New HIV screening guidelines issued — How will they impact your practice?
The Centers for Disease Control and Prevention (CDC) is recommending that voluntary HIV screening become a routine part of medical care for all patients ages 13 to 64. The agency also is implementing extra steps to improve diagnosis of HIV infection among pregnant women.1
The new recommendations replace previous guidance issued in 1993 for HIV testing in acute care hospital settings,2 as well as updates portions of the CDC's 2001 guidelines for HIV counseling, testing, and referral, and recommendations for HIV screening of pregnant women.3 The new recommendations address HIV testing in health care settings only; they do not change current recommendations for HIV counseling and testing in nonclinical settings, such as community centers or in outreach programs, says the CDC.
The new guidelines respond to an urgent need for new approaches to finding the quarter-million Americans who have HIV and do not know they are infected, says Julie Gerberding, MD, MPH, CDC director. "These people have the right to know so that they can seek treatment, and we believe when they know they will take steps to protect themselves and their partners," she announced at a press conference. About 40% of individuals diagnosed with HIV are diagnosed within one year of developing AIDS, when it may be too late for them to fully benefit from treatment.4 By moving toward earlier diagnoses, patients will be treated earlier and receive prevention counseling and will be less likely to transmit HIV infection to others, notes Bernard Branson, MD, associate director of laboratory science in the CDC's Division of HIV/AIDS Prevention.
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If screening is made universal, rather than tied to risk behaviors, clinicians will have increased opportunities for early diagnosis in medical settings as well as reduce the stigma still associated with HIV testing.
While the recommendations do not specify frequency of screening, repeat testing is encouraged at least annually — or more frequently — for patients with recognized risk factors. This group includes individuals with HIV-positive sex partners; injection drug users and their sex partners; those who exchange sex for money or drugs; and individuals who have had, or whose sex partners have had, more than one sex partner since their most recent HIV test. All patients initiating treatment for tuberculosis or seeking treatment for sexually transmitted diseases (STDs) should be screened.
Here are other key recommendations for adults and adolescents:
- Provide a voluntary, "opt-out" approach to testing.
HIV testing must be voluntary and undertaken only with the patient's knowledge, the new recommendations stress. Patients should be specifically informed that HIV testing is part of routine care and have the opportunity to decline testing. Before making this decision, patients should be provided basic information about HIV and the meaning of positive and negative test results, and they should have the opportunity to ask questions, the CDC advises.
- Simplify testing procedures.
In an effort to streamline testing procedures, pre-test counseling and separate, written consent for HIV testing should no longer be required, the new recommendations state. Consent for HIV testing can be incorporated into general consent for medical care. Patients who test positive for HIV should be provided prevention counseling and linked to ongoing care. However, those in family planning and sexual health clinics still are encouraged to provide prevention counseling, CDC officials suggest. Intensive HIV prevention counseling for high-risk populations will continue as a component of community-based HIV prevention interventions.5
Why change existing consent guidelines for testing? When streamlined counseling and consent procedures were made a part of routine prenatal HIV testing, the number of pregnant women tested was increased, CDC officials note.6
The opt-out approach to HIV testing without separate consent already has proven successful in increasing diagnosis among pregnant women, which led to significant declines of mother-to-child infections in the United States, says Timothy Mastro, MD, acting director of CDC's Division of HIV/AIDS Prevention. The estimated number of infants born with HIV declined from a peak of about 1,650 cases in 1991 to fewer than 240 each year currently,7 he states.
Will patients be comfortable with the revised consent procedure? In 2006, about 65% of U.S. adults surveyed said that HIV testing should be treated the same as screening for any other disease, without special procedures such as written permission from the patient.8
Clinicians will need to check their individual state guidelines for direction on incorporating HIV testing into general consent for medical care. Specific requirements related to informed consent and pretest counseling differ among states, the CDC notes.
"Certain states, local jurisdictions, or agencies may not allow opt-out screening, or they may impose other specific requirements for counseling, written consent, confirmatory testing, or communicating HIV test results that conflict with these recommendations," advises the CDC. "Where policies exist that are in conflict with the new recommendations, jurisdictions should examine strategies to best implement these recommendations within current parameters and initiate steps to resolve conflicts with these recommendations."9
Look to early 2007 for additional information from the CDC in the form of practical tools to implement the recommendations in various types of health care settings, as well as examples of model approaches for health care providers. The agency also is working with other federal government entities to ensure that people diagnosed with HIV have access to care. "It is also important to recognize that while knowledge of HIV infection status is critical, testing efforts must be part of a comprehensive program of prevention and care," says Timothy Fenton, MD, PhD, director of the CDC's National Center for HIV, STD, and TB Prevention. "To ensure that newly diagnosed individuals have access to necessary treatment and ongoing prevention services, CDC will continue to collaborate with Health Resources and Services Administration personnel and other government and private organizations."
References
1. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 2006; 55(RR-14):1-17; quiz CE1-4.
2. Centers for Disease Control and Prevention. Recommendations for HIV testing services for inpatients and outpatients in acute-care hospital settings. MMWR 1993; 42(No. RR-2):1-10.
3. Centers for Disease Control and Prevention. Revised recommendations for HIV screening of pregnant women. MMWR 2001; 50(No. RR-19):63-85.
4. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2004. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2005.
5. Centers for Disease Control and Prevention. CDC's Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings. Fact sheet. Atlanta; Sept. 21, 2006.
6. Centers for Disease Control and Prevention. HIV testing among pregnant women — United States and Canada, 1998-2001. MMWR 2002; 51:1,013–1,016.
7. Centers for Disease Control and Prevention. Achievements in public health. Reduction in perinatal transmission of HIV infection — United States, 1985-2005. MMWR 2006; 55: 592-597.
8. Kaiser Family Foundation. Survey of Americans on HIV/ AIDS. Washington, DC: Kaiser Family Foundation; 2006. Available at www.kff.org/kaiserpolls/7521.cfm.
9. Centers for Disease Control and Prevention. Questions and Answers for Professional Partners: Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Healthcare Settings. Accessed at: www.cdc.gov/hiv/topics/testing/resources/qa/qa_professional.htm.
Resource
Visit the Centers for Disease Control and Prevention's HIV/AIDS web site, www.cdc.gov/hiv. Under "Featured Items," click on "HIV Testing in Healthcare Settings" for a host of resources on the revised recommendations, including a fact sheet, podcasts, and a slide set. By clicking on the "View PDF" of Revised Recommendations For HIV Testing of Adults, Adolescents, and Pregnant Women In Health-Care Settings, readers will be able to download a version of the recommendations, published in Morbidity and Mortality Weekly Report. Clinicians can earn free continuing medical education upon reviewing the recommendations by following the information included after the recommendations.
The Centers for Disease Control and Prevention (CDC) is recommending that voluntary HIV screening become a routine part of medical care for all patients ages 13 to 64.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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