COMMENTARY

A Call for Early HIV Diagnosis

Philip Peters, MD

Disclosures

January 29, 2018

Editorial Collaboration

Medscape &

Hello. I'm Dr Phil Peters from the Division of HIV/AIDS Prevention at the Centers for Disease Control and Prevention (CDC). I'm pleased to speak with you today about the need for increased HIV testing in clinical settings and how to implement routine testing in your practice.

As clinicians, you have a critical role in moving us closer to a future free of HIV in the United States. Approximately 166,000 people in the United States have HIV infection but don't know it, and they will account for about 40% of ongoing HIV transmissions. Increased HIV testing—both routine screening and risk-based testing—is needed to identify those individuals and link them to care. Early treatment helps people with HIV live long, healthy lives and it prevents HIV transmission.

But many people live with HIV for years before their infection is diagnosed. Half of all people who receive an HIV diagnosis have been living with HIV for at least 3 years, and a quarter have been living with HIV for 7 or more years at the time of diagnosis. Some of these people may be patients in your medical practice and may exhibit no symptoms suggestive of having HIV. CDC data show that at least two thirds of people at high risk for HIV who were not tested in the past year had visited a healthcare provider during that time.

So, what can you do to increase testing and reduce HIV diagnosis delays? I would like to present two approaches to HIV diagnosis that work hand-in-hand in clinical settings: routine HIV screening and risk-based testing.

Opt-out testing. CDC guidelines call for opt-out HIV testing at least once for all patients aged 13-64 years. Testing can be done in any healthcare setting in which the patient is receiving services. Opt-out testing means the patient is notified that an HIV test will be performed along with other standard preventive screenings unless the patient declines. Opt-out testing can identify HIV infections among people who do not think they are at risk or who are not comfortable talking about their risk.

If you are not already conducting opt-out HIV testing as part of routine care, you can remove barriers to HIV testing within your practice or hospital, such as requiring a special consent form. You can also use proven structural interventions to increase testing, such as electronic medical records to track whether patients have previously received their HIV screening test. For those who have not been tested, one of your staff can mention the routine HIV test during the initial check-in or have it included in the general medical consent, and HIV testing can be bundled with other necessary tests so the patient doesn't require any additional blood draws.

Risk-based testing. While opt-out HIV screening is important, it is not enough. CDC guidelines also recommend more frequent HIV testing for people at known risk for infection. Not all persons at risk for HIV recognize their risk factors, but they deserve to know about their best options to prevent HIV. Accurately assessing exposure risk does take a concerted effort to collect sexual and drug use history at all patient encounters, just as you would take a smoking history. You can learn more about taking a sexual history through the Medscape CME activity called Sexual History: Skills for HIV Assessment and Prevention.

Incorporating a sexual history into your practice can be done by including questions in your patient health history forms or linking the questions to the patient's routine HIV test: For example: "It is now standard of care to screen for HIV and to talk about sexual behaviors." Also, assessing your patient's presenting signs or symptoms can be an opportunity to discuss HIV risk. Common illnesses like pneumonia and herpes zoster are more common with HIV infection. Therefore, it is more important to screen patients with cough, fever, rash, and other symptoms. Asking about private behaviors is not always easy for healthcare providers, but a few open-ended questions can improve patient care. For example:

  • Do you have sex with men, women, or both? How many men or women have you had sex with in the past 6 months?

  • What kind of sex do you have—oral, vaginal, or anal?

  • What do you and your partner do to protect yourselves against HIV?

All at-risk patients should be evaluated either at your practice or through a facilitated referral to determine whether they are candidates for HIV pre-exposure prophylaxis. And as with any serious medical illness, identify in advance the steps you will take when someone tests positive for HIV infection.

Working together, we can maximize opportunities to test patients for infection and reduce the number of people with undiagnosed HIV. Getting people diagnosed and into treatment is the best way to improve their health and prevent further HIV infections.

Web Resources

CDC Recommendations for HIV Testing in Health-Care Settings

Sexual History: Skills for HIV Assessment and Prevention

Serostatus Matters

HIV Screening. Standard Care

US Preventive Services Task Force HIV Screening Recommendations

US Public Health Service Preexposure Prophylaxis Guidelines

Vital Signs: Human immunodeficiency virus testing and diagnosis delays — United States.

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