Frequent Missed Opportunities for Earlier HIV Diagnosis in a Routine Opt-out Testing Environment in Atlanta

Background Routine, opt-out HIV testing strategies aim to diagnose HIV earlier and decrease ongoing transmission. We report missed opportunities (MO) and missed testing opportunities (MTO) for earlier HIV diagnosis in a safety-net healthcare system using routine opt-out testing. Methods This retrospective study analyzed adults diagnosed with HIV between 2015 and 2022 with eligible encounters 30–365 days before diagnosis. MO is defined as no HIV testing in the year before diagnosis. MTOs are encounters where testing was indicated but not performed. Logistic regression identified factors associated with MO and MTO. To evaluate the opt-out testing program, we measured the number of individuals eligible for testing, tests completed, reactive results, and new HIV diagnoses. Results Of 713 newly diagnosed individuals, 499 (70%) had MO. Among 1845 encounters, 1235 (67%) were MTO. Sexual health–related encounters and STI testing had lower MO odds (adjusted odds ratio [aOR] 0.62; 95% confidence interval [CI], 0.42–0.90; P = .013) and (aOR 0.36; 95% CI, 0.28–0.48; P < .0001), respectively. MO was associated with higher odds of CD4 < 350 cells/mm3 at diagnosis (aOR 1.8; 95% CI, 1.2–2.9; P = .011). Outpatient encounters, particularly primary care, had higher MTO odds than emergency department (OR 0.67; 95% CI, 0.54–0.82; P < .0001). Among 531,848 eligible individuals, 357,771 tests were conducted in 199,004 individuals (37.4%); 4719 (1.3%) tests were reactive, resulting in 861 (0.4%) new HIV diagnoses. Conclusions Despite routine opt-out HIV testing, most individuals newly diagnosed with HIV had no testing in the prior year, highlighting the need to optimize opt-out testing procedures, particularly in primary care and nonsexual health visits.