Human Immunodeficiency Virus (HIV) Infection Screening-Adult

Summary of Recommendations and Evidence

Population	Recommendation	Grade (What's This?)
Adolescents and Adults 15-65 Years Old	The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. Go to the Clinical Considerations for more information about screening intervals.	A
Pregnant Women	The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown.	A

Population

Recommendation

Adolescents and Adults 15-65 Years Old

The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened.

Go to the Clinical Considerations for more information about screening intervals.

A

Pregnant Women

The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown.

A

Importance

An estimated 1.2 million persons in the United States are currently living with HIV infection, and the annual incidence of the disease is approximately 50,000 cases. Since the first cases of AIDS were reported in 1981, more than 1.1 million persons have been diagnosed and nearly 595,000 have died from the condition. Approximately 20% to 25% of individuals living with HIV infection are unaware of their positive status.

Detection

The USPSTF found convincing evidence that conventional and rapid HIV antibody tests are highly accurate in diagnosing HIV infection.

Benefits of Detection and Early Intervention

The USPSTF found convincing evidence that identification and treatment of HIV infection is associated with a markedly reduced risk for progression to AIDS, AIDS-related events, and death in individuals with immunologically advanced disease (defined as a CD4 count <0.200 × 10⁹ cells/L). Adequate evidence shows that initiating combined antiretroviral therapy (ART) earlier (that is, at CD4 counts between 0.200 and 0.500 × 10⁹ cells/L)—when individuals are more likely to be asymptomatic and detected by screening rather than clinical presentation—is also associated with reduced risk for AIDS-related events or death. The USPSTF found convincing evidence that the use of ART is associated with a substantially decreased risk for transmission from HIV-positive persons to uninfected heterosexual partners. Convincing evidence also shows that identification and treatment of HIV-positive pregnant women dramatically reduces rates of mother-to-child transmission. The overall benefits of screening for HIV infection in adolescents, adults, and pregnant women are substantial.

Harms of Detection and Early Intervention

The USPSTF found convincing evidence that individual antiretroviral drugs, drug classes, and combinations are all associated with short-term adverse events; however, many of these events are transient or self-limited, and effective alternatives can often be found. Although the long-term use of certain antiretroviral drugs may be associated with increased risk for cardiovascular and other adverse events, the magnitude of risk seems to be small. The overall harms of screening for and treatment of HIV infection in adolescents, adults, and pregnant women are small.

USPSTF Assessment

The USPSTF concludes with high certainty that the net benefit of screening for HIV infection in adolescents, adults, and pregnant women is substantial.

Patient Population Under Consideration

These recommendations apply to adolescents, adults, and pregnant women.

Screening for HIV infection could begin at age 15 years unless an individual is identified at an earlier age with risk factors for HIV infection. Screening after age 65 years is indicated if there is ongoing risk for HIV infection, as indicated by risk assessment (for example, new sexual partners).

Assessment of Risk

According to estimates from the Centers for Disease Control and Prevention (CDC), men who have sex with men account for about 60% of HIV-positive persons in the United States¹. Among men living with HIV infection who were diagnosed at age 13 years or older, 68% of infections are attributed to male-to-male sexual contact, 8% are attributed to male-to-male sexual contact and injection drug use, and 11% are attributed to heterosexual contact. Among women living with HIV infection, 74% of infections are attributed to heterosexual contact and the remainder to injection drug use¹^,². According to the CDC, heterosexual contact accounted for an estimated 25% of new HIV infections in 2010 and 27% of existing infections in 2009³^,⁴. Data from the CDC on HIV prevalence in different subpopulations are available at www.cdc.gov/hiv/topics/surveillance This link goes offsite. Click to read the external link disclaimer.

On the basis of HIV prevalence data, the USPSTF considers men who have sex with men and active injection drug users to be at very high risk for new HIV infection. Behavioral risk factors for HIV infection include having unprotected vaginal or anal intercourse; having sexual partners who are HIV-infected, bisexual, or injection drug users; or exchanging sex for drugs or money. Other persons at high risk include those who have acquired or request testing for other sexually transmitted infections (STIs). Patients may request HIV testing in the absence of reported risk factors. Individuals not at increased risk for HIV infection include persons who are not sexually active, those who are sexually active in exclusive monogamous relationships with uninfected partners, and those who do not fall into any of the aforementioned categories. The USPSTF recognizes that these categories are not mutually exclusive, the degree of sexual risk is on a continuum, and individuals may not be aware of their sexual partners' risk factors for HIV infection. For patients younger than 15 years and older than 65 years, it would be reasonable for clinicians to consider HIV risk factors among individual patients, especially those with new sexual partners. However, clinicians should bear in mind that adolescent and adult patients may be reluctant to disclose having HIV risk factors, even when asked.

