According to 2007 NHIS data, fewer than 40 percent of adults in the United States reported ever having been tested for HIV. In a recent survey by the Henry J. Kaiser Family Foundation, the primary reason people gave for not being tested is that they do not think they are at risk. The second most common reason was that their doctor never recommended HIV testing. While 38 percent of adults said that they had talked to their doctor about HIV, only 17 percent said that their doctor had suggested an HIV test. According to this survey, African Americans and Latinos were more likely than adults overall to have had such a conversation with their doctor and for the doctor to have suggested testing. Sixty-seven percent of African Americans and 45 percent of Latinos said that they had talked to their doctor about HIV and 29 percent of African Americans and 28 percent of Latinos said that their doctor had suggested an HIV test. Technological advances have increased the benefits associated with HIV testing as well as with regular care and treatment for HIV. First, advances in testing methods, such as rapid HIV tests, have made testing more feasible in a variety of different settings and increased the likelihood that individuals will receive their results. Rapid tests differ from conventional HIV tests in that results are ready sometime from immediately after the test is performed to 20 minutes after the test is performed, which means that individuals can get tested and receive their results in the same visit. Second, the advent of highly active antiretroviral therapy (HAART) has transformed HIV from a fatal disease to a treatable condition. For example, a 25-year-old individual who is in care for HIV can expect to live only 12 years less than a 25-year-old individual who does not have HIV. In addition, studies have found that people generally reduce risky behaviors once they learn of their HIV-positive status. According to one study, people who are unaware that they are HIV positive are 3.5 times more likely to transmit the disease to their partners than people who know their status. At the same time, research has shown that individuals are often unaware of their status until late in the course of the disease despite visits to health care settings. For example, one study looked at HIV case reporting in a state over a 4-year period. The study found that of people who were diagnosed with HIV late in the course of the disease, 73 percent made at least one visit to a health care setting prior to their first reported positive HIV test, and the median number of prior visits was four. Funding for HIV testing can come from insurance reimbursement by private insurers as well as Medicaid and Medicare, although these payers do not cover HIV testing under all circumstances. Funding for HIV testing can also come from other government sources, such as CDC, CARE Act programs, or state and local funding. A study by CDC and the Henry J. Kaiser Family Foundation that looked at the insurance coverage of individuals at the time of their HIV diagnosis from 1994-2000 found that 22 percent were covered by Medicaid, 19 percent were covered by other public-sector programs, and 27 percent were uninsured. The cost of an HIV test varies based on a number of factors, including the type of test performed, the test result, and the amount of counseling that is associated with the test. For example, from a payer’s perspective, the costs of a rapid HIV test are higher for someone who is HIV positive than for someone who is not, primarily because rapid testing requires an initial rapid test and a confirmatory test when the result is positive with counseling conducted after both tests. Additionally, eliminating pretest counseling can lower the cost of HIV testing by about $10, regardless of the type of test. According to the most recent data available from CDC, in 2006, the cost of an HIV test could range from $10.16 to $86.84 depending on these and other factors. CDC issued its first recommendations for HIV testing in health care settings in 1987. These recommendations focused on individuals engaged in high-risk behaviors and specifically recommended that people who were seeking treatment for STDs be tested for HIV on a routine basis. Throughout the 1990s and 2000s CDC updated these recommendations periodically to reflect new information about HIV. For example, in 2001, CDC modified its recommendations for pregnant women to emphasize that HIV testing should be a routine part of prenatal care and that the testing process should be simplified to eliminate barriers to testing, such as requiring pretest counseling. CDC’s 2001 recommendations also recommended that HIV testing be conducted routinely in all health care settings with a high prevalence of HIV; in low-prevalence settings it was recommended that HIV testing be conducted based on an assessment of risk. In 2003, CDC introduced a new initiative called “Advancing HIV Prevention: New Strategies for a Changing Epidemic.” The initiative had a number of strategies, including two that specifically applied to health care settings: (1) making HIV testing a routine part of medical care; and (2) further reducing