By Karen Parker and Lindsey Zwicker

For full report click here.

Mayor Antonio Villaraigosa recently launched the City of Los Angeles HIV Testing Initiative - an endeavor to increase the availability and accessibility of HIV screening so that one million individuals in Los Angeles know their HIV status by 2011. This important public health intervention targets the estimated 7,500 Angelinos living with HIV who are unaware that they are infected and therefore precluded from obtaining life-prolonging medical treatment and social welfare services that could reduce their likelihood of transmitting the infection to other individuals.

The City of Los Angeles AIDS Coordinator's Office has requested assistance and advice for implementing one of five strategic components to the City of Los Angeles HIV Testing Initiative: addressing legislative, regulatory, and structural changes needed to facilitate increased HIV testing.

This report initially sought to identify regulatory, legislative, and structural impediments to increasing the number of HIV screening tests performed in the City of Los Angeles. In the process of identifying such barriers we unearthed a disturbing discrepancy: an alarming number of people who test positive during HIV screening tests do not submit to confirmatory tests - a prerequisite for commencing medical treatments. Los Angeles County data reveal that 32% of people who test positive for HIV at government-funded rapid testing sites do not submit a specimen for confirmatory testing. Out of the 68% who do submit a specimen, 50% do not return for the confirmatory results.

In response to this discovery, we recommend that our client redirect focus away from strategies to increase the absolute number of screening tests administered, and towards strategies to resolve the screening-to-confirmatory testing discrepancy. Merely increasing the provision of screening tests, without addressing the salient issue of the testing discrepancy could potentially undermine the very purpose of screening for HIV - to inform infected individuals of their HIV status so that they can receive proper medical care and curb risky behaviors that can lead to further transmission. We therefore contend that our client can achieve The City of Los Angeles HIV Testing Initiative's ultimate goal - increase the number of people who know their HIV status - by pursuing the following recommendations:

• Reframe the issue: meet the stated goal of increasing the number of people who are aware of their HIV status by redirecting the focus away from strategies to increase the provision of screening tests, and towards the issue of people who fail to submit to confirmatory tests and do not get linked to life-saving, behavior-altering treatment and care.
• Raise provider awareness: draw attention to the discrepancies in testing submission among community based organizations that provide rapid HIV testing in the City of Los Angeles. Encourage leaders to implement procedural adjustments to help decrease the number of HIV positive people who do not submit to confirmatory testing.
• Decrease providers' overreliance on oral-swab testing: fund phlebotomy training for staff members of community based organizations. Using funds from the City of Los Angeles HIV Testing Initiative, create a grant, subsidy or loan program to help offset the costs of limited phlebotomy certification.
• Increase Director-level participation in the Los Angeles County HIV Prevention Planning Committee: work with the group that is federally mandated to conduct evidence-based research on prevention strategies in Los Angeles and influence county-wide change.
• Support AB221: lobby Los Angeles-area legislators who sit on critical sub-committees and members of the California Nurses Association who wield political power and currently oppose legislation.