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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Ujjwal Rastogi, MBBS ; Ammu Susheela, M.D. [2]

Overview

The major determinant of the morbidity and mortality of HIV infections is adequate antiretroviral therapy. For that reason, early detection is essential in improving outcomes.[1] In 2006, the Centers for Disease Control announced an initiative for voluntary, routine testing of all Americans aged 13–64 during health care encounters. An estimated 25% of infected individuals were unaware of their status.[2] Routine prenatal HIV testing was also recommended for all women as part of their normal gestational screening tests.

Who to screen

Everyone

  • According to the U.S. guidelines, all sexually active individuals have to be tested at least once for HIV at ages 15–65 years.[3]
  • Recommended for all persons seeking STI evaluation who are not already known to have HIV infection at the time of the STI evaluation.[4]
  • At least annual testing is recommended for those with an ongoing high risk of infection (sexual partners of individuals with sexually transmitted infections, individuals with more than one sexual partner since their most recent HIV test, injection-drug users, and individuals who exchange sex for drugs or money).[5]
  • Providers should assess eligibility of all persons seeking STI services for HIV PrEP and PEP. For persons with substantial risk whose results are HIV negative, providers should offer or provide referral for PrEP services, unless the last potential HIV exposure occurred <72 hours, in which case PEP might be indicated.[4]

Rationale for Routine Screening for HIV Infection

  • People who are infected with HIV but not aware of it are not able to take advantage of the therapies that can keep them healthy and extend their lives, nor do they have the knowledge to protect their sex or drug-use partners from becoming infected. Knowing whether one is positive or negative for HIV confers great benefits in healthy decision making.
  • Cohort studies have demonstrated that many infected persons decrease behaviors that help transmit infection to sex or needle-sharing partners once they are aware of their positive HIV status.[6][7][8]
  • HIV-infected persons who are unaware of their infection do not reduce risk behaviors.[9][10][11]
  • Persons tested for HIV who do not return for test results might even increase their risk for transmitting HIV to partners.[12]
  • Early referral to medical care could prevent HIV transmission in communities while reducing a person's risk for HIV-related illness and death, because medical treatment that lowers HIV viral load might also reduce risk for transmission to others.[13]
  • Several patients with undiagnosed HIV infection had multiple health care visits before getting an HIV test.[14]
  • Approximately 38% of new HIV cases are transmitted by individuals with undiagnosed HIV infection.[15]
  • HIV infection is consistent with all generally accepted criteria that justify screening:
  1. HIV infection is a serious health disorder that can be diagnosed before symptoms develop.
  2. HIV can be detected by reliable, inexpensive, and noninvasive screening tests.
  3. Infected patients have years of life to gain if treatment is initiated early, before symptoms develop.
  4. The costs of screening are reasonable in relation to the anticipated benefits.[16] Among pregnant women, screening has proven substantially more effective than risk-based testing for detecting unsuspected maternal HIV infection and preventing perinatal transmission.[17][18][19]
  • The use of “opt-out” testing (i.e., all adults are informed that an HIV test could be done; however, they can opt out if they want) has been shown to be more reliable in detection of HIV cases and cost-effective.[20][21][22]

Specific groups:

  • Sexually active gay, bisexual, and other men who have sex with men, should be screened for HIV at least annually.[4]

Screening Donors of Blood and Cellular Products

HIV can be transmitted to a person receiving blood or organs from an infected donor. To reduce this risk, blood banks and organ donor programs screen donors, blood, and tissues thoroughly. People who received blood transfusions or clotting products between 1977 and 1985 (before screening for the virus became standard practice) are at highest risk for getting HIV. Basic screening lab tests and regular cervical Pap smears are important to monitor in HIV infection, due to the increased risk of cervical cancer in women with a compromised immune system. Tests selected to screen donor blood and tissue must provide a high degree of confidence that HIV will be detected if present (that is, a high sensitivity is required). A combination of antibody, antigen and nucleic acid tests are used by blood banks in Western countries. The World Health Organization estimated that, inadequate blood screening had resulted in 1 million new HIV infections worldwide. In the USA, since 1985, all blood donations are screened with an ELISA test for HIV-1 and HIV-2, as well as a nucleic acid test. These diagnostic tests are combined with careful donor selection. The risk of transfusion-acquired HIV in the U.S. was approximately one in 2.5 million for each transfusion.[23]

Screening for HIV in Pregnant Women and their Infants[3]