Screening Intervals

The evidence is insufficient to determine optimum time intervals for HIV screening. One reasonable approach would be one-time screening of adolescent and adult patients to identify persons who are already HIV-positive, with repeated screening of those who are known to be at risk for HIV infection, those who are actively engaged in risky behaviors, and those who live or receive medical care in a high-prevalence setting. According to the CDC, a high-prevalence setting is a geographic location or community with an HIV seroprevalence of at least 1%. These settings include sexually transmitted disease (STD) clinics, correctional facilities, homeless shelters, tuberculosis clinics, clinics serving men who have sex with men, and adolescent health clinics with a high prevalence of STDs. Patient populations that would more likely benefit from more frequent testing include those who are known to be at higher risk for HIV infection, those who are actively engaged in risky behaviors, and those who live in a high-prevalence setting. Given the paucity of available evidence for specific screening intervals, a reasonable approach may be to rescreen groups at very high risk (see Assessment of Risk) for new HIV infection at least annually and individuals at increased risk at somewhat longer intervals (for example, 3 to 5 years). Routine rescreening may not be necessary for individuals who have not been at increased risk since they were found to be HIV-negative. Women screened during a previous pregnancy should be rescreened in subsequent pregnancies.

Screening Tests

The conventional serum test for diagnosing HIV infection is the repeatedly reactive immunoassay followed by confirmatory Western blot or immunofluorescent assay. The test is highly accurate (sensitivity and specificity, >99.5%), and results are available within 1 to 2 days from most commercial laboratories.

Rapid HIV testing may use either blood or oral fluid specimens and can provide results in 5 to 40 minutes. The sensitivity and specificity of the rapid test are also both greater than 99.5%; however, initial positive results require confirmation with conventional methods.

Other U.S. Food and Drug Administration–approved tests for detection and confirmation of HIV infection include combination tests (for p24 antigen and HIV antibodies) and qualitative HIV-1 RNA.

Treatment

No cure for chronic HIV infection currently exists. However, appropriately timed interventions in HIV-positive persons can reduce risks for clinical progression, complications or death from the disease, and disease transmission. Effective interventions include ART (specifically, the use of combined ART, defined as ≥3 antiretroviral agents used together, usually from ≥2 classes), immunizations, and prophylaxis for opportunistic infections.

Other Approaches to Prevention

The USPSTF recognizes that the most effective strategy for reducing HIV-related morbidity and mortality in the United States is primary prevention or avoidance of exposure to HIV infection. Condom use can also substantially decrease the risk for transmission of HIV and other STIs.

The USPSTF recommends high-intensity behavioral counseling to prevent STIs for all sexually active adolescents and for adults at increased risk for infection. More information can be found at www.uspreventiveservicestaskforce.org//Page/Topic/recommendation-summary/sexually-transmitted-infections-behavioral-counseling1.

The Community Preventive Services Task Force has made several recommendations related to the prevention of HIV, AIDS, and other STIs, including person-to-person behavioral interventions (information and skill building to change knowledge, attitudes, beliefs, and self-efficacy) for men who have sex with men that can be implemented at the individual, group, or community level. It also recommends health provider notification and encouragement for HIV testing for sexual or needle-sharing partners of individuals diagnosed with HIV, as well as comprehensive risk reduction interventions in adolescents. More information can be found at www.thecommunityguide.org/hiv/index.html This link goes offsite. Click to read the external link disclaimer.

Other Resources

More information about HIV and AIDS is available at www.aids.gov This link goes offsite. Click to read the external link disclaimer& and www.cdc.gov/hiv/default.htm This link goes offsite. Click to read the external link disclaimer.

The CDC's recommendations on HIV testing in adults, adolescents, and pregnant women in health care settings are available at www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm This link goes offsite. Click to read the external link disclaimer. More information on HIV testing is available at www.cdc.gov/hiv/topics/testing/index.htm This link goes offsite. Click to read the external link disclaimer and www.fda.gov/ForConsumers/ByAudience/ForPatientAdvocates/HIVandAIDSActivities/ucm117922.htm This link goes offsite. Click to read the external link disclaimer.

Antiretroviral treatment guidelines are regularly updated and available at http://aidsinfo.nih.gov/guidelines This link goes offsite. Click to read the external link disclaimer.

Information about state-based HIV and AIDS hotlines is available at http://hab.hrsa.gov/gethelp/statehotlines.html This link goes offsite. Click to read the external link disclaimer.