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

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