CDC Recommends HIV Testing and Screening in Routine Clinical Care

News Author: Laurie Barclay, MD

September 25, 2006 ” The US Centers for Disease Control and Prevention (CDC) recommend that diagnostic HIV testing and opt-out HIV screening be a part of routine clinical care in all healthcare settings, according to a report in the September 22 issue of the Morbidity and Mortality Weekly Report.

"Human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) remain leading causes of illness and death in the United States," write Bernard M. Branson, MD, from the Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, and colleagues. "Treatment has improved survival rates dramatically, especially since the introduction of highly active antiretroviral therapy (HAART) in 1995. However, progress in effecting earlier diagnosis has been insufficient."

The goals of these recommendations are to increase HIV screening of pregnant women and other patients in healthcare settings, to allow earlier detection of HIV infection, to identify and counsel persons with unrecognized HIV infection and refer them to clinical and prevention services, and to further reduce perinatal transmission of HIV in the United States. These revised guidelines update previous recommendations for HIV testing in healthcare settings and for screening of pregnant women.

These recommendations for HIV testing are intended for all healthcare providers in both public and private settings, including hospital emergency departments, urgent care clinics, inpatient services, substance abuse treatment clinics, public health clinics, community clinics, correctional healthcare facilities, and primary care.

The recommendations are limited to HIV testing in healthcare settings only, and they do not alter existing guidelines concerning HIV counseling, testing, and referral for persons at high risk for HIV who seek or receive HIV testing in nonclinical settings, such as community-based organizations, outreach settings, or mobile vans.

"To increase diagnosis of HIV infection, destigmatize the testing process, link clinical care with prevention, and ensure immediate access to clinical care for persons with newly identified HIV infection, IOM [Institute of Medicine] and other health-care professionals with expertise have encouraged adoption of routine HIV testing in all health-care settings," the authors write. "More patients accept recommended HIV testing when it is offered routinely to everyone, without a risk assessment."

Compared with previously published guidelines, these recommendations contain several major revisions.

• For patients in all healthcare settings, opt-out HIV screening is recommended, meaning that the patient is notified that testing will be performed unless the patient declines screening. Individuals at high risk for HIV infection should be screened for HIV at least annually.
  General consent for medical care should be considered sufficient to allow consent for HIV testing, and separate written consent for HIV testing should not be required. In healthcare settings, prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs.

"These revised CDC recommendations advocate routine voluntary HIV screening as a normal part of medical practice, similar to screening for other treatable conditions," the guidelines state. "Screening is a basic public health tool used to identify unrecognized health conditions so treatment can be offered before symptoms develop and, for communicable diseases, so interventions can be implemented to reduce the likelihood of continued transmission."

HIV infection meets all generally accepted criteria that justify screening: (1) it is a serious health condition that can be diagnosed while still asymptomatic, (2) HIV can be diagnosed by reliable, inexpensive, and noninvasive screening, (3) infected patients may gain years of life if treatment is started before symptoms develop, and (4) screening costs are reasonable compared with the anticipated benefits.

• For all pregnant women, opt-out HIV screening should be included in the routine panel of prenatal screening tests, and separate written consent for HIV testing should not be required. In certain jurisdictions with increased rates of HIV infection among pregnant women, repeat screening is recommended in the third trimester.

For pregnant women, screening has been shown to be significantly more effective than risk-based testing for detecting unsuspected maternal HIV infection and preventing perinatal transmission. Routine prenatal HIV testing with streamlined counseling and consent procedures has substantially increased the number of pregnant women tested.

The guidelines note that these recommendations apply equally to adolescents and that it is crucial to communicate test results to patients and to link patients who have received a diagnosis of HIV infection to prevention and care services.

"Although moving patients into care incurs substantial costs, it also triggers sufficient survival benefits that justify the additional costs," the authors conclude. "Even if only a limited fraction of patients who receive HIV-positive results are linked to care, the survival benefits per dollar spent on screening represent good comparative value."

MMWR Morbid Mortal Wkly Rep. 2006;55(RR-14):1-17.