Revised HIV testing guidelines for adults scrutinized

LAST YEAR ACKNOWLEDGED the 25th year since AIDS was first recognized, and to coincide with that anniversary, the U.S. Centers for Disease Control and Prevention (CDC) revised its recommendations for HIV testing for adults, adolescents and pregnant women in healthcare settings. The new guidelines remove the onus of determining who is at high risk for HIV infection and makes testing a routine part of medical care for all patients between ages 13 and 64 years.

The CDC recommendations also eliminate some barriers to testing, such as HIV prevalence and risk assessments, separate written consent and pre-test counseling. That is not to say, however, that prevention counseling should not be available to those who test positive and are at high risk for developing AIDS.

The CDC also sees the recommendation as a means of remedying a missed opportunity for healthcare facilities to screen for HIV. Even with access to healthcare, more than 60% of those newly diagnosed with HIV already had progressed to an advanced stage of the disease-indicating that they are learning about their infection too late. Ruth says the new recommendations will serve to mitigate the stigma surrounding HIV testing.

The revised recommendations announced last September replace CDC's 1993 "Recommendations for HIV Testing Services for Inpatients and Outpatients in Acute Care Hospital Settings," which called for routine testing for those at high risk and for everyone living in high-prevalence areas-a population where more than 1% have HIV.

The new guidelines also enhance portions of CDC's 2001 "Revised Guidelines for HIV Screening of Pregnant Women" to prevent transmission from mother to child. New recommendations for pregnant women suggest a repeat HIV test in the third trimester not only for women of child-bearing age (15 to 45 years) who are at high risk for HIV, but also for those living in high-prevalence areas. In addition, the new recommendations specify that a rapid HIV test be used during labor for all women whose HIV status is unknown.

The CDC says that prior existence of voluntary screening for all pregnant women without separate consent has decreased the number of infants born with HIV from 1,650 in 1991 to less than 240 cases each successive year.

ANOTHER VIEW

The U.S. Preventive Services Task Force (USPSTF), sponsored by the Agency for Healthcare Research and Quality (AHRQ), does not agree with CDC recommendations for routine HIV screening for everyone between 13 and 64 years. Instead, it makes no recommendation for or against routine HIV tests for adolescents and adults who are not at increased risk for HIV infection. It does, however, recommend that clinicians screen all pregnant women for HIV. USPSTF evaluates the benefits of individual preventive services and the magnitude of those benefits based on scientific evidence to guide in the delivery of those services.

"We see two major benefits from routine HIV screening-early diagnosis leading to interventions to prevent mortality and morbidity and awareness of the infection to decrease transmission," says Diana Petitti, MD, vice chair of USPSTF. "Although there is a definite yield of cases in routine testing, there is no evidence that the benefits outweigh the harms of testing low-risk populations." USPSTF recommends that clinicians consider the prevalence of HIV infection or risk characteristics of their populations to determine a screening strategy.

Dr. Petitti says that the large number of false positives inherent in routine testing in low-risk populations was another consideration of USPSTF; however, rapid HIV antibody testing without specific counseling and written consent as recommended by the CDC is highly accurate but not feasible in many states because of laws requiring written consent. She points out that her organization's conclusions about transmission prevention because of routine testing differed from those of CDC, but that USPSTF is willing to look at any new evidence.