Patient Care

Who Should Be Screened for HIV Infection?


 

Case

A 31-year-old male with a history of asthma is admitted with an asthma exacerbation. He has no regular outpatient provider. He denies tobacco use and reports that he is in a monogamous relationship with his girlfriend. On rounds, a medical student mentions that new HIV screening guidelines have been released recently and asks whether this patient should be screened for HIV.

Background

By the mid-2000s, approximately one to 1.2 million people in the United States were infected with HIV.1 Approximately one quarter of these patients are estimated to be unaware of their HIV status, and this subgroup is believed responsible for a disproportionately higher percentage of new HIV infections each year.1

While older HIV screening recommendations focused on screening patients who were deemed to be at high risk for HIV infection, there has been a paradigm change in recent years toward universal screening of all patients.2,3 The ultimate goal is for earlier identification of infected patients, which will, in turn, lead to earlier treatment and better prevention efforts.

Universal screening has been supported by a number of different professional societies and screening guidelines.4

The CDC guidelines also recommend HIV screening for all patients starting treatment for tuberculosis, patients being screened for STDs, and patients visiting STD clinics regardless of chief complaint.2

2013 Guideline

In 2013, the United States Preventive Services Task Force (USPSTF) issued new recommendations regarding HIV screening. Although the previous USPSTF guidelines (released in 2005) recommended screening patients who were believed to be at increased risk for contracting HIV, the 2013 guidelines now recommend screening all patients aged 15 to 65.4

Screening patients outside of this age range is recommended if the patient is deemed to be at increased risk for contracting HIV.4 The USPSTF provides criteria for identifying patients who are at increased risk of contracting HIV. These include:

  • Men who have sex with men;
  • People having unprotected vaginal or anal intercourse;
  • People using injection drugs;
  • People exchanging sex for drugs or money; and
  • People requesting testing for other sexually transmitted diseases (STDs).4

Patients are also considered to be high risk if their sexual partners are infected with HIV, are bisexual, or use injection drugs.4

The shift toward universal HIV screening has been a trend for many years, because risk-based targeting of HIV screening will miss a significant number of HIV infections.2 In fact, the 2013 recommendations bring the USPSTF guidelines into agreement with current CDC guidelines, which were released in 2006.2

The CDC, in its 2006 guidelines, recommended screening for all patients 13 to 64 years old unless HIV prevalence in the patient population has been found to be less than 0.1%, the minimum prevalence deemed necessary for HIV screening to be cost-effective.2 The CDC guidelines also recommend HIV screening for all patients starting treatment for tuberculosis, patients being screened for STDs, and patients visiting STD clinics regardless of chief complaint.2 They recommend that HIV screening be performed in an “opt-out” fashion, meaning that patients are informed that screening will be performed unless they decline.2 Furthermore, they recommend against the need for a separate written consent form for HIV screening, as well as the prior requirement that pre-screening counseling be performed, because these requirements were felt to create potential time constraint barriers that prevented providers from screening patients.2

The CDC and the USPSTF are less conclusive with regard to frequency of rescreening for HIV infection. Both recommend rescreening patients considered high risk for HIV infection, but the interval for rescreening has not been concretely defined.2,4 The guidelines urge providers to use clinical judgment in deciding when to rescreen for HIV infection.2 For example, one reason for rescreening cited by the CDC would be the initiation of a new sexual relationship.2

In the 2013 guidelines, the USPSTF also recommends screening all pregnant women, including those presenting in labor without a known HIV status.4 This stance is supported by the American College of Gynecologists and Obstetricians.3 In high-risk patients with a negative screening test early in pregnancy, consideration should be given to repeat testing in the third trimester.3 Routinely screening pregnant women for HIV and starting appropriate therapy in positive patients has lowered the incidence of perinatal HIV transmission dramatically.2

It has been suggested that early initiation of antiretroviral therapy could reduce risk of transmission to noninfected partners by lowering viral load in the infected patient.2 Knowledge of HIV status has also been shown to reduce high-risk behaviors.4.