  • Public health services (PHS) recommends that all pregnant women in the United States be tested for HIV infection. All health-care providers should recommend HIV testing to all of their pregnant patients, pointing out the substantial benefit of knowledge of HIV status for the health of women and their infants. HIV screening should be a routine part of prenatal care for all women.
  • A second test during the third trimester, preferably at <36 weeks’ gestation, should be considered and is recommended for women who are at high risk.[4]
  • HIV testing should be voluntary and free of coercion. Informed consent before HIV testing is essential. Information regarding consent can be presented orally or in writing and should use language the client understands. Accepting or refusing testing must not have detrimental consequences to the quality of prenatal care offered. Documentation of informed consent should be in writing, preferably with the client's signature. State or local laws and regulations governing HIV testing should be followed. HIV testing should be presented universally as part of routine services to pregnant women, and confidential informed consent should be maintained.
  • Although HIV testing is recommended, women should be allowed to refuse testing. Women should not be tested without their knowledge.
  • Women who refuse testing should not be coerced into testing, denied care for themselves or their infants, or threatened with loss of custody of their infants or other negative consequences.
  • Discussing and addressing reasons for refusal (e.g., lack of awareness of risk or fear of the disease, partner violence, potential stigma, or discrimination) could promote health education and trust-building and allow some women to accept testing at a later date.
  • Women who refuse testing because of a previous history of a negative HIV test should be informed of the importance of retesting during pregnancy. All logistical reasons for not testing (e.g., scheduling) should be addressed as well. Health-care providers should remember that some women who initially refuse testing might accept at a later date, particularly if their concerns are discussed.
  • Some women who refuse confidential testing might be willing to obtain anonymous testing. However, they should be informed that if they choose anonymous testing, no documentation of the results will be recorded in the medical chart, and their providers might have to retest them, potentially delaying provision of antiretroviral drugs for therapy or perinatal prophylaxis. Some women will continue to refuse testing, and their decisions should be respected.
  • Before HIV testing, health-care providers should provide the following minimum information. Although a face-to-face counseling session is ideal, other methods can be used (e.g., brochure, pamphlet, or video) if they are culturally and linguistically appropriate.
    • HIV is the virus that causes AIDS. HIV is spread through unprotected sexual contact and injection-drug use. Approximately 25% of HIV-infected pregnant women who are not treated during pregnancy can transmit HIV to their infants during pregnancy, during labor and delivery, or through breast feeding.
    • A woman might be at risk for HIV infection and not know it, even if she has had only one sex partner.
    • Effective interventions (e.g., highly active combination antiretrovirals) for HIV-infected pregnant women can protect their infants from acquiring HIV and can prolong the survival and improve the health of these mothers and their children.
    • For these reasons, HIV testing is recommended for all pregnant women.
    • Services are available to help women reduce their risk for HIV and to provide medical care and other assistance to those who are infected.
    • Women who decline testing will not be denied care for themselves or their infants.
  • Health-care providers should perform HIV testing in consenting women as early as possible during pregnancy to promote informed and timely therapeutic decisions. Retesting in the third trimester, preferably before 36 weeks of gestation, is recommended for women known to be at high risk for acquiring HIV (e.g., those who have a history of sexually transmitted diseases [STDs], who exchange sex for money or drugs, who have multiple sex partners during pregnancy, who use illicit drugs, who have sex partner[s] known to be HIV-positive or at high risk, and who have signs and symptoms of seroconversion). Routine universal retesting in the third trimester may be considered in health-care facilities with high HIV seroprevalence among women of childbearing age. Retesting for syphilis during the third trimester and again at delivery also is recommended for pregnant women at high risk. [4]
  • Some states mandate syphilis screening at delivery for all pregnant women.
  • Women admitted for labor and delivery with unknown or undocumented HIV status should be assessed promptly for HIV infection to allow for timely prophylactic treatment. Expedited testing by either rapid return of results from standard testing or use of rapid testing (with confirmation by a second licensed test when available) is recommended for these women. The goal is to identify HIV-infected women or their infants as soon as possible because the efficacy of prophylactic therapy is greatest if given during or as soon after exposure as possible (i.e., within 12 hours of birth). Informed consent is essential for women tested prenatally, and women in labor with unknown status should be allowed to refuse testing without undue consequences. After delivery, standard confirmatory testing should be done for women with positive rapid test results.
  • Regulations, laws, and policies regarding HIV screening of pregnant women and infants are not standardized throughout all states and U.S. territories. Health-care providers should be familiar with and adhere to state/local laws, regulations, and policies concerning HIV screening of pregnant women and infants.
  • Routine prenatal HIV testing with streamlined counseling and consent procedures has increased the number of pregnant women tested substantially.

Selection of tests to screen

Per the United States Preventive Services Task Force (USPSTF)[24][25]:


Ethics of HIV Screening

The UNAIDS/WHO policy statement on HIV Testing states that conditions under which people undergo HIV testing must be anchored in a human rights approach that pays due respect to ethical principles.[26] According to these principles, the conduct of HIV testing of individuals must be

  • Confidential.
  • Accompanied by counseling (for those who test positive).
  • Conducted with the informed consent of the person being tested.

