Time to revise your HIV testing routine: the CDC now recommends more aggressive screening than does the USPSTF. So, what's best for your practice?

Journal of Family Practice, April, 2007 by Doug Campos-Outcalt

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 states (1)--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 USPSTF (13) 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.

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.

References

(1.) Branson BM, Handsfield HH, Lampe MA, et al; CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health care settings. MMWR Recomm Rep 2006; 55(RR-14):1-17. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1 .htm. Accessed on March 16, 2007.

(2.) CDC. US HIV and AIDS cases reported through December 2001. HIV/AIDS Surveillance Report 2001; 13(2). Available at: www.cdc.gov/hiv/stats/hasr1302. htm. Accessed on March 13, 2007.

(3.) Institute of Medicine. No Time to Lose: Getting More from HIV Prevention. Washington, DC: National Academy Press; 2001.

(4.) Peterman TA, Todd KA, Mupanduki I. Opportunities for targeting publicly funded human immunodeficiency virus counseling and testing. J Acquir Immune Defic Syndr Hum Retrovirol1996; 12:69-74.

(5.) CDC. HIV testing among pregnant women--US and Canada, 1998-2001. MMWR Morb Mortal Wkly Rep 2002; 51:1013-1016.

(6.) McNaghten AD, Hanson DL, Jones JL, Dworkin MS, Ward JW. Effects of antiretroviral therapy and opportunistic illness primary chemoprophylaxis on survival after AIDS diagnosis. Adult/Adolescent Spectrum of Disease Group. AIDS 1999; 13:1687-1695.

(7.) Palella F J, Delaney KM, Moorman AC, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. N Engl J Med 1998; 338:853-860.