Editorials
The CDC and USPSTF Recommendations for HIV Testing
The Centers for Disease Control and Prevention (CDC) released new recommendations in 2006 for human immunodeficiency virus (HIV) testing.1 These far-reaching recommendations are a major revision from the CDC's previous guidelines. They aim to reduce the number of people with undiagnosed HIV infection in the United States (estimated to be one fourth of the 1.0 to 1.2 million persons living with HIV, or 252,000 to 312,000 persons2) and to reduce the stigma and barriers associated with testing. The guidelines represent a policy shift from testing only persons at high risk for HIV infection to universal testing for adolescents and adults. The CDC now recommends that all persons 13 to 64 years of age in all health care settings be tested for HIV after the patient is notified that testing will be performed unless he or she declines (i.e., opt-out screening). Table 1 presents a summary of key recommendations.1
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Table 1. New HIV Screening Recommendations |
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Screen all patients 13 to 64 years of age in all health care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening); continue screening until low prevalence has been demonstrated Screen high-risk persons annually (i.e., men who have sex with men, intravenous drug users, persons who have multiple sex partners, persons who exchange sex for money) Repeat screening in the third trimester of pregnancy in areas with high HIV infection rates and in high-risk patients Eliminate separate written consent and prevention counseling for HIV testing Eliminate requirements for direct personal contact to deliver negative test results Do not link HIV prevention counseling with testing Implement rapid testing for women in labor with no documented HIV test result during pregnancy |
| HIV = human immunodeficiency virus. Information from Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, et al., for the Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 2006;55(RR-14):1-17. |
The recommendations are based on changing HIV epidemiology, results from universal blood and prenatal screening programs, and expert opinion. About 40,000 persons are newly infected with HIV each year in the United States.3 This number has been stable over the past decade, but an increasing number of blacks and other racial and ethnic minorities are being infected. Increasing proportions of infected persons are adolescent males who have sex with males; women now make up 30 percent of newly diagnosed cases.4,5 Only about 40 percent of U.S. adults have been tested for HIV.6 Strikingly, the number of infants and children with newly diagnosed acquired immunodeficiency syndrome (AIDS) from perinatal transmission peaked at 945 in 1992 and fell to 48 in 2004 as the result of widespread prenatal testing.7
About 40 percent of persons with newly diagnosed HIV infection develop AIDS within one year.7 This statistic suggests that there are missed opportunities for diagnosis. The transmission rate is estimated to be 3.5 times higher among persons who are unaware of their infection, and early treatment with highly active antiretroviral therapy decreases the risk of transmission and prolongs life. Therefore, it is estimated that new sexually transmitted HIV infections could be reduced by more than 30 percent if all persons infected with HIV knew their status and adopted behavior changes similar to those of persons who are aware of their infection.8
Other professional groups have also made recommendations for screening. In 2001, the Institute of Medicine recommended an opt-out approach to HIV testing and recommended eliminating written consent and extensive pretest counseling.5 In 2005, the U.S. Preventive Services Task Force (USPSTF) recommended HIV testing for high-risk persons and pregnant women (Level A recommendation).3 However, it made no recommendation for or against routinely screening adults and adolescents who are not at increased risk (Level C recommendation).9 The USPSTF recently reaffirmed this recommendation for nonpregnant adolescents and adults.10 The policy of the American Academy of Family Physicians (AAFP) echoes that of the USPSTF; the AAFP has not yet taken a position on the new CDC recommendations.
Finding the persons who do not know they are HIV positive will not be easy. There are many barriers to implementing universal screening. In light of competing health care prevention priorities, many physicians think the benefits may not outweigh the time and resources required to implement this recommendation. The prevalence of undiagnosed infections in primary care practices is unknown. In a low-prevalence population, false-positive or indeterminate results will take time to explain and follow up. Universal screening is an unfunded mandate in settings where patients are uninsured or where insurers reimburse less than costs. Follow-up services for persons who test positive may not be known or available. Despite the CDC recommendation, many states require time-consuming written consent and pretest counseling. Blood is not routinely drawn in most patients until they are in their 30s, making testing of young adults more difficult as part of regular care. Physicians still will not be able to test persons who do not seek medical care or who have difficulty accessing the health care system.
