Seek and treat: HIV update 2011
ABSTRACTAlthough mortality rates from human immunodeficiency virus (HIV) infection have declined dramatically in the United States, the incidence of new infections has not improved for more than a decade. The case is now strong for routine screening and early treatment of HIV infection to reduce transmission of the infection and to give patients an opportunity to live a reasonably healthy life. Clinicians in all health care settings should routinely and matter-of-factly test their patients for HIV infection, just as they screen for other diseases.
KEY POINTS
- Recommendations from the US Centers for Disease Control and Prevention call for routine HIV screening for all people ages 13 to 64 at least once regardless of their risk profile, and annual testing for people with known risk factors for acquiring HIV.
- Early treatment of HIV infection may reduce the risk of cancer, cardiovascular disease, neurocognitive disorders, and osteoporotic fractures and improve the rate of survival compared with patients treated late in the course of HIV infection.
- Finding and treating patients early in the course of infection has the potential to reduce infectivity in the community.
- Reliable rapid testing is now available to screen for HIV in community settings, emergency departments, and public health clinics, and during labor for those not tested in the prenatal period. It is also useful when follow-up is uncertain.
Rapid tests for HIV are available
There is a public health need to have rapid HIV testing available in all health care settings. With standard HIV tests, which can take 48 to 72 hours to run, about one-third of patients do not return for results. Subsequently locating them can be a huge challenge and is sometimes impossible. The ability to have rapid test results can improve this situation. It is especially important in prenatal care settings, where the mother can be immediately treated to reduce the risk of transmission to the child. Rapid testing increases the feasibility of testing in multiple venues, particularly acute-care settings with almost immediate results and linkage to care.
Several rapid tests are available and can be performed on whole blood, serum, plasma, and oral fluid. The tests provide reliable results in minutes, with 99% sensitivity and specificity. Positive results must be confirmed by subsequent two-stage laboratory testing, enzyme-linked immunosorbent assay, and Western blot. Patients who have negative or have indeterminate results on Western blot testing should be tested again after 4 weeks.
The cost-effectiveness of routine screening for HIV, even in populations with a low prevalence, is similar to that of commonly accepted interventions.25 In populations with a 1% prevalence of HIV, the cost is $15,078 per quality-adjusted life-year.26 Even if the prevalence is less than 0.05%, the cost is less than $50,000 per quality-adjusted life-year, which is normally the cutoff for acceptability for screening tests.25,26
‘OPT-OUT’ TESTING
In the past, patients were asked if they would like to have HIV testing (“opt-in” testing). It is now recommended that physicians request testing to be performed (“opt-out” testing). This still allows the patient to decline but also conveys a “matter of fact” nonjudgmental message, indicative of a routine procedure no different than other screening tests. When testing was done on an opt-in basis, only 35% of pregnant women agreed to be tested. Some women felt that accepting an HIV test indicated that they engage in high-risk behavior. When testing was instead offered as routine but with an opportunity to decline, 88% accepted testing, and they were significantly less anxious about testing.27
CDC RECOMMENDATIONS
The CDC now recommends that routine, voluntary HIV screening be done for all persons ages 13 to 64 in health care settings, regardless of risk.28 Screening should be repeated at least annually in persons with known risk. Screening should be done on an opt-out basis, with the opportunity to ask questions and the option to decline. Consent for HIV testing should be included with general consent for care. A separate signed informed consent is not recommended, and verbal consent can merely be documented in the medical record. Prevention counseling in conjunction with HIV screening in health care settings is not required.
Testing should be done in all health care settings, including primary care settings, inpatient services, emergency departments, urgent care clinics, and sexually transmitted disease clinics. Test results should be communicated in the same manner as other diagnostic and screening care. Clinical HIV care should be available onsite or reliable referral to qualified providers should be established.
For pregnant women, the CDC recommends universal opt-out HIV screening, with HIV testing as part of the routine panel of prenatal screening tests. The consent for prenatal care includes HIV testing, with notification and the option to decline. Women should be tested again in the third trimester if they are known to be at risk for HIV, and in areas and health care facilities in which the prevalence of HIV is high.
In women whose HIV status is undocumented in labor and delivery, opt-out rapid testing should be performed, and antiretroviral prophylaxis should be given on the basis of the rapid test result. Rapid testing of the newborn is recommended if the mother’s status is unknown at delivery, and antiretroviral prophylaxis should be started within 12 hours of birth on the basis of the rapid test result.
Widespread routine screening and earlier treatment could significantly reduce the incidence and improve the outcomes of HIV in this country. Health care providers are encouraged to adopt these practices.
