or other private location and on their own schedule. A difference between these two types of self-tests is that a rapid self-test can be completed entirely in your home, including producing test results in approximately 20 minutes. The mail-in test does not produce results at home; instead, you administer a fingerstick test to collect a small sample of blood to send to a lab for testing. After the sample is processed, the results of the mail-in self-test will be provided by a healthcare provider. There are different benefits to each test: the home test provides quick results, while a mail-in test can better detect HIV after a recent exposure. CDC’s web page on HIV self-testing has all the details.

Similar to telemedicine, the expansion and increased accessibility of rapid and mail-in self-tests were a response to COVID-19 pandemic, which not only limited the availability of in-person HIV testing due to mitigation strategies such as social distancing, but also redirected the communicable diseases workforce to the COVID-19 response. As a recent paper observed,  this important innovation in at-home and non-clinic based testing increases the accessibility of testing in addition to addressing current COVID-19 related service disruptions, establishing rapid and mail-in self tests as a permanent measure in our HIV prevention toolkit. I think this is really promising for our efforts to end the HIV epidemic.

Also, similar to its effects on retention in care and adherence to treatment, HIV stigma often acts as a large barrier to testing, particularly among those at higher-risk for HIV who often face compounding forms of intersectional stigma. The option to test and receive a result for HIV in the home or other safe environment has the potential to increase the proportion of those at risk of HIV who know their status.

KH: As you said, about 13% of people with HIV in the U.S. haven’t yet been diagnosed. But studies tell us that many of them have had missed opportunities for HIV diagnoses when they have interacted with different segments of the healthcare system but an HIV test wasn’t offered. What can we do to prevent these missed opportunities for HIV diagnoses?

VGR: Testing and diagnosing the 13% of undiagnosed people living with HIV and rapidly connecting them to care and treatment is a critical step in ending the HIV epidemic. By starting and adhering to treatment, people with HIV can lead long and healthy lives and stop the progression of HIV from damaging their immune system and advancing to AIDS. Additionally, maintaining an undetectable viral load means that there is effectively no risk in transmitting HIV to sexual partners, marking the importance of treatment as prevention. So that’s the great potential.

To actually reduce the number of undiagnosed people living with HIV and prevent late diagnosis, we need to expand awareness of the importance of HIV testing, prevention, and treatment across a wide variety of clinicians and the larger health care workforce. Increasing the use and scope of practice of professional nurses, the largest sector of the healthcare workforce, has the potential to prevent many of these missed opportunities for HIV diagnosis while relieving the longstanding strain in the HIV workforce.

In addition, integrating sexual and reproductive health services within a variety of clinical settings outside of primary care can prevent missed opportunities for HIV diagnosis. Bottom line is that a key to increasing HIV testing is ensuring that people at risk for HIV have a variety of easily accessible, culturally competent, and non-stigmatizing opportunities to receive an HIV test and get linked to the appropriate prevention or treatment services based on their test result.

I so appreciated Dr. Guilamo-Ramos’ insights and wisdom. My great conversation with him about HIV testing continued as we explored more in-depth two topics that have been central to his work: HIV among youth and the important roles that nurses play in HIV prevention, care and treatment. Stay tuned for the second installment of our conversation soon.