Rationale

There are several reasons behind the shift to universal HIV screening, regardless of risk. First, providers often do not accurately identify patients’ HIV risk, often because patients are not aware of their actual risk or are uncomfortable discussing their high-risk behaviors with healthcare providers.2 Using risk factors as a basis of screening will miss a significant number of HIV-positive patients.4

Additionally, screening all patients will result in the detection of HIV infection in a greater number of patients during the early asymptomatic phase, rather than when they later become symptomatic from HIV or AIDS.2,4 Recent data has led the International Antiviral Society—USA Panel to issue updated recommendations advising initiation of antiretroviral therapy at all CD4 levels.5 Studies and observational data suggest that this could result in reduced AIDS complications and death rates.4

Early detection of HIV infection also has the potential of reducing spread of the virus.2,4 It has been suggested that early initiation of antiretroviral therapy could reduce risk of transmission to noninfected partners by lowering viral load in the infected patient.2 Knowledge of HIV status has also been shown to reduce high-risk behaviors.4

Moreover, by facilitating earlier detection of HIV, universal screening will allow for earlier and better counseling for infected patients.4 This has the potential to further alter behaviors and possibly reduce transmission of HIV and/or other sexually transmitted diseases.4 Additionally, routine screening of pregnant women allows for better detection of HIV-infected mothers.3 With appropriate interventions during pregnancy, including antiretroviral therapy, rates of mother-to-child transmission have decreased significantly.4

On the other hand, potential harms from HIV screening were considered during the USPSTF analysis, including risk of false positive test results, as well as the side effects of antiretroviral medications.4 Although there are known short-term and long-term side effects of antiretroviral medications, some of these side effects can be avoided by changing drug regimens.4 For many other side effects, the benefits appeared to outweigh the risks of these medications.4

Studies have also shown some potential side effects in infants exposed to antiretroviral medications, but the overall evidence is not strong.4 In the end, thorough analysis performed by the USPSTF resulted in the opinion that the benefits of HIV screening far outweigh the associated risks.4

Challenges for Hospitalists

Several potential drawbacks to universal HIV screening are relatively unique to hospitalists and other providers of hospital-based care.6 First, hospitalists must be prepared to counsel patients regarding their test results, particularly if patients are hospitalized for another issue. Second, hospitalists must be able to communicate these test results to primary care providers in a timely fashion, a challenge that is not unique to HIV testing.

The biggest concern for hospitalists is what to do with HIV test results that are still pending at the time of hospital discharge. Hospitalists will likely face this issue more as increasing numbers of patients are screened in a growing number of medical settings, including the ED and inpatient admissions. Hospitalists who plan to screen inpatients for HIV testing must ensure that these issues have been worked out prior to screening.

Back to the Case

Looking back to the initial case discussion, based on the 2006 CDC and 2013 USPSTF guidelines, this patient should be offered HIV screening if he has not been tested previously. Although the patient states that he is in a monogamous relationship and does not report any high-risk behaviors, patients often do not recognize the true risk associated with their behaviors and fail to accurately report them.2 Additionally, patients often are embarrassed by high-risk behaviors and may not report them completely to providers.2

The patient has admitted that he does not seek medical care on a regular basis. This inpatient admission may be his only interaction with the medical field for some time, and thus his only opportunity to undergo screening. But, prior to screening the patient, the hospitalist must ensure that he or she will be able to counsel the patient regarding test results, will be able to communicate those results to the patient’s primary care physician, and will be able to handle pending results if the patient is discharged before the test results are returned.


Drs. Gwyn, Carbo and Li are hospitalists at Beth Israel Deaconess Medical Center in Boston.

Key Points

  • Based on current USPSTF and CDC guidelines, all adolescent and adult patients should be screened for HIV at least once.
  • Pregnant patients should also be screened so that steps can be taken to try to prevent perinatal HIV transmission.
  • Rescreening should be considered in patients deemed high risk for HIV infection.
  • Hospitalists who screen inpatients must be able to counsel patients, communicate results with outpatient providers, and have a system in place for handling results pending at discharge.

Additional Reading

  • Moyer VA; U.S. Preventive Services Task Force. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013;159(1):51-60.
  • Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-17.

References

  1. Branson B. Current HIV epidemiology and revised recommendations for HIV testing in health-care settings. J Med Virol. 2007;79 Suppl 1:S6-S10.
  2. Moyer VA; U.S. Preventive Services Task Force. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013;159(1):51-60.
  3. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-17.
  4. Clark J, Lampe MA, Jamieson DJ. Testing women for human immunodeficiency virus infection: who, when, and how? Clin Obstet Gynceol. 2008;51(3):507-517.
  5. Thompson MA, Aberg JA, Hoy JF, et al. Antiretroviral treatment of adult HIV infection: 2012 recommendations of the International Antiviral Society–USA Panel. JAMA. 2012;308(4):387-402.
  6. Arbelaez C, Wright EA, Losina E, et al. Emergency provider attitudes and barriers to universal HIV testing in the emergency department. J Emerg Med. 2012;42(1):7-14.

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