New HIV guidelines make screening even more routine

The U.S. Preventive Services Task Force released new HIV screening guidelines that may affect the nearly one in five people infected with HIV who are not aware they have it. The guidelines, aimed at making screening part of routine practice for the public, may open doors for earlier diagnosis and treatment, doctors said.

“All I can say is, ‘It’s about time,’ ” said Carlos del Rio, MD, program director of the Emory University AIDS International Training and Research Program in Atlanta. “In the past, HIV testing was diagnostic, and now it is a screening. Everyone should know where they stand with HIV.”

The change was spurred by recent research that says treating people with HIV earlier not only reduces the risk of developing AIDS but also can change behaviors.

“Now there is better evidence of the effectiveness of early intervention,” said Douglas K. Owens, MD, task force member and associate director of the Center for Health Care Evaluation at the VA Palo Alto Health Care System in California. “Treatment helps reduce transmission, and people can live longer and healthier lives.”

In addition to reaffirming its 2005 recommendation for HIV screening for pregnant women and persons at increased risk, the new USPSTF guidelines, issued April 30, include adolescents and adults ages 15 to 65 who are not known to be at increased risk for HIV infection. Younger adolescents and older adults who are at increased risk also should be screened.

Since the first cases of AIDS were reported in 1981, more than 1.1 million Americans have been diagnosed with the illness, and nearly 595,000 have died. Twenty percent to 25% of individuals living with HIV infection are unaware of it.

“HIV is a critical public health problem,” Dr. Owens said. “There are 50,000 new infections each year.”

Primary care doctors can play an important role in reducing HIV-related disease and death, he said. “That is why our recommendation, which closely aligns with the HIV screening guidelines from the [Centers for Disease Control and Prevention], encourages clinicians to screen their patients for HIV.”

A way to reduce stigma

But some patients still don’t want to get tested for HIV. AIDS experts hope that normalizing such screening — just like cholesterol — will help remove barriers.

“We hope the recommendation to make it routine will help remove the stigma,” Dr. Owens said. “Perhaps it will be an easier conversation with the patient.”

With routine testing, doctors are hoping for other changes.

“It’s not just the test,” said William R. Short, MD, MPH, assistant professor of medicine in the Division of Infectious Diseases at Jefferson Medical College in Philadelphia. “Practitioners don’t know what to do with a positive diagnosis. We need a mindset change over a long period.”

When the HIV antibody screening test first became available in 1985, the main goal was to protect the blood supply, according to the CDC. At that time, professional opinion was divided regarding the value of HIV testing and whether it should be encouraged.

Today, conventional and rapid HIV antibody tests are highly accurate in diagnosing HIV infection, the task force said.

Until the task force recommended a change, HIV testing was diagnostic, requiring a reason for testing. That meant physicians had to talk to patients about lifestyle and behaviors.

“Now, with screening, you don’t have to say, ‘I’m concerned you may have AIDS,’ ” Dr. del Rio said. “It can be incorporated into routine care. In the past there was a lot of time involved in pre- and post-counseling. Now it should be no different than ordering any other test.”

Nonetheless, physicians need to see how this screening will fit into busy schedules, and they must feel more comfortable talking about it with patients, doctors said. Dr. Short questions whether the guideline change will make much difference.

“It’s been seven years since the CDC adopted similar recommendations for universal screening, and people still have not increased screening,” he said. “[Practitioners] say, ‘I’ve got a schedule of 40 people and now you want me to add this screening?’ Practitioners need to realize that it can be done easily, to realize that screening is not going to add a ton of time.”

Even though screening is now routine, lumping it in with a handful of other tests is not an option, because it remains an opt-out test, meaning patients must be given the chance to decline. Still, Dr. Short said, doctors can train staff to ask while taking vitals.

Dr. del Rio warns of missing opportunities with patients who go too long without a diagnosis.

“It needs to go beyond a recommendation on paper,” he said. “Routine screening needs to be implemented in clinics, and each clinic will need someone to champion the effort.”