The Title X Family Planning Program, administered by the HHS Office of Population Affairs (OPA), provides funding to more than 4,000 service delivery sites across the country to support voluntary, confidential, and low-cost education, counseling, testing, and related preventive health services that allow individuals and couples to plan and space births. The family planning service sites funded through this program are key allies in the nation’s response to HIV, providing family planning and related preventive health services—including HIV prevention and testing—to more than 5 million low-income or uninsured men, women, and adolescents each year. All Title X funded agencies are required to provide, at a minimum, HIV/AIDS prevention education, including education on HIV risks and infection prevention, and HIV testing, either on-site or by referral.
Number of HIV Tests Increases Over Time
The table below highlights the trend in on-site HIV testing at Title X service sites over a nine-year period from 2003-2011. The number of HIV tests has more than doubled over this period, rising to 1.3 million in 2011, with more than 1,600 clients testing positive in 2011.
However, because of limited resources, not all service providers have been able to offer on-site HIV testing. So, since September 2001, with funding from both the Secretary’s Minority AIDS Initiative Fund (SMAIF) and the Title X Family Planning Program’s annual appropriation, OPA has provided supplemental funding through a competitive process to select Title X sites to enable them to expand the availability of on-site HIV counseling, testing, and linkage to HIV care and treatment services. Consideration was given to key variables such as the HIV prevalence rates in the applicants’ communities. These supplemental funds currently support 437 Title X service delivery sites across 34 states in areas that have need, but limited resources, for these important health services.
Historically, Title X sites that have offered on-site HIV testing were required to refer HIV-positive clients for care and treatment services. In addition, since 2010 the OPA-supported HIV testing projects have been required to go one step further and put in place systems and structures to ensure that clients who test positive for HIV are actually linked to care, meaning the client was seen in a health‐care setting by a physician, nurse practitioner, or physician assistant within three months of a positive HIV test. In 2011, 81% of clients who tested positive in these projects were linked to HIV care. The projects regularly review their data on linkage to HIV care, using it to improve systems to ensure linkage to care, increase the number of formal referral agreements with HIV service providers, and improve systems and processes for documenting linkage episodes.
Reaching Women at Risk for or Living with HIV
Title X family planning sites play a particularly important role in reaching many women at risk for or living with HIV because these sites often serve as vital entry points to the health care system for women in need of subsidized care. In fact, more than 60% of women of reproductive age who receive health care in a publicly-funded family planning service site (including both Title X and non-Title X sites), report that the site is their usual source of health care [i]. In addition, 41% report that the site is their only source of health care[ii].
The HIV prevention and testing services women receive at these sites are especially critical given that the implementation of recommendations for universal prenatal HIV counseling and testing, antiretroviral (ARV) prophylaxis, scheduled cesarean delivery, and avoidance of breast feeding has dramatically decreased perinatal HIV transmission to less than 2% of all births to HIV infected mothers in the U.S.[iii].
Serving Populations Disproportionately Impacted by HIV/AIDS
Title X family planning sites also play an important role in reaching populations that have long been disproportionately impacted by HIV/AIDS. This includes racial and ethnic minorities who represent the majority of new infections in the U.S., as well as new AIDS diagnoses, people living with HIV/AIDS, and AIDS deaths. In 2011, racial and/or ethnic minorities comprised 77% of all the clients tested in OPA-supported HIV prevention projects and 82% of all the clients who tested HIV-positive.
In addition, HIV prevalence has been notably higher among heterosexuals in many low-income communities. A recently published CDC report[iv] found that heterosexuals in 24 large U.S. urban areas with annual household incomes at or below the poverty level had an HIV prevalence rate of 2.3%, compared with an HIV prevalence rate of 1.0% among those with incomes above the poverty level. This led the authors to conclude that in urban areas with high AIDS prevalence, HIV prevention activities aimed at heterosexuals should focus on low-income communities. Low-income populations are given priority for services in Title X service sites. In 2011, two-thirds of Title X users had family incomes at or below the Federal poverty level and 89% had family incomes at or below 200% of the poverty level.
As highlighted above, Title X family planning service sites across the nation are active partners in efforts to achieve the goals of the National HIV/AIDS Strategy (NHAS). OPA is committed to continuing and expanding these important HIV prevention, testing and linkages to care efforts. We look forward to working with our partners across HHS and in states and communities in the coming year to raise the bar on these efforts and to share both successes and promising practices[v].
[i] Frost, J. J., & Data from the 2002 National Survey of Family Growth. (2008). Trends in U.S. women’s reliance of publicly funded family planning clinics as their usual source of medical care. Paper presented at the 2008 Research Conference on the National Survey of Family Growth, Hyattsville, Maryland.
[ii] Frost, J, Benson Gold, R & Bucek, A. Specialized Family Planning Clinics in the United States: Why Women Choose Them and Their Role in Meeting Women’s Health Care Needs. Women’s Health Issues 22-6 (2012) e519–e525.
[iii] Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission, Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1 Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States, 2012, http://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/143/introduction.
[iv] Denning, P.H. DiNenno, E. & Wiegand, R.E. Characteristics Associated with HIV Infection Among Heterosexuals in Urban Areas with High AIDS Prevalence — 24 Cities, United States, 2006–2007. MMWR August 12, 2011 / 60(31);1045-1049, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6031a1.htm
[v] Fowler, C.L., Lloyd, S.W., Gable, J., Wang, J., & McClure, E. (October 2012). Family Planning Annual Report: 2011 National Summary. Research Triangle Park, N.C.: RTI International.