Who should get tested and how often?

The CDC now recommends that clinicians:

Do HIV testing in all health care settings after the patient is notified that testing will be performed (unless the patient declines).
Test high-risk patients annually.
Discontinue use of a separate written consent for HIV testing, if allowed by state law. General consent for medical care should be considered sufficient.
Drop the requirement that prevention counseling be conducted with HIV testing.
Include HIV testing in the routine panel of prenatal screening tests for all pregnant women.
Perform a repeat test on women in their third trimester in regions with elevated rates of HIV infection among pregnant women.

Should all adults and adolescents be screened for HIV? Do all persons at high risk deserve annual screening? The Centers for Disease Control and Prevention thinks so, but the US Preventive Services Task Force takes a less aggressive stance. The 2 agencies looked at the evidence and interpreted it differently—and likewise we must each decide what is best for our own patients and community.

Routine screening is one of several recently revised recommendations from the CDC (at right).¹ Though the CDC has historically taken a cautious approach to HIV testing, the winds appear to be changing. The reasons:

Risk-based screening did not reduce incidence. The previous approach—targeted counseling and testing—has not led to a decline in HIV incidence—it has hovered at around 40,000 cases per year for over a decade.²
An estimated one fourth of HIV-positive people in the US don’t know their status, and thus are at increased risk of transmitting the disease to others.
Risk-based screening failed to detect many who are HIV-infected because patients either don’t appreciate—or don’t want to acknowledge—their risks.^3,4
Risk-based screening failed to detect many HIV-infected pregnant women, leading to preventable infection in newborns; routine opt-out testing has been more successful.⁵
Highly active antiretroviral therapy has had marked success in reducing mortality from HIV infection. Chemoprophylaxis has proven benefits for preventing certain opportunistic infections.^6,7

Removing barriers to testing

The CDC is also advising clinicians that requiring pretest counseling or a separate written consent is a barrier to testing. Clinicians still should inform patients that HIV testing is being conducted and that they have a right to refuse. There is evidence, though, that making the test routine reduces its stigma and increases acceptance.^8-11

Evidence also indicates that preventive counseling is very effective in reducing risky behavior among those who are HIV-positive. It’s unclear, however, whether such counseling is effective among those who are HIV-negative.¹²

Thus, the CDC’s new approach stresses finding those who are infected, getting them medical care, and lowering their risk of transmitting infection to others.

If a pregnant women refuses HIV testing, ask why

The new CDC recommendations take an especially aggressive approach to screening pregnant women, stating that women who refuse testing should be questioned about their reasons for refusal and counseled about the benefits of the test.

The CDC advises repeat testing in the third trimester, in areas of increased risk—which includes 20 states¹—and for pregnant women with individual risk factors, as well as those who receive care in facilities with rates of infection of 1 per 1000 women screened. The CDC also urges rapid HIV testing during labor, in women who were not tested during pregnancy, and on newborns whose mothers were not tested during pregnancy or labor.

USPSTF is less aggressive

The USPSTF¹³ does not recommend for or against testing persons who are not at high risk (TABLE). Both the CDC and the USPSTF recognize that routine screening is probably warranted in populations with HIV prevalence of 1/1000 or greater. However, the CDC recommends routine screening in all settings until there is evidence that the site or population-specific prevalence is lower than this threshold, while the USPSTF simply states that routine screening may be warranted in populations with a prevalence above this level.

TABLE
USPSTF vs CDC recommendations on HIV testing

GROUP	USPSTF	CDC
High-risk adolescents	Recommends testing, no frequency mentioned	Recommends annual testing and before starting a new sexual relationship
High-risk adults	Recommends testing, no frequency mentioned	Recommends annual testing as well as before starting a new sexual relationship
Adolescents not at high risk	No recommendation for or against	Recommends testing, no frequency mentioned, and testing before starting a new sexual relationship.
Adults not at high risk	No recommendation for or against	Recommends testing, no frequency mentioned. recommends testing before starting a new sexual relationship.
Pregnant women	Recommends testing	Recommends testing at first visit, repeat test in the third trimester in regions with high rates of HIV infection in pregnant women.
Written consent	Does not comment about	Recommends against

The take-away message

It’s time to review both sets of guidelines and adopt HIV testing policies that are most appropriate for your clinical and community situation, and that meet state laws, many of which still require separate written consent and pretest counseling.

Correspondence
Doug Campos-outcalt, MD, MPA, 4001 N. Third Street #415, phoenix, AZ 85012. dougco@u.arizona.edu

Time to revise your HIV testing routine