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
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.