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; 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.