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U.S. Preventive Services Task Force Recommends Routine HIV Screening for Adolescents and Adults

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On April 30 the U.S. Preventive Services Task Force (USPSTF) issued a "Grade A," or highest-level, recommendation that all adolescents and adults ages 15 through 65 years should receive routine HIV screening. "These recommendations...reinforce the importance of people everywhere knowing their HIV status and, if positive, accessing care, receiving treatment and other prevention services," said CDC's Jonathan Mermin.

The new recommendation -- published in the April 30, 2013, advance online edition of theAnnals of Internal Medicineand available via the USPSTF website-- updates guidelines last issued in 2005, as follows:

The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults ages 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened.
Grade: A Recommendation.

The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown.
Grade: A Recommendation.

The USPSTF is a voluntary group that makes recommendations about preventive care services for people without recognized signs or symptoms of a target condition. It bases its recommendations on evidence of the benefits and harms of the service, but claims it does not consider cost-effectiveness.

As rationale for the expanded recommendation, the USPSTF notes that of the estimated 1.2 million people living with HIV in the U.S., approximately 20% to 25% are unaware of their positive status.

The task force found "convincing evidence that identification and treatment of HIV infection is associated with a markedly reduced risk for progression to AIDS, AIDS-related events, and death" for people with a CD4 T-cell count below 200 cells/mm3 and "adequate evidence" that starting antiretroviral therapy (ART) at CD4 counts between 200 and 500 cells/mm3 is also associated with reduced risk of AIDS-related events or death. The USPSTF found further convincing evidence that effective ART decreases the risk of sexual transmission to heterosexual partners as well as mother-to-child transmission. "The overall benefits of screening for HIV infection in adolescents, adults, and pregnant women are substantial," the task force summarized.

Turning to potential harms, the task force acknowledged that antiretroviral drugs are associated with short-term adverse events, and long-term use may be associated with increased risk for cardiovascular and other adverse events, but "[t]he overall harms of screening for and treatment of HIV infection in adolescents, adults, and pregnant women are small."

"Nearly a quarter of people with HIV don’t know that they have it, and they’re missing out on a chance to take control of their disease," said Task Force member Douglas Owens, MD, MS. "Universal screening will help identify more people with HIV, allowing them to start combined antiretroviral therapy earlier and live healthier and longer lives."

The 2005 recommendation advised testing for people considered to be at risk for HIV infection. The revision recommends repeat HIV screenings for people at increased risk including men who have sex with men and injection drug users, but goes on to acknowledge that risk groups overlap, people may not know their sexual partners' level of risk, and some people may not disclose risk factors even when asked.

With insufficient evidence to determine optimum intervals for HIV screening, the task force stated, "One reasonable approach would be one-time screening of adolescent and adult patients to identify persons who are already HIV-positive, with repeated screening of those who are known to be at risk for HIV infection, those who are actively engaged in risky behaviors, and those who live or receive medical care in a high-prevalence setting" -- that is, facilities or communities in which HIV seroprevalence is 1% or higher.

The new USPSTF recommendations are now more in line with those of the Centers for Disease Control and Prevention (CDC), which started calling for expanded routine HIV testing in 2006.

"These recommendations are a critical step forward for HIV prevention and care in the United States," said Jonathan Mermin, MD, MPH, director of the CDC's Division of HIV/AIDS Prevention. "They reinforce the importance of people everywhere knowing their HIV status and, if positive, accessing care, receiving treatment and other prevention services."

"HIV testing is the only way to help the 240,000 Americans unaware that they are living with HIV, learn their status and get access to care and prevention," he continued. "Implementation of these recommendations will not only increase access to HIV testing for people throughout the nation, but may also help reduce the stigma associated with HIV testing that prevents too many Americans from seeking testing or treatment."

5/3/13

Sources

VA Moyer on behalf of the U.S. Preventive Services Task Force. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine. April 30, 2013 (Epub ahead of print).

Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Summary for Patients. Annals of Internal Medicine. April 30, 2013 (Epub ahead of print).

AIDS.gov blog. U.S. Preventive Services Task Force Issues
Final Recommendation Statement on Screening for HIV. April 30, 2013

CDC. USPSTF Recommends Routine HIV Screening. e-HAP FYI Updates. April 30. 2013.