Routine HIV screening could be key to finding the unknown infected
Counseling, separate informed consent no longer needed
To Americans who donate blood or buy life insurance, the routine HIV test long has been a part of the process. For pregnant women, it's increasingly a part of their prenatal care. But to the millions of Americans who visit an emergency room or sexually-transmitted disease (STD) clinic each year, HIV screening has been offered as a slightly inconvenient add-on health feature.
And it's the latter group of Americans that public health officials at the CDC of Atlanta, GA, want to test for HIV, particularly in urban areas with above average HIV prevalence.
"We've come close to protecting children, but we're not there yet in terms of the rest of the population," says CDC Director Julie Gerberding, MD, MPH. "Nearly 40 percent of individuals diagnosed with HIV are diagnosed late, usually 10 years after they became infected and, often, this puts them in a situation where they can't benefit from this treatment."
The CDC launched in late September recommendations and a comprehensive plan for bridging that gap and finding those Americans who are infected but won't know it until they become very ill.
Several years of pilot studies and other data confirm that routine HIV screening in health care settings is feasible and acceptable, provided more flexibility is put into the requirements for counseling, CDC officials say.
"It's simply not acceptable for HIV-infected individuals to visit a health care facility without having the opportunity to learn they have a life-threatening illness," says Kevin Fenton, MD, PhD, director for the National Center of HIV, STD, and TB Prevention at the CDC.
CDC officials have been working several years at increasing HIV testing nationwide, but they still estimate that one-fourth of the one million Americans who are believed to be HIV infected do not know their status.
The CDC's new recommendations for HIV testing in health-care settings were created partly to make it easier to find those 250,000 Americans.
"We are making a recommendation that HIV screening be routine for all people between the ages 13 and 64, and we've added additional steps to enhance voluntary screening of pregnant women," Gerberding says.
"This is a great bold move by the CDC," says Rochelle Walensky, MD, MPH, an infectious disease physician at Massachusetts General Hospital and Brigham & Women's Hospital in Boston. Walensky also is an assistant professor of medicine at the Harvard Medical School.
"What this is drawing attention to is that the guidelines have been out there recommending HIV testing since 1993; they simply have not been adhered to for the past 13 years," Walensky says.
For several years, the CDC has actively pushed to routinize HIV testing, partly because of recent research showing feasibility and cost-effectiveness of such programs, Walensky adds.
Also, the OraQuick rapid HIV test, approved by the FDA in 2004, makes it easier for health care sites to test for HIV, Walensky says.
The CDC's updated guidelines, published in the Sept. 22, 2006, MMWR, include these revisions:
- Patients in all health care settings are recommended to be screened for HIV after they're notified that testing will be performed unless they decline.1
- Annual screenings are recommended for people at high risk for HIV infection.1
- General consent for medical care should be adequate, and separate consent for HIV testing should not be required.1
- Prevention counseling should not be required with HIV diagnostic testing or screening in health-care settings.1
- Pregnant women should be screened again in the third trimester in certain areas with elevated rates of HIV infection.1
Michigan was one of the first states to introduce community HIV testing and one of the first to adopt rapid testing as well, and now the state can lead the way with its own successful, full-scale HIV testing program for an emergency department in a high prevalence area.
State health officials studied the impact of HIV testing in an emergency room setting where trained testers approached patients about having a routine HIV test, says Liisa M. Randall, PhD, manager of the community partnerships unit of the HIV/AIDS Prevention and Intervention Section, Division of Health, Wellness and Disease Control at the Michigan Department of Community Health in Lansing, MI.
When compared to the state's targeted community-based HIV testing in 2005, the emergency department, routine testing resulted in a higher HIV infection rate, Randall says.
"We spent a fair amount of time talking about how and why we wanted to do this, and everyone was in agreement that HIV testing would be good for the community," Randall recalls.
"Recent survey data suggest that two-thirds of Americans agree that separate procedures for HIV testing are unnecessary," says Timothy Mastro, MD, acting director of the Division of HIV/AIDS Prevention of the CDC.
"We have learned from the experience of prenatal testing that patients are more comfortable when HIV testing is treated like other diagnostics," Mastro says. "They report less anxiety and do not feel like they are being singled out for having high-risk behavior."
The opt-out testing method has proven highly successful with pregnant women, and helped to result in a decline of HIV transmission to infants of 1,650 cases in 1991 to 240 annually now, Mastro says.
CDC officials believe the new recommendations will reinforce and reduce mother-to-child transmission even further, as well as screen more Americans for HIV infection.
The way HIV testing currently is treated in emergency rooms and STD clinics leaves much to be desired, CDC officials say.
"For example, one recent study found that even for patients infected with other sexually-transmitted diseases, HIV testing is rarely provided," Mastro says. "In that study, 76 percent of emergency department professionals said they never or rarely encouraged HIV testing for these patients."
The main reasons clinicians said they didn't offer the test was because of concerns about the time-consuming process and the lack of certification they perceived necessary for counseling, Mastro explains.
"So there continues to be major missed opportunities for diagnosis in health care settings, and it is simply not acceptable for HIV-infected individuals to visit a health care facility without having the opportunity to learn that they have a life threatening illness," Mastro adds.
Walensky, who says that it's her passion to get more HIV testing done, says the opt-out screening for HIV is an intuitive idea.
"It's hard to find a disease that we screen for in medicine that more closely meets the criteria for which we should screen than does HIV," Walensky says. "It's a quick, easy test; it's very inexpensive; it's a treatable disease; and it's a public health threat."
Investigators provided routine HIV testing of more than 2,500 people in several urgent care clinics in Massachusetts where the HIV prevalence was the highest statewide, Walensky says.
"Maybe the first time people were asked they said, 'No thanks,' but acceptance rates increased over time," Walensky says. "If people felt stigmatized or targeted when they walked in the door, they were reluctant to be tested."
But once they realized that every time they walked in they would be asked, it was much more routine and gained acceptance from 33 percent to more than 50 percent within a year, Walensky adds.
The program found an HIV prevalence of about 2 percent, higher than the state's 1.4 percent prevalence from targeted HIV testing, she notes.
The Massachusetts study used community counselors to provide the HIV test, and the tests were conducted before the rapid HIV test was available, Walensky recalls.
"We had the counselor for pre-test counseling, doing the test, and then making sure that everyone who had the test returned for their results," she says. "Once they received a positive result, we had a linkage program with a social worker from a treatment site who would meet them in the urgent care clinic and take them over to the HIV clinic."
Reference:
- Branson BM, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. 2006;55(RR-14):
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