Confidentiality

Considerable controversy exists over the ethical obligations of health care providers to inform the sexual partners of individuals infected with HIV that they are at risk of contracting the virus.[27] Some legal jurisdictions permit such disclosure, while others do not. More state funded testing sites are now using confidential forms of testing. This allows for monitoring of infected individuals easily, compared to anonymous testing that has a number attached to the positive test results. Controversy exists over privacy issues.

In developing countries, home-based HIV testing and counseling (HBHTC) is an emerging approach for addressing confidentiality issues. HBHTC allows individuals, couples, and families to learn their HIV status in the convenience and privacy of their home environment. Rapid HIV tests are most often used, so results are available for the client between 15 and 30 minutes. Furthermore, when an HIV positive result is communicated, the HTC provider can offer appropriate linkages for prevention, care, and treatment.

Anonymous Testing

Testing that has only a number attached to the specimen that will be delivered for testing. Items that are confirmed positive will not have the HIV infected individual's name attached to the specimen. Sites that offer this service advertise this testing option.


Evaluation and Screening in Patients with HIV Infection

At the Time of Diagnosis

STDs Screening

  • Specific testing includes syphilis serology and NAAT for N. gonorrhoeae and C. trachomatis at the anatomic site of exposure.[4]
  • Women should also be screened for trichomoniasis at the initial visit and annually thereafter.[4]
  • Women should be screened for cervical cancer precursor lesions per existing guidelines.[4]

Medical appointment

At First Clinic Visit

At Subsequent Visits

  • Assessment of cognitive function in patients older than 60 year of age or as indicated clinically, every 2 years

With Regimen Change

Follow-up

  • It is recommended that follow-up visits should be scheduled 4 to 6 weeks after the initiation of ART and then every 3 months until virologic suppression is reached.
  • After maintaining the virologic suppression for a year, follow-up visits should be scheduled every 6 months.[28]

