To Screen or Not to Screen: Is That Really the Question?

Few diagnostic tests or screening procedures have engendered as much controversy as the HIV test. From the inception of HIV testing, unique social issues have complicated deliberations about HIV testing. In 1985, when the HIV antibody test was first introduced, evidence suggested that approximately half of persons who were antibody-positive would become persistently infected carriers, and only 10% would develop AIDS (1).

No effective treatment existed, and specific pretest counseling evolved (based on models used with genetic testing for untreatable conditions) to ensure that persons who sought HIV testing were aware of the uncertain meaning of a positive test result. In the context of widespread fear, stigma, and concern about discrimination, many states adopted requirements for separate written consent for HIV testing and established dedicated HIV testing sites, often outside of health care facilities, to allow anonymous testing. Routine HIV screening was unheard of except for blood donors.

Once studies showed that HIV was highly fatal, the Centers for Disease Control and Prevention (CDC) recommended HIV counseling and testing for persons at high risk and patients at hospitals with HIV prevalence rates greater than 1%. The discovery that zidovudine prophylaxis reduced perinatal transmission by two thirds led directly to a recommendation to screen all pregnant women. As of 2002, 38% of adults aged 18 to 64 years (68 million people) reported that they had been tested for HIV at least once; an estimated 16 to 18 million adults are tested annually (2). However, an estimated one quarter of the approximately 1 million to 1.2 million HIV-infected persons in the United States are unaware that they are infected (3). Infection often remains undiagnosed until late in the course of disease despite multiple encounters with the health care system (4, 5). With the advent of effective treatment, clinicians …