Who Should Get an HIV Test (and When)?

U.S. Task Force Calls for the One-Time Testing for All Persons Age 15 to 65

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On April 30, 2013, the U.S. Preventive Services Task Force (USPSTF) issued recommendations that all persons between the ages of 15 and 65 be screened for HIV as part of a routine doctor visit. The recommendations were made in line with evidence showing that early initiation of antiretroviral therapy will result in fewer HIV- and non-HIV-associated illnesses, as well as reduce the infectivity of a person with HIV

Previous incarnations of the USPSTF guidelines limited HIV testing to individuals identified as being of higher risk of infection, such as men who have sex with men (MSM), injecting drug users (IDUs), persons with multiple sex partners, or individuals who exchanged sex for money.

The newer guidelines are aligned with recommendations made by the U.S. Centers for Disease Control and Prevention (CDC) in 2006. By expanding HIV testing beyond identified high-risk groups, many believe that the stigma associated with HIV will be greatly alleviated.

Rationale for the Updated Recommendations

The updated guidelines reflect not only the enormous advances made in the effectiveness and safety of antiretroviral medications, but fast changing attitudes about the disease itself. The recommendations are seen by many as yet another step toward dismantling the so-called "HIV exceptionalism" which often placed patient autonomy ahead of patient care.

The USPSTF recommendations instead envision HIV testing as a normal part of healthcare, ensuring timely interventions to allay avoidable illnesses while preventing the spread of infection—particularly among those unaware of their status. By contrast, HIV exceptionalism is often seen to perpetuate outdated beliefs and fears about HIV, supporting rather than reducing barriers to testing.

The U.S. health panel further concluded that the benefits of early testing and treatment far outweigh any concerns about treatment side effects, both short- and long-term.

Currently an estimated 20% of the 1.2 million Americans infected HIV remain undiagnosed, according to epidemiological research conducted by the CDC.

Recommended Frequency of HIV Testing

The USPTSF guidelines support the one-time screening of all adolescents and adults age 15-65. The panel further recommends that all pregnant women be screened for HIV, including those who present in labor who are either untested and whose HIV status is unknown.

For persons identified as being at higher risk of infection, regular testing is recommended. Groups considered at high risk (i.e., having an HIV prevalence of at least 1%) include:

  • MSM, who account for approximately 60% of all new HIV infections in the U.S.
     
  • Individuals who actively engage in high risk behaviors, including multiple sexual partners, unprotected anal or vaginal sex, or injection drug use.
     
  • Persons with sexual partners who are either HIV-positive, bisexual, or inject drugs.
     
  • Individuals who exchanges sex for money or drugs.
     
  • Persons who have either acquired or requested testing for a sexually transmitted disease.

Persons considered at high risk should be screened on an annual basis, while those at increased risk may be tested every three to five years. Determination of risk should be made on an individual basis with a qualified treater.

Additionally, adolescents under the age of 15 and adults over the age of 65 should be tested if a risk of HIV infection is identified.

HIV testing is entirely voluntary and should be performed with the full understanding and consent of the patient, with the right to "opt out" should the patient decline a testing request.

The USPSTF recommendations have been categorized as grade "A." Under the Affordable Care Act (ACA), private health insurance policies created after March 23, 2010 are required to offer preventative services graded "A" or "B" by the USPSTF at no cost to the consumer.

Similarly, state Medicaid programs are provided financial incentives to cover all USPSTF-recommended preventative services.

Sources:

U.S. Preventive Services Task Force (USPSTF). "Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement." Rockville, Maryland; April 2013; accessed February 7, 2014.

National Institutes of Health (NIH). "Starting antiretroviral therapy early improves outcomes for HIV-infected individuals." Bethesda, Maryland; issued May 27, 2015.

Cohen, M.; Chen, Y.; McCauley, M.; et al. "Prevention of HIV-1 infection with early antiretroviral therapy." New England Journal of Medicine. August 11, 2011; 365(6):493-505.

U.S. Preventive Services Task Force (USPSTF). "Screening for HIV: Recommendation Statement." Annals of Internal Medicine. July 5, 2005; 143(1):32-37.

U.S. Centers for Disease Control and Prevention (CDC). "HIV Surveillance Report: Diagnoses of HIV Infection and AIDS in the United States and Dependent Areas, 2010." Atlanta, Georgia; access February 7.

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