References

  1. ↑ Long EF, Brandeau ML, Owens DK (2010). "The cost-effectiveness and population outcomes of expanded HIV screening and antiretroviral treatment in the United States". Ann Intern Med. 153 (12): 778–89. doi:10.7326/0003-4819-153-12-201012210-00004. PMC 3173812. PMID 21173412.
  2. ↑ CDC fact sheet
  3. ↑ Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB; et al. (2006). "Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings". MMWR Recomm Rep. 55 (RR-14): 1–17, quiz CE1-4. PMID 16988643.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I; et al. (2021). "Sexually Transmitted Infections Treatment Guidelines, 2021". MMWR Recomm Rep. 70 (4): 1–187. doi:10.15585/mmwr.rr7004a1. PMC 8344968 Check |pmc= value (help). PMID 34292926 Check |pmid= value (help).
  5. ↑ DiNenno EA, Prejean J, Irwin K, Delaney KP, Bowles K, Martin T; et al. (2017). "Recommendations for HIV Screening of Gay, Bisexual, and Other Men Who Have Sex with Men - United States, 2017". MMWR Morb Mortal Wkly Rep. 66 (31): 830–832. doi:10.15585/mmwr.mm6631a3. PMC 5687782. PMID 28796758.
  6. ↑ Coates TJ, Morin SF, McKusick L (1987). "Behavioral consequences of AIDS antibody testing among gay men". JAMA. 258 (14): 1889. PMID 3477652. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  7. ↑ Wenger NS, Linn LS, Epstein M, Shapiro MF (1991). "Reduction of high-risk sexual behavior among heterosexuals undergoing HIV antibody testing: a randomized clinical trial". Am J Public Health. 81 (12): 1580–5. PMC 1405278. PMID 1746653. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  8. ↑ Fox R, Odaka NJ, Brookmeyer R, Polk BF (1987). "Effect of HIV antibody disclosure on subsequent sexual activity in homosexual men". AIDS. 1 (4): 241–6. PMID 3126772. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  9. ↑ Wenger NS, Kusseling FS, Beck K, Shapiro MF (1994). "Sexual behavior of individuals infected with the human immunodeficiency virus. The need for intervention". Arch. Intern. Med. 154 (16): 1849–54. PMID 8053754. Retrieved 2012-02-23. Unknown parameter |month= ignored (help)
  10. ↑ Dawson J, Fitzpatrick R, McLean J, Hart G, Boulton M (1991). "The HIV test and sexual behaviour in a sample of homosexually active men". Soc Sci Med. 32 (6): 683–8. PMID 2035044. |access-date= requires |url= (help)
  11. ↑ Desenclos JC, Papaevangelou G, Ancelle-Park R (1993). "Knowledge of HIV serostatus and preventive behaviour among European injecting drug users. The European Community Study Group on HIV in Injecting Drug Users". AIDS. 7 (10): 1371–7. PMID 8267911. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  12. ↑ Otten MW, Zaidi AA, Wroten JE, Witte JJ, Peterman TA (1993). "Changes in sexually transmitted disease rates after HIV testing and posttest counseling, Miami, 1988 to 1989". Am J Public Health. 83 (4): 529–33. PMC 1694465. PMID 8460729. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  13. ↑ Quinn TC, Wawer MJ, Sewankambo N, Serwadda D, Li C, Wabwire-Mangen F, Meehan MO, Lutalo T, Gray RH (2000). "Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group". N. Engl. J. Med. 342 (13): 921–9. doi:10.1056/NEJM200003303421303. PMID 10738050. Retrieved 2012-02-23. Unknown parameter |month= ignored (help)
  14. ↑ Nakao JH, Wiener DE, Newman DH, Sharp VL, Egan DJ (2014). "Falling through the cracks? Missed opportunities for earlier HIV diagnosis in a New York City Hospital". Int J STD AIDS. 25 (12): 887–93. doi:10.1177/0956462414523944. PMID 24535693.
  15. ↑ Li Z, Purcell DW, Sansom SL, Hayes D, Hall HI (2019). "Vital Signs: HIV Transmission Along the Continuum of Care - United States, 2016". MMWR Morb Mortal Wkly Rep. 68 (11): 267–272. doi:10.15585/mmwr.mm6811e1. PMC 6478059. PMID 30897075.
  16. ↑ Wilson JM, Jungner YG (1968). "[Principles and practice of mass screening for disease]". Bol Oficina Sanit Panam (in Spanish; Castilian). 65 (4): 281–393. PMID 4234760. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  17. ↑ Barbacci MB, Dalabetta GA, Repke JT, Talbot BL, Charache P, Polk BF, Chaisson RE (1990). "Human immunodeficiency virus infection in women attending an inner-city prenatal clinic: ineffectiveness of targeted screening". Sex Transm Dis. 17 (3): 122–6. PMID 2247801. |access-date= requires |url= (help)
  18. ↑ Fehrs LJ, Hill D, Kerndt PR, Rose TP, Henneman C (1991). "Targeted HIV screening at a Los Angeles prenatal/family planning health center". Am J Public Health. 81 (5): 619–22. PMC 1405093. PMID 2014863. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  19. ↑ Lindsay MK, Adefris W, Peterson HB, Williams H, Johnson J, Klein L (1991). "Determinants of acceptance of routine voluntary human immunodeficiency virus testing in an inner-city prenatal population". Obstet Gynecol. 78 (4): 678–80. PMID 1923172. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  20. ↑ Haukoos JS, Hopkins E, Conroy AA, Silverman M, Byyny RL, Eisert S; et al. (2010). "Routine opt-out rapid HIV screening and detection of HIV infection in emergency department patients". JAMA. 304 (3): 284–92. doi:10.1001/jama.2010.953. PMID 20639562.
  21. ↑ Prekker ME, Gary BM, Patel R, Olives T, Driver B, Dunlop SJ; et al. (2015). "A comparison of routine, opt-out HIV screening with the expected yield from physician-directed HIV testing in the ED". Am J Emerg Med. 33 (4): 506–11. doi:10.1016/j.ajem.2014.12.057. PMID 25727169.
  22. ↑ Mwachofi A, Fadul NA, Dortche C, Collins C (2020). "Cost-effectiveness of HIV screening in emergency departments: a systematic review". AIDS Care: 1–12. doi:10.1080/09540121.2020.1817299. PMID 32933322 Check |pmid= value (help).
  23. ↑ Adverse reactions associated with blood transfusion. From the Puget Sound Blood Center. Accessed 5 Oct 2006.
  24. ↑ United States Preventive Services Task Force 2019). Human Immunodeficiency Virus (HIV) Infection: Screening. Available at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/human-immunodeficiency-virus-hiv-infection-screening
  25. ↑ Centers for Disease Control and Prevention (2018). 2018 Quick reference guide: Recommended laboratory HIV testing algorithm for serum or plasma specimens. Available at https://stacks.cdc.gov/view/cdc/50872
  26. ↑ UNAIDS/WHO policy statement on HIV Testing (PDF), accessed 5 Oct 2006.
  27. ↑ JM Appel (2006). "Must My Doctor Tell My Partner? Rethinking Confidentiality in the HIV Era". Medicine and Health Rhode Island. 89 (6): 223–4. PMID 16875013. Unknown parameter |month= ignored (help)
  28. ↑ Saag MS, Gandhi RT, Hoy JF, Landovitz RJ, Thompson MA, Sax PE; et al. (2020). "Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2020 Recommendations of the International Antiviral Society-USA Panel". JAMA. 324 (16): 1651–1669. doi:10.1001/jama.2020.17025. PMID 33052386 Check |pmid= value (help).

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