What Is New in HIV Infection?



FREE PREVIEW Log in or buy this issue to read the full article. AAFP members and paid subscribers get free access to all articles. Subscribe now.


FREE PREVIEW Subscribe or buy this issue. AAFP members and paid subscribers get free access to all articles.

Am Fam Physician. 2014 Feb 15;89(4):265-272.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

  Related U.S. Preventive Services Task Force Recommendation Statement: Screening for HIV

  Related Putting Prevention into Practice: Screening for HIV

  Related editorial: AAFP Recommends Universal Screening for HIV Infection Beginning at 18 Years of Age

Author disclosure: No relevant financial affiliations.

Human immunodeficiency virus (HIV) prevention and treatment updates include screening recommendations, fourth-generation testing, preexposure prophylaxis, and a paradigm shift; treatment is prevention. The U.S. Preventive Services Task Force recommends routine HIV screening in persons 15 to 65 years of age, regardless of risk. Fourth-generation testing is replacing the Western blot and can identify those with acute HIV infection. The U.S. Food and Drug Administration approved the OraQuick In-Home HIV Test; however, there are concerns about reduced sensitivity, possible misinterpretation of results, potential for less effective counseling, and possible cost barriers. Preexposure prophylaxis (effective in select high-risk adult populations) is the combination of safer sex practices and continuous primary care prevention services, plus combination antiretroviral therapy. Concerns for preexposure prophylaxis include the necessity of strict medication adherence, limited use among high-risk populations, and community misconceptions of appropriate use. Evidence supports combination antiretroviral therapy as prevention for acute HIV infection, thus lowering community viral loads. Evidence has increased supporting combination antiretroviral therapy for treatment at any CD4 cell count. Resistance testing should guide therapy in all patients on entry into care. Within two weeks of diagnosis of most opportunistic infections, combination antiretroviral therapy should be started; patients with tuberculosis and cryptococcal meningitis require special considerations.

Persistent high rates of human immunodeficiency virus (HIV) transmission in the United States require new strategies to combat the ongoing epidemic. Latest recommendations and evidence address routine HIV screening, implementation of fourth-generation testing, targeted use of preexposure prophylaxis (PrEP) for high-risk adults without HIV, treatment as prevention to lower community viral loads, and treatment guidelines on single fixed-dose combination antiretroviral therapy (CART).17

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReference

All adolescents and adults 15 to 65 years of age should be screened for HIV unless they explicitly refuse.

A

1

All persons at high risk younger than 15 years and older than 65 years should be screened for HIV.

A

1

Rapid HIV tests should be used for screening, including fourth-generation testing when available.

C

1, 9, 10

All pregnant women should be screened for HIV during each pregnancy.

A

1

Preexposure prophylaxis should be provided to men and women (except those who are breastfeeding) who are at highest risk of HIV infection (e.g., men who have sex with men, those with an HIV-positive sex partner).

A

24

It is recommended that combination antiretroviral therapy be initiated early to prevent HIV transmission.

A

1, 5, 7


HIV = human immunodeficiency virus.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReference

All adolescents and adults 15 to 65 years of age should be screened for HIV unless they explicitly refuse.

A

1

All persons at high risk younger than 15 years and older than 65 years should be screened for HIV.

A

1

Rapid HIV tests should be used for screening, including fourth-generation testing when available.

C

1, 9, 10

All pregnant women should be screened for HIV during each pregnancy.

A

1

Preexposure prophylaxis should be provided to men and women (except those who are breastfeeding) who are at highest risk of HIV infection (e.g., men who have sex with men, those with an HIV-positive sex partner).

A

24

It is recommended that combination antiretroviral therapy be initiated early to prevent HIV transmission.

A

1, 5, 7


HIV = human immunodeficiency virus.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

What Is New in Screening?

The U.S. Preventive Services Task Force recommends routine HIV screening, known as opt-out screening, regardless of patient or physician perception of risk for all persons 15 to 65 years of age, unless a patient refuses.1 Those younger than 15 years

The Authors

KEVIN SHERIN, MD, MPH, MBA, FAAFP, FACPM, is a clinical professor of family medicine at Florida State University College of Medicine; an associate professor of family medicine at the University of Central Florida College of Medicine; and the public health director of the Florida Department of Health in Orange County, all of which are located in Orlando. He also serves as chair of the Prevention Practice Committee at the American College of Preventive Medicine.

BENJAMIN G. KLEKAMP, MSPH, CPH, is a Florida Epidemic Intelligence Service Fellow with the Florida Department of Health in Orlando.

JEFFREY BEAL, MD, AAHIVS, is a clinical associate professor at the University of South Florida Center for HIV Education and Research and is the principal investigator and clinical director for the Florida/Caribbean AIDS Education and Training Center, both in Tampa. He also is the medical director of the HIV/AIDS and Hepatitis Section in the Bureau of Communicable Diseases at the Florida Department of Health.