Unrecognized infections are likely more common in certain settings (e.g., emergency departments, sexually transmitted disease [STD] clinics, correctional facilities, substance abuse programs). Undiagnosed HIV infection also may be more prevalent in other settings, such as hospital inpatient services, community health centers, and urgent care centers. Routine HIV screening in emergency departments, hospitals, and STD clinics has found HIV prevalence rates of 2 to 7 percent.11
In summary, the new CDC recommendations aim to close many of the loopholes in testing and will help remove the stigma associated with testing and simplify testing procedures. However, the USPSTF took a more conservative approach, concluding that the benefit of screening adults without risk factors for HIV infection is too small to justify a general screening recommendation. I believe we should proceed by implementing universal testing in certain settings where there is likely a higher prevalence of undiagnosed HIV infection, such as in emergency departments and STD clinics. If rapid testing is used, patients can get results quickly, and fewer will be lost to follow-up. A recent report from South Carolina found that three fourths of persons who were diagnosed with HIV infection late in the disease course had visited a health care facility within the previous few years; 79 percent of these persons had visited an emergency department, and 12 percent were inpatients.12 This suggests that we would gain the most if HIV testing were increased in emergency departments. To reconcile the CDC and USPSTF recommendations, we should continue to test high-risk persons, work to decrease legislative and financial barriers to testing, and first expand universal testing to clinical sites where the prevalence is likely to be high.
Address correspondence to Jonathan E. Rodnick, MD, at rodnickj@fcm.ucsf.edu. Reprints are not available from the author.
Author disclosure: Nothing to disclose.
REFERENCES
1. Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, et al., for the Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 2006;55(RR-14):1-17.
2. Glynn M, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003 [Abstract]. National HIV Prevention Conference, Atlanta, Georgia-June 12-15, 2005. Accessed September 13, 2007, at: http://www.aegis.com/conferences/NHIVPC/2005/T1-B1101.html.
3. Centers for Disease Control and Prevention. Persons reported to be living with HIV infection and AIDS, as of December 2001. HIV/AIDS Surveillance Report. Accessed September 13, 2007, at: http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2001report/pdf/2001surveillance-report_year-end.pdf.
4. Centers for Disease Control and Prevention. Trends in HIV/AIDS diagnoses-33 states, 2001-2004. MMWR Morb Mortal Wkly Rep 2005;54:1149-53.
5. Ruiz MS, for the Committee on HIV Prevention Strategies in the United States, Division of Health Promotion and Disease Prevention, Institute of Medicine. No Time to Lose: Getting More From HIV Prevention. Washington, D.C.: National Academy Press; 2001.
6. Centers for Disease Control and Prevention. Number of persons tested for HIV-United States, 2002. MMWR Morb Mortal Wkly Rep 2004;53:1110-3.
7. Centers for Disease Control and Prevention. Cases of HIV/AIDS, by area of residence, diagnosed in 2004-33 states with confidential name-based HIV infection reporting. HIV/AIDS Surveillance Report. Accessed September 13, 2007, at: http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2004report/pdf/2004SurveillanceReport.pdf.
8. Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS 2006;20:1447-50.
9. U.S. Preventive Services Task Force. Screening for HIV: recommendation statement. Ann Intern Med 2005;143:32-7.
10. U.S. Preventive Services Task Force. Recommendation statement: screening for HIV. Accessed September 13, 2007, at: http://www.ahrq.gov/clinic/uspstf05/hiv/hivrs.htm#clinical.
11. Kelen GD, Shahan JB, Quinn TC. Emergency department-based HIV screening and counseling: experience with rapid and standard serologic testing. Ann Emerg Med 1999;33:147-55.
12. Centers for Disease Control and Prevention. Missed opportunities for earlier diagnosis of HIV infection-South Carolina, 1997-2005. MMWR Morb Mortal Wkly Rep 2006;55:1269-72.
It's Time to Normalize Testing for HIV
Testing for human immunodeficiency virus (HIV) became available in 1985 with the development of an enzyme-linked immunosorbent assay. The first test was actually developed to protect the blood supply, not to identify persons who were already infected. The more specific western blot test followed in 1987, and two-step testing became the national standard. However, testing for a fatal disease for which there were no effective treatments was not well accepted. Moreover, learning that one was HIV-positive often led to ostracism by family and friends, and loss of employment, housing, and health insurance. Acquired immunodeficiency disease (AIDS) was said to be part of the civil rights movement of the 1980s and 1990s.1 It was because of the stigma associated with AIDS that legislation was enacted to protect persons with the disease. Written informed consent was required, as was pre- and post-test counseling.
