clinical care services (ranging from closer monitoring of immune status to intervention with antiretroviral therapies or prophylaxis for opportunistic infections). The CDC has long maintained the importance of HIV testing as a prevention tool, and recent studies have shown that counseling and testing can be a cost-effective prevention intervention (e.g., Kamb et al., 1998; Weinhardt et al., 1999; The Voluntary HIV-1 Counseling and Testing Efficacy Study Group, 2000).
The CDC also has supported an anonymous HIV counseling and testing infrastructure that is separate from the clinical care setting. Originally created to keep high risk people from using blood banks to learn their HIV status, these alternative testing sites funded by the CDC have often been considered an important part of prevention interventions and a valuable resource for individuals who fear the stigma of HIV testing and want to learn their status in an anonymous setting.
The CDC estimates that 24.6 million people were tested in the United States in 1996. Of these, an estimated 2.6 million tests (not individuals) were performed at CDC publicly funded test sites (CDC, 1998),4 meaning that the overwhelming majority of HIV tests in 1996 occurred in clinical care settings. If one of the objectives of testing is to identify individuals with HIV and get them into appropriate care (both clinical care and prevention services), the integration of HIV testing services into existing clinical care settings would accomplish several important goals, including assuring that those identified as HIV-infected would have immediate access to clinical care, destigmatizing HIV testing and making it a routine part of care, and promoting the linkage of clinical care and prevention services.
If the clinical care setting is to become a venue for prevention, then it is important to understand where people with HIV are served and how clinical care programs can be better adapted to address prevention needs.
The CDC defines its publicly funded sites as those receiving CDC funds; the majority of these sites are clinical care settings but about 26 percent are freestanding counseling and testing sites (CDC, 1990). The CDC definition may exclude HRSA-funded testing sites where a significant number of HIV tests are performed. Community Health Centers (CHCs) alone report performing 218,742 tests in 1998 (National Summary Data, 1999), whereas Title III grantees report performing 315,234 tests in 1997 (HRSA, 1997). This may overlap significantly with the CHC data, since many Title III grantees are CHCs and report to both programs. In addition, many Title III grantees also receive CDC counseling and testing money, and some of these tests might be included in the CDC’s data.