perinatal transmission of HIV by universally testing all pregnant women and by using HIV rapid tests during labor and delivery or postpartum if the mother had not been tested previously. Elements of the Advancing HIV Prevention initiative were incorporated into CDC’s revised HIV testing recommendations for heath care settings in 2006. The 2006 recommendations represent a major shift from prior recommendations for health care settings in that they no longer base HIV testing guidelines on risk factors. Rather, they recommend that routine HIV testing be conducted for all patients ages 13 through 64 in all health care settings on an opt-out basis. CDC also recommends that persons at high risk of HIV be tested annually; that general consent for medical care encompass consent for HIV testing (i.e., separate written consent is not necessary); and that pretest information, but not pretest counseling be required. According to CDC, tracking the prevalence of HIV is necessary to help prevent the spread of the disease. CDC’s surveillance system consists of case counts submitted by states on the number of HIV and AIDS diagnoses, the number of deaths among persons with HIV, the number of persons living with HIV or AIDS, and the estimated number of new HIV infections. HIV laboratory tests, specifically CD4 or viral load tests, can be used to determine the stage of the disease, measure unmet health care needs among HIV-infected persons, and evaluate HIV testing and screening activities. Current CDC estimates related to HIV are not based on data from all states because not all states have been reporting such data by name long enough to be included in CDC’s estimates. While all states collect AIDS case counts through name-based systems, prior to 2008 states collected HIV data in one of two different formats, either by name or by code. CDC does not accept code-based case counts for counting HIV cases because CDC does not consider them to be accurate and reliable, primarily because they include duplicate case counts. In order for CDC to use HIV case counts from a state for CDC’s estimated diagnoses of HIV infection, the name-based system must be mature, meaning that the state has been reporting HIV name-based data to CDC for 4 full calendar years. CDC requires this time period to allow for the stabilization of data collection and for adjustment of the data in order to monitor trends. In its most recent surveillance report, CDC used the name-based HIV case counts from 34 states and 5 territories and associated jurisdictions in its national estimates. Name-based HIV reporting had been in place in these jurisdictions since the end of 2003 or earlier. Under the CARE Act, approximately $2.2 billion in grants were made to states, localities, and others in fiscal year 2009. Part A of the CARE Act provides for grants to selected metropolitan areas that have been disproportionately affected by the HIV epidemic to provide care for HIV- positive individuals. Part B provides for grants to states and territories and associated jurisdictions to improve quality, availability, and organization of HIV services. Part A and Part B base grants are determined by formula based on the number of individuals living with HIV and AIDS in the grantee’s jurisdiction. For the living HIV/AIDS case counts HRSA used to determine fiscal year 2009 Part A and Part B base grants, see appendices II and III. Part C provides for grants to public and private nonprofit entities to provide early intervention services, such as HIV testing and ambulatory care. Part F provides for grants for demonstration and evaluation of innovative models of HIV care delivery for hard-to-reach populations, training of health care providers, and for Minority AIDS Initiative grants. Since the 2006 reauthorization of CARE Act programs, HRSA has placed an emphasis on states’ unmet need, which is the number of individuals in a state’s jurisdiction who know they are HIV positive but who are not receiving care for HIV. According to the framework used by HRSA, addressing unmet need is a three-step process. First, states are required to produce an unmet need estimate, which is submitted to HRSA on the state’s annual Part B grant application. To calculate the unmet need, the state must determine the total number of individuals who are aware of their HIV positive status in their jurisdiction, and then subtract the number of individuals who are receiving care for HIV. Second, the state must assess the service needs and barriers to care for individuals who are not receiving care for HIV, including finding out who they are and where they live. Third, the state must address unmet need by connecting these individuals to care. CDC and HRSA have coordinated on activities to assist health care professionals who provide HIV-related services. HRSA has encouraged routine HIV testing by providing for training for health care providers, as part of CDC-funded initiatives. CDC has taken other steps to encourage routine HIV testing by funding special initiatives that focus on certain populations. Since 2006, CDC and HRSA have coordinated activities to assist health care professionals who provide HIV-related services.