HIV testing guidelines were first issued by the Centers for Disease Control and Prevention (CDC) in 1987.2 These recommendations focused on targeting high-risk groups for screening: injection drug users, men who have sex with men, and persons with multiple sex partners. However, this approach was not effective. When the CDC guidelines were updated in 2002, physicians were encouraged to focus on persons with high-risk behaviors as well as clinical indicators such as recurrent pneumonia, oral candidiasis, varicella zoster, or unintentional weight loss.3 Routine HIV testing in settings with a disease prevalence of at least 1 percent was also recommended. This approach proved inadequate for several reasons. Patients are often unwilling to disclose high-risk behaviors, and physicians may not be comfortable asking about them. Many physicians are unaware of presentations that suggest HIV as the disease cause or co-factor. A significant number of patients who are tested at community sites do not return for their results. Consequently, illness remains the most common reason in the United States for HIV testing.4
High-quality studies have shown that HIV screening is cost-effective, in light of the overall HIV prevalence of about 0.3 percent in the Unites States.5,6 A recent study found that routine one-time HIV screening has a cost-effectiveness ratio of $30,800 per quality-adjusted life-year gained (QALY) when the disease prevalence is 1 percent, and about $50,000 per QALY when the prevalence is 0.12 percent.7 These ratios are similar to those for breast and colon cancer screening. In addition, effective treatments are available for HIV infection. As of September 2007, more than 20 drugs have been approved by the U.S. Food and Drug Administration to treat HIV, and at least three others are likely to be approved by the end of 2007. In general, the earlier patients are treated, the better their clinical status and life expectancy.
It is estimated that 25 percent of persons infected with HIV in the United States are unaware of their serostatus; these persons are thought to account for more than 50 percent of all new HIV infections.8 Identification of these individuals and implementation of risk-reduction counseling could reduce the number of new HIV infections by one half. New guidelines from the CDC recommend HIV screening for all persons between 13 and 64 years of age in all health care settings.9 The guidelines are a call for family physicians on the front lines of disease prevention to begin implementing routine HIV screening in their practices. The CDC recommends streamlining the screening process by eliminating mandatory pre- and post-test counseling and written informed consent. For family physicians who do not think they have the time, skills, or knowledge to offer routine HIV screening, I recommend that you avail yourself of testing resources in your community. By normalizing HIV testing, we can diminish the stigma and discrimination associated with testing that have persisted for 25 years. By failing to test patients routinely, we will continue to see 40,000 new infections per year-something our health care system cannot afford.
Address correspondence to Jeffrey T. Kirchner, DO, AAHIVS, at jtkirchner@comcast.net. Reprints are not available from the author.
Author disclosure: Nothing to disclose.
REFERENCES
1. Gostin LO. HIV screening in health care settings: public health and civil liberties in conflict? JAMA 2006;296:2023-5.
2. Centers for Disease Control and Prevention. Recommended additional guidelines for HIV antibody counseling and testing in the prevention of HIV infection and AIDS. Atlanta, Ga.: US Dept. of Health and Human Services, Public Health Service, 1987.
3. Centers for Disease Control and Prevention. Revised guidelines for HIV counseling, testing, and referral. MMWR Recomm Rep 2001; 50(RR-19):1-57.
4. Centers for Disease Control and Prevention (CDC). Late versus early testing of HIV-16 Sites, United States, 2000-2003. MMWR Morb Mortal Wkly Rep 2003;52:581-6.
5. Paltiel AD, Weinstein MC, Kimmel AD, Seage GR III, Losina E, Zhang H, et al. Expanded screening for HIV in the United States-an analysis of cost-effectiveness. N Engl J Med 2005;352:586-95.
6. Sanders GD, Bayoumi AM, Sundaram V, Bilir SP, Neukermans CP, Rydzak CE, et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med 2005;352:570-85.
7. Paltiel AD, Walensky RP, Schackman BR, Seage GR III, Mercincavage LM, Weinstein MC, et al. Expanded HIV screening in the United States: effect on clinical outcomes, HIV transmission, and costs. Ann Intern Med 2006;145:797-806.
8. Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS 2006;20:1447-50.
9. Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, et al., for the Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 2006;55 (RR-14):1-17.
| Copyright © 2007 by the American
Academy of Family Physicians. |
