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Routine HIV Testing and Screening in Healthcare Settings

Recent results from an NIH-funded international study highlight the importance of early diagnosis and screening, showing that individuals with HIV benefit from antiretroviral therapy (ART) sooner rather than later to reduce the risk of developing AIDS and the risk of passing HIV on to partners. HIV infection is diagnosed through conventional and rapid HIV antibody tests. These tests are highly accurate.

The U.S. Preventive Services Task Force (USPSTF) recommends that providers screen individuals between the ages of 15 to 65 for HIV. In addition, the USPSTF also recommends that both younger adolescents and older adults should be screened if they are at an increased risk for acquiring HIV. All pregnant women with an unknown HIV status should be tested when present in a healthcare setting.

Healthcare settings can include places like:

  • Primary and specialty care clinics
  • Substance use disorder treatment settings
  • Dental clinics
  • Emergency departments
  • Community health centers

Like many other kinds of routine screenings for conditions such as high blood pressure, the Centers for Disease Control and Prevention (CDC) recommends HIV screening be provided on an “opt-out” basis. This means that testing will be performed after the patient is informed of the test unless he or she specifically declines. It also means that general consent for medical care includes HIV screening and that providers do not need to obtain separate written consent before the test.

CDC maintains a state-by-state list of these laws on its website, and the Council of State Governments provides an overview of progress towards implementing six different HIV prevention policies in rural states.

Testing all pregnant women for HIV is an important step in preventing mother-to-child transmission. The CDC recommendations for HIV testing in healthcare settings report that routine screening instead of risk-based testing for pregnant women is more effective in preventing perinatal transmission. Furthermore, the rates of HIV testing in pregnant women are much higher in states where “opt-out” policies exist. Once HIV-positive pregnant women are identified, providers can work with the mother to identify the best way to prevent transmission to her baby.

Opt-out screening has been found to be cost-effective when used in clinical settings, including emergency or urgent care centers, primary care, and STI clinics. CDC reports that depending on setting and the way in which the testing program was implemented, the cost per HIV diagnosis ranged from $1,900 to $10,000.

Examples of HIV Testing in Healthcare Settings:

  • The North Carolina Department of Health and Human Services supports a number of programs designed to integrate routine HIV testing into healthcare settings across the state. These include Federally Qualified Health Centers, substance use disorder facilities, and emergency departments. The Communicable Disease Branch provides training, funding, and free testing kits to participating sites.
  • In 2010, the Montana Veterans Administration (VA) Healthcare System launched a pilot program to implement routine HIV screening at over a dozen clinics across the state. The program started with a training session from an infectious disease specialist who educated VA healthcare providers about HIV epidemiology, the CDC recommendations, and HIV testing best practices. It also put into place an electronic clinical reminder prompting healthcare providers to offer an HIV test to every patient. After implementing the reminder, the lab started processing hundreds more tests per month.

Considerations for Implementation

It is estimated that approximately 50,000 people become newly infected with HIV in the U.S. each year. While guidelines clearly outline recommendations for routine HIV screening in healthcare settings to identify cases, especially for specific populations, there are still challenges to implementing testing models.

According to the Mayo Clinic, some of these challenges include a lack of time for testing and structural barriers at health facilities, concerns about payment, as well as barriers to reaching the populations at highest risk including misconceptions about the value of screening.

Although rapid HIV antibody tests can now provide results in less than an hour, most test results will have to be verified with additional lab testing, which can take up to several days. Patients may feel rushed during a routine clinical encounter with their provider and may feel that there is not sufficient time for testing. Also, confidentiality is a concern and people may not feel comfortable testing close to home for fear that someone in the community may find out the results.

In addition, reaching populations at highest risk and who may be infrequently seen by a primary care doctor can be a challenge. In particular, adolescents and young adults make up a significant portion of new HIV cases in the U.S. each year and are often one of the most difficult populations to reach for testing. Targeted screening strategies and innovative outreach methods are necessary to reach high-risk and hard-to-reach populations. Health departments and clinics can partner with community organizations who are conducting testing at various sites to reach some of these populations. Community health centers provide primary care services to underserved populations and are especially important in rural communities. Implementing routine HIV testing in community health centers is another way to reach high-risk populations.

Resources to Learn More

Implementation of Routine HIV Testing in Health Care Settings: Issues for Community Health Centers
Document
Provides guidance to community health centers considering the addition of routine HIV screening to their practice. Discusses confidentiality and reporting processes. Also includes information about post-test counseling, clinical management, and referral issues.
Organization(s): Centers for Disease Control and Prevention: National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Date: 4/2011

Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings
Document
This report intended for healthcare providers contains the full revised recommendations for routine clinic-based HIV screening and routine HIV screening for pregnant women. Describes the evidence and rationale used to update the recommendations and compares the current recommendations with previous versions.
Author(s): Branson, B., Handsfield, H., Lampe, M., et al.
Organization(s): Centers for Disease Control and Prevention
Date: 9/2006