Declines in HIV testing and diagnoses: a policy analysis of the 2019 Title X federal regulations on family planning clinics.

In 2019 the Trump administration instituted a federal regulation (hereinafter the Policy) requiring that Title X family planning clinics have financial and physical separation of abortion services from other health services, and prohibited abortion referrals. In response, 32% (1,280) of Title X funded sites left the programme nationally. Our analysis connects public data from Title X Family Planning Reports (2016-2021) and CDC surveillance reports (2016-2021), to examine the Policy's impact on: (1) HIV testing at Title X clinics by region, and (2) the proportion of a region's total HIV diagnoses at Title X clinics. We use mixed multivariable linear regression modelling to examine interactions between "high" regional-level Policy exposure (defined as >25% Policy-related clinic withdrawal from the programme) and pre- and post-Policy implementation for HIV outcomes. Interaction models showed that while in effect the Policy resulted in 69,626 fewer HIV tests (95% CI -108,893 to -30,359 P < .001) and a 4% reduction (95% CI -7% to -0%; P = .052) in overall regional HIV diagnoses at Title X clinics in high-exposed regions compared to low-exposed regions. Results show notable declines in HIV testing and the proportion of HIV cases diagnosed at Title X sites as a result of Policy implementation. Policies that endanger the Title X family planning network also weaken the US HIV response. Future policies governing the Title X family planning programme should consider the full consequences for sexual and reproductive health outcomes, including HIV, in the US before implementation.