NICOLLE MARTIN, MD, MPH, is an assistant professor in the Department of Community Health and Preventive Medicine at the Morehouse School of Medicine in Atlanta, Ga.

The authors thank Berry Bennett, MPH, Florida Department of Health Bureau of Public Health Laboratories, for his review of the section on laboratory fourth-generation testing; Steve Hale, MD, Florida Department of Health in Orange County, for his review of the entire manuscript; and the Prevention Practice Committee at the American College of Preventive Medicine for review of the section on opt-out testing.

Address correspondence to Kevin Sherin, MD, MPH, 5060 Jetsail Dr., Orlando, FL 32812 (e-mail: kevin.sherin@flhealth.gov). Reprints are not available from the authors.

REFERENCES

1. Moyer VA; U.S. Preventive Services Task Force. Screening for HIV. U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159(1):51–60.

2. Centers for Disease Control and Prevention. Interim guidance for clinicians considering the use of preexposure prophylaxis for the prevention of HIV infection in heterosexually active adults. MMWR Morb Mortal Wkly Rep. 2012;61(31):586–589.

3. Centers for Disease Control and Prevention. Interim guidance: preexposure prophylaxis for the prevention of HIV infection in men who have sex with men. MMWR Morb Mortal Wkly Rep. 2011;60(3):65–68.

4. Okwundu CI, Uthman OA, Okoromah CA. Antiretroviral pre-exposure prophylaxis (PrEP) for preventing HIV in high-risk individuals. Cochrane Database Syst Rev. 2012;(7):CD007189.

5. Cohen MS, Chen YQ, McCauley M, et al.; HPTN 052 Study Team. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493–505.

6. U.S. Department of Health and Human Services. Strategic plan: Division of HIV/AIDS prevention, 2011 through 2015. August 2011. http://www.cdc.gov/hiv/strategy/dhap/pdf/dhap-strategic-plan.pdf. Accessed June 6, 2013.

7. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. http://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf. Accessed June 9, 2013.

8. Branson BM, Handsfield HH, Lampe MA, et al.; 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.

9. Torian LV, Forgione LA, Punsalang AE, Pirillo RE, Oleszko WR. Comparison of multispot EIA with Western blot for confirmatory serodiagnosis of HIV. J Clin Virol. 2011;52(suppl 1):S41–S44.

10. Styer LM, Sullivan TJ, Parker MM. Evaluation of an alternative supplemental testing strategy for HIV diagnosis by retrospective analysis of clinical HIV testing data. J Clin Virol. 2011;52(suppl 1):S35–S40.

11. Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr. 2005;39(4):446–453.

12. Das M, Chu PL, Santos GM, et al. Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS One. 2010;5(6):e11068.

13. Walensky RP, Losina E, Steger-Craven KA, Freedberg KA. Identifying undiagnosed human immunodeficiency virus: the yield of routine, voluntary inpatient testing. Arch Intern Med. 2002;162(8):887–892.

14. Bartlett JG, Branson BM, Fenton K, Hauschild BC, Miller V, Mayer KH. Opt-out testing for human immunodeficiency virus in the United States: progress and challenges. JAMA. 2008;300(8):945–951.

15. Owen SM. Testing for acute HIV infection: implications for treatment as prevention. Curr Opin HIV AIDS. 2012;7(2):125–130.

16. Patel P, Bennett B, Sullivan T, Parker MM, Heffelfinger JD, Sullivan PS; CDC AHI Study Group. Rapid HIV screening: missed opportunities for HIV diagnosis and prevention. J Clin Virol. 2012;54(1):42–47.

17. U.S. Food and Drug Administration. OraQuick In-Home HIV Test. Summary of safety and effectiveness. http://www.fda.gov/downloads/BiologicsBloodVaccines/BloodBloodProducts/ApprovedProducts/PremarketApprovalsPMAs/UCM312534.pdf. Accessed September 5, 2012.

18. Association of Public Health Laboratories. Issue in brief: HIV diagnostics survey. December 2012. http://www.aphl.org/AboutAPHL/publications/Documents/ID_2012Dec_HIV-Diagnostics-Survey-Issue-Brief.pdf. Accessed June 10, 2013.

19. Centers for Disease Control and Prevention. Immigrant and refugee health: Screening for HIV infection during the refugee domestic medical examination. http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/screening-hiv-infection-domestic.html. Accessed June 10, 2013.

20. Long EF. HIV screening via fourth-generation immunoassay or nucleic acid amplification test in the United States: a cost-effectiveness analysis. PLoS One. 2011;6(11):e27625.

21. Determine. HIV-1/2 Ag/Ab combo controls [package insert]. http://www.fda.gov/downloads/BiologicsBloodVaccines/BloodBloodProducts/ApprovedProducts/PremarketApprovalsPMAs/UCM364697.pdf. Accessed October 30, 2013.

