Racial, ethnic, and regional disparities in HIV testing during the COVID-19 pandemic in the USA: a nationwide, retrospective, observational study using National Clinical Cohort Collaborative data.

BACKGROUND

The COVID-19 pandemic caused major disruptions to health care, affecting the delivery of HIV care and prevention services. We aimed to determine the impact of the pandemic on HIV testing rates in medical settings across regions and racial and ethnic populations in the USA.

METHODS

In this retrospective cohort study, we used data from the National Clinical Cohort Collaborative (N3C) from Jan 1, 2018, to Dec 31, 2022, of individuals aged 15-64 years with active health-care records. In this dataset, COVID-19 cases were matched (1:2) to COVID-negative controls on the basis of age, sex, and race and ethnicity within each site. We used interrupted time-series analyses to estimate changes in the monthly HIV testing rate, measured as the number of individuals tested per 10 000 people in four geographical regions (midwest, northeast, south, and west) among four racial and ethnic groups (White [non-Hispanic], Black [non-Hispanic], Hispanic, other). We estimated these changes in three time periods: prepandemic (January, 2018, to February, 2020), early pandemic (March, 2020, to August, 2020), and late pandemic (September, 2020, to December, 2022).

FINDINGS: 9 704 278 individuals were included and had a mean age of 41·2 years (SD 13·5). 5 667 609 (58·4%) of 9 704 278 individuals were female and 4 036 669 (41·6%) were male. Most individuals were White, followed by other, Black, and Hispanic, with notable geographical differences in racial and ethnic composition. Prepandemic, HIV testing rates were relatively stable, although levels varied by region and racial and ethnic group. The impact on testing rates differed substantially during the early and late pandemic, with the west experiencing the sharpest and most prolonged decline (-30·94 per 10 000 people, 95% CI -42·29 to -19·59). Among racial and ethnic groups, the Black population showed the greatest reduction in testing at the onset of the pandemic across all four regions, and specifically in the northeast, which decreased by 53·09 per 10 000 people (95% CI -73·43 to -32·77). The decline was more modest among White individuals at the national level (-13·55 per 10 000 people, -20·27 to -6·84) and no racial or ethnic groups showed a significant decline in the south. Testing rates rebounded to varying degrees during the late pandemic.

INTERPRETATION: The COVID-19 pandemic, particularly early on, caused substantial disruptions in HIV testing rates across the USA, with pronounced racial, ethnic, and regional disparities. These findings highlight the need for targeted interventions to mitigate the impact of public health emergencies on communities disproportionately affected by pre-existing health inequities, including expanding mobile testing units, supporting community-based outreach, and investing in culturally responsive care to improve access to testing during future public health disruptions.

FUNDING: National Institutes of Health, National Institute of Mental Health, and National Institute on Drug Abuse.