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Clinical Guidelines: U.S. Preventive Services Task Force* Screening for HIV: Recommendation Statement Ann Intern Med 2005; 143: 32-37 [Abstract] [Full text] [PDF]

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HIV Infection; Ignorance Is Not Bliss

Curt G. Beckwith, Timothy P. Flanigan (Brown Medical School), Carlos del Rio (Emory University School of Medicine), John G. Bartlett (Johns Hopkins School of Medicine)   (13 July 2005)

HIV Infection; Ignorance Is Not Bliss 13 July 2005
Curt G. Beckwith, MD Brown Medical School, Division of Infectious Diseases, Timothy P. Flanigan (Brown Medical School), Carlos del Rio (Emory University School of Medicine), John G. Bartlett (Johns Hopkins School of Medicine) Send rapid response to journal: Re: HIV Infection; Ignorance Is Not Bliss CBeckwith{at}Lifespan.org Curt G. Beckwith, et al.	The U.S. Preventive Services Task Force (USPSTF) recently published updated guidelines for HIV screening [1]. In preparing these guidelines, the USPSTF reviewed studies that demonstrated how routinely offering HIV testing, as opposed to offering testing only when HIV risk is identified, increases the number of persons diagnosed with HIV and is cost-effective [2-4]. Despite this, the USPSTF, along with the CDC, ACP, Infectious Disease Society of America and other healthcare organizations, have failed to expand recommendations for routine testing. The updated USPSTF guidelines, similar to guidelines published over the past decade, recommend routine testing only for persons identified as high-risk; for those residing in areas with increased HIV prevalence (greater than or equal to 1%); and for all pregnant women. Unfortunately, this strategy has failed to decrease the proportion of persons infected with undiagnosed HIV in this country and this is unlikely to change as a result of these revised guidelines. Experience has revealed that testing strategies that depend on risk assessment are inadequate. Twenty to twenty-six percent of HIV-positive patients report "no risk factors"[5]. Risk assessment is inherently inaccurate as healthcare providers may be reluctant or uncomfortable obtaining detailed risk histories and patients may not divulge risk behavior. Screening pregnant women for HIV, which is not based on risk, has led to dramatic decreases in vertical transmission of HIV infection. Why can't we learn from our successes and expand routine testing to all persons? The benefits of expanding routine HIV testing are unmistakable. Knowledge of infection provides an opportunity to prevent others from being infected, to initiate of highly effective therapy, and to prevent opportunistic infections. The potential harm associated with HIV screening is minimal. The HIV testing algorithm is highly accurate and inexpensive. Concerns about potential harm associated with routine testing, as discussed in the USPSTF guidelines, revolve mostly around the psychosocial consequences associated with true-positive results. These are important factors requiring attention when caring for newly diagnosed patients. However, fear of these possible consequences is not an acceptable reason to withhold testing. Routine "opt-out" testing strategies with simple consent procedures, in settings other than the pre-natal arena, are urgently needed. Routinely offering HIV testing in primary care, inpatient, urgent care and emergency departments will decrease stigma and anxiety associated with HIV testing and will lead to more persons being diagnosed. We cannot allow ineffective HIV testing policies to be perpetuated when experience demonstrates that change is required. References: 1. U.S. Preventive Services Task Force. Screening for HIV: Recommendation Statement. Ann Intern Med. 2005; 143: 32-37. 2. Voluntary HIV testing as part of routine medical care¡ªMassachusetts, 2002. MMWR Morb Mortal Wkly Rep. 2004;53:523-6. 3. Routinely recommended HIV testing at an urban urgent-care clinic¡ªAtlanta, Georgia, 2000. MMWR Morb Mortal Wkly Rep. 2001;50:538-41. 4. Paltiel AD, Weinstein MC, Kimmel AD, Seage GR 3rd, Losina E, Zhang H, et al. Expanded screening for HIV in the United States¡ªan analysis of cost-effectiveness. N Engl J Med. 2005;352:586-95. 5. Peterman TA, Todd KA, Mupanduki I. Opportunities for targeting publicly funded human immunodeficiency virus counseling and testing. J Acquir Immune Defic Syndr Hum Retrovirol. 1996;12:69-74. Conflict of Interest: None declared