June 27 is National HIV Testing Day! This is an important part of the Center for Disease Control and Prevention (CDC) campaign to increase awareness and highlight the importance of HIV testing. Healthcare organizations, prevention and community-based services, and clinicians of all backgrounds and training levels can play a major role in ensuring that people are appropriately screened for HIV.
The current CDC recommendations for HIV screening in the U.S. support voluntary, opt-out testing as a part of routine clinical care in all healthcare settings (REF 1):
- Screening for HIV infection should be performed routinely for all patients aged 13-64 years, unless the prevalence of undiagnosed HIV infection in their community has been documented to be < 0.1%.
- All persons likely to be at high risk for HIV should subsequently be tested at least annually.
- Women who are pregnant should also be screened as early as possible in their pregnancy.
HIV screening is important because it is the first step in getting patients into care and successfully on antiretroviral treatment (figure 1). Experts also agree that widespread, effective HIV treatment plays an important role in reducing the number of new HIV infections. However, it is estimated that only ~80%* of those infected in the U.S. have been diagnosed and are aware of their HIV status, and significantly fewer are retained in care (figure 2). In 2009, persons who were undiagnosed and those who were diagnosed but not retained in medical care were responsible for > 90% of transmissions (REF 2).
* More recent data indicate a slight growth in percentage of diagnosed persons — up to 87% (REF 3).
Since 2014, the CDC has recommended that laboratories conduct initial testing for HIV with an FDA-approved antigen/antibody combination immunoassay (“4th generation HIV test”) that detects HIV-1 and HIV-2 antibodies and HIV-1 p24 antigen (REF 3). This test screens for both established infection with HIV-1 or HIV-2 and has the additional benefit over previously-favored assays of being able to detect acute HIV-1 infection. However, standard HIV screening not using 4th generation assays may still be acceptable for routine screening, especially in situations where acute or early HIV are not of concern.
The CCC encourages all health providers to contact our consultation services for questions about HIV testing through the CCC HIV/AIDS Management Service at 1-800-933-3413 or through our online case submission service, the electronic Clinician Consultation Service (e-CCS). Our consultants can provide expert advice on implementing routine testing at your practice location, describe differences between various HIV-related assays, help you interpret results, and provide decision support for additional management considerations such as post-test counseling and follow-up (see a sample of HIV testing calls we have received below). We are staffed with physicians, nurses, and clinical pharmacists who can help with any HIV testing questions.
Below is a sample of questions answered by CCC consultants about performing rapid and standard HIV testing and interpreting and disclosing test results:
- A physician from a small town in Iowa with little experience managing HIV called seeking guidance on diagnosis, treatment, counseling, and other aspects of initial management of a 27-year-old woman who was possibly HIV-infected. The patient had returned home from graduate school to run her parents’ small business. As part of a routine “check-up” with the family physician, an standard HIV test was obtained and results returned positive. The caller asked whether a single test was sufficient to diagnose HIV, what other tests would be appropriate to obtain at this time, and whether antiretroviral medications needed to be initiated. The CCC consultant worked with the physician on an immediate plan of action and offered to be available for any future follow-up.
- A nurse practitioner in a large metropolitan area in New York called regarding a 41-year-old man she had evaluated in an urgent care center. The man complained of flu-like symptoms for two days and was hoping to receive antibiotics. The examination was normal other than a low-grade fever. As part of the evaluation, a rapid HIV test was performed and results were positive. The nurse practitioner asked the CCC consultant what further evaluation was necessary at this time and how she should proceed with additional testing.
- A primary care physician in Georgia called to ask for clarification and interpretation of HIV test results. The caller’s patient was a healthy, asymptomatic 35-year-old woman with two teenage daughters. Standard HIV screening during her second pregnancy returned a positive ELISA test and a negative Western Blot test, and she was told at that time that she did not have HIV. Standard HIV testing at the time of the call, however, showed a positive ELISA test and an indeterminate Western Blot test. The physician asked for assistance with interpretation of the tests and whether additional tests were indicated.
1. CDC 2006 Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings
2. “Human Immunodeficiency Virus Transmission at Each Step of the Care Continuum in the United States”. Skarbinski J, Rosenberg E, Paz-Bailey G, Hall HI, Rose CE, Viall AH, Fagan JL, Lansky A, Mermin JH. JAMA Intern Med. 2015 Apr; 175(4): 588-96.
3. CDC estimated number of persons aged ≥13 years with HIV infection (diagnosed and undiagnosed)
4. CDC 2014 Laboratory Testing for the Diagnosis of HIV recommendations
Additional HIV Testing Resources: