Declines in HIV Testing and Diagnoses: A Policy Analysis of the 2019 Title X Federal Regulations on Family Planning Clinics

ABSTRACT 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 program 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 modeling to examine interactions between high regional-level Policy exposure (defined as >25% Policy-related clinic withdrawal from the program) and pre- and post-Policy implementation for HIV outcomes. Interaction models showed that 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 from pre- to post-Policy. 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 U.S. HIV response. Future policies governing the Title X family planning program should consider the full consequences for sexual and reproductive health outcomes, including HIV, in the U.S. before implementation. PLAIN LANUGAGE SUMMARY The Title X Family Planning Program is a key provider of sexual and reproductive health services in the United States (U.S.), especially for low-income women. It is important to examine any policies governing this safety net program to ensure that we continue to provide these populations with the best care. In 2019 the Trump administration passed a federal rule (hereinafter the Policy) which required that any clinics which receive Title X funding must have “financial and physical separation” of abortion services from other health services and prohibited clinics from making abortion referrals for their patients. About a third (32%) of clinics in the Title X program across the U.S. refused to comply with these restrictions and gave up federal Title X funding. Given the important role of Title X clinics for HIV testing services, we examined what the impact of this mass clinic withdrawal had on HIV testing services and HIV diagnoses in the Title X program. We found that there were significant reductions in both HIV testing and diagnoses in the Title X program related to the Policy. Our results show how policies that reduce providers in the Title X family planning network also weaken the U.S. HIV response. Sound health policy that advances efforts to end the U.S. HIV epidemic will support reproductive health clinics, such as those in the Title X program, as key providers of HIV services.