Published in UAB Insight, Winter 2008
CDC Recommendations: Rationale and Roadblocks
| CDC Recommendations
The CDC recommends HIV screening for:
- All patients aged 13 to 64 years (after notification that testing will be performed unless the patient declines).
- All patients initiating treatment for tuberculosis.
- All patients seeking treatment for sexually transmitted diseases.
- All patients who begin a sexual relationship with a new partner.
- All pregnant women during routine prenatal screening. Repeat screening in the third trimester is recommended for women from areas with elevated HIV infection rates.
Additional Recommendations
- Persons at high risk for HIV infection should be screened for HIV at least annually.
- Separate written consent for HIV testing is not required.
- Prevention counseling is not required as part of diagnostic testing.
Adapted from: MMWR Recomm Rep. 2006;55(RR-14):1-17.
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In 2006 the Centers for Disease Control and Prevention (CDC) and the US Department of Health and Human Services issued revised recommendations for HIV testing. The CDC based revisions on a 2-year review that conclude testing limited to individuals at high risk for HIV proved difficult to implement and was largely ineffective. The CDC now advocates voluntary HIV screening as a routine component of all medical practice. “This paradigm shift from risk-based testing to routine opt-out testing is a step in the right direction,” says UAB infectious diseases expert Michael J. Mugavero, MD.
Recommendations specify that medical practitioners offer an HIV test to all Americans aged 13 to 64 years once, when individuals have new partners, and annually if patients engage in high-risk behavior. Physicians should test all pregnant women as part of routine prenatal screening and retest those at high risk in the third trimester. Individuals must be informed that the test is being done but that it may be declined (opt-out). No separate consent is required, counseling is unnecessary, and repeat testing is at the provider’s discretion. Those who test positive should be referred for HIV care.
Rationale for Revision
In the United States 1 million persons have HIV, but 25% of those infected do not know it. Yearly incidence has remained at 40,000 since 1998 despite widespread availability of prevention information. HIV epidemiology has changed — 35% of new cases diagnosed between 1999 and 2002 were acquired heterosexually, and women, minorities, and those aged <20 years are increasingly infected. A growing number of people with HIV infection do not perceive themselves as at risk; nor do their health care providers. “Risk-based testing exacerbates stigma for an already stigmatizing infection, and risk behaviors often are not disclosed in medical encounters,” says Mugavero.
Compared with opt-in programs, HIV screening rates are consistently higher in settings providing prenatal and sexually transmitted disease services that use opt-out screening with streamlined counseling and consent procedures. Routine prenatal HIV testing has substantially increased the number of pregnant women tested and decreased incidence of pediatric HIV/AIDS.
“To benefit optimally from highly active antiretroviral therapy [HAART] and prophylactic medications, HIV-infected persons must know their serostatus, access care early in the course of disease, and remain engaged in care,” Mugavero says. “HAART is very effective when initiated before a patient’s CD4+ cell count is <200/mcL. At this earlier stage, significant increases in survival have occurred. Yet an alarming number of people present late — nearly 50% in recent studies.”
Many ethical, legal, and logistical issues must be resolved before CDC recommendations can be normalized. Discrimination continues to plague people living with HIV. Medicare does not cover HIV screening, and Medicaid’s coverage varies. In contrast with new CDC recommendations, some state laws require signed, written consent for HIV tests.
“The rapid HIV test now available is inexpensive, accurate, and easily done at point-of-care. However, universal opt-out testing must be implemented with thoughtful consistency to reduce the number of new HIV infections, link people to care earlier, save lives, and ultimately reduce costs of care,” Mugavero says.
For more information:
Dr. Michael Mugavero
1.800.UAB.MIST
mist@uabmc.edu