22. Cragin L, Pan F, Peng S, et al. Cost-effectiveness of a fourth-generation combination immunoassay for human immunodeficiency virus (HIV) antibody and p24 antigen for the detection of HIV infections in the United States. HIV Clin Trials. 2012;13(1):11–22.

23. Golub SA, Kowalczyk W, Weinberger CL, Parsons JT. Preexposure prophylaxis and predicted condom use among high-risk men who have sex with men. J Acquir Immune Defic Syndr. 2010;54(5):548–555.

24. Centers for Disease Control and Prevention. HIV/AIDS: Pre-exposure prophylaxis (PrEP). http://www.cdc.gov/hiv/prevention/research/prep/index.html. Accessed June 6, 2013.

25. TRUVADA for a pre-exposure prophylaxis (PrEP) indication. https://www.truvadapreprems.com/hcp. Accessed June 6, 2013.

26. Truvada (emtricitabine/tenofovir disoproxil fumarate) tablets for oral use [package insert]. http://www.gilead.com/~/media/Files/pdfs/medicines/hiv/truvada/truvada_pi.pdf. Accessed January 6, 2014.

27. Lampe MA, Smith DK, Anderson GJ, Edwards AE, Nesheim SR. Achieving safe conception in HIV-discordant couples: the potential role of oral preexposure prophylaxis (PrEP) in the United States. Am J Obstet Gynecol. 2011;204(6):488.e1–488.e8.

28. Centers for Disease Control and Prevention. Update to CDC's sexually transmitted diseases treatment guidelines, 2010: oral cephalosporins no longer a recommended treatment for gonococcal infections. MMWR Morb Mortal Wkly Rep. 2012;61(31):590–594.

29. Recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. http://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/0/. Accessed September 5, 2012.

30. Jay JS, Gostin LO. Ethical challenges of preexposure prophylaxis for HIV. JAMA. 2012;308(9):867–868.

31. Baeten JM, Donnell D, Ndase P, et al.; Partners PrEP Study Team. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367(5):399–410.

32. Van Damme L, Corneli A, Ahmed K, et al.; FEM-PrEP Study Group. Pre-exposure prophylaxis for HIV infection among African women. N Engl J Med. 2012;367(5):411–422.

33. Grant RM, Lama JR, Anderson PL, et al.; iPrEx Study Team. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363(27):2587–2599.

34. Centers for Disease Control and Prevention. HIV/AIDS Prevention Research Synthesis Project. http://www.cdc.gov/hiv/topics/research/prs/index.htm. Accessed December 21, 2012.

35. Cheever LW. Engaging HIV-infected patients in care: their lives depend on it. Clin Infect Dis. 2007;44(11):1500–1502.

36. U.S. Department of Health and Human Services. National HIV/AIDS strategy: Update of 2011–2012 federal efforts to implement the national HIV/AIDS strategy. http://aids.gov/federal-resources/national-hiv-aids-strategy/implementation-update-2012.pdf. Accessed September 5, 2012.

37. Thompson MA, Aberg JA, Hoy JF, et al. Antiretroviral treatment of adult HIV infection: 2012 recommendations of the International Antiviral Society-USA panel. JAMA. 2012;308(4):387–402.

38. Plaeger SF, Collins BS, Musib R, Deeks SG, Read S, Embry A. Immune activation in the pathogenesis of treated chronic HIV disease: a workshop summary. AIDS Res Hum Retroviruses. 2012;28(5):469–477.

39. Cohen MS, Dye C, Fraser C, Miller WC, Powers KA, Williams BG. HIV treatment as prevention: debate and commentary—will early infection compromise treatment-as-prevention strategies? PLoS Med. 2012; 9(7):e1001232.

40. DeJesus E, Rockstroh JK, Henry K, et al.; GS-236-0103 Study Team. Co-formulated elvitegravir, cobicistat, emtricitabine, and tenofovir disoproxil fumarate versus ritonavir-boosted atazanavir plus co-formulated emtricitabine and tenofovir disoproxil fumarate for initial treatment of HIV-1 infection: a randomised, double-blind, phase 3, non-inferiority trial. Lancet. 2012;379(9835):2429–2438.

41. Sax PE, DeJesus E, Mills A, et al.; GS-US-236-0102 study team. Co-formulated elvitegravir, cobicistat, emtricitabine, and tenofovir versus co-formulated efavirenz, emtricitabine, and tenofovir for initial treatment of HIV-1 infection: a randomised, double-blind, phase 3 trial, analysis of results after 48 weeks [published correction appears in Lancet. 2012;380(9843):730]. Lancet. 2012;379(9835):2439–2448.


Copyright © 2014 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

Article Tools

  • Download PDF
  • Print page
  • Share this page
  • AFP CME Quiz

More in Pubmed

Navigate this Article