HIV testing becomes more routine with new guidance

Change aids HCWs with exposure

Routine HIV screening of patients could benefit health care workers who need to know the HIV status of patients following a bloodborne pathogen exposure.

In guidance that will greatly expand HIV testing at hospitals, the Centers for Disease Control and Prevention has recommended HIV screening for all patients unless they decline. "HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women," the agency stated.1

Today, there is a patchwork of consent laws that vary greatly from state to state, related to testing source patients following a bloodborne pathogen exposure. But the CDC advises that "separate written consent for HIV testing should not be required. General consent for medical care should be considered sufficient to encompass consent for HIV testing."

With this dramatic change in its approach to HIV testing, the CDC intends to promote early detection and treatment of HIV.

Previously, the CDC recommended HIV testing based on a risk assessment. But risk-based testing became less effective as the demographics of the HIV/AIDS epidemic shifted to include more adolescents, women, and minority populations, the CDC says. Many people did not identify themselves as at-risk.

"Routine HIV testing reduces the stigma associated with testing that requires assessment of risk behaviors," the CDC recommendations state. "More patients accept recommended HIV testing when it is offered routinely to everyone, without a risk assessment."

In some cases, health care workers still will encounter patients whose HIV status is not known or whose last HIV test was not recent. But those difficult situations will become rarer as patients are tested as a routine part of their hospital care.

That ultimately will benefit health care workers who have a bloodborne pathogen exposure, says Ronald H. Goldschmidt, MD, director of the National HIV/AIDS Clinicians' Consultation Center (NCCC) at the University of California in San Francisco, which runs the PEPLine (Post-Exposure Prophylaxis Hotline) advice call line for clinicians.

"When exposed health care workers and the clinicians treating them do not know the HIV status of a source patient, it can create unnecessary anxiety and often unnecessary [post-exposure] treatment until the source patient's HIV status has been determined," says Goldschmidt, who also is vice chair of the department of family and community medicine at the University of California in San Francisco.

With routine testing, a health care worker's exposure still may involve someone whose HIV test was not recent. But Goldschmidt notes that few people will have seroconverted since their last HIV test. "Obtaining an exposure history will identify most of those who have become infected since their last HIV test," he says.

Clinicians and health care workers can call the NCCC's PEPLine for advice about post-exposure treatment [(888) 448-4911]. It is available 24 hours a day, seven days a week.

The CDC's updated recommendations for HIV testing include:

Screening for HIV infection

  • In all health care settings, screening for HIV infection should be performed routinely for all patients aged 13-64 years. Health care providers should initiate screening unless prevalence of undiagnosed HIV infection in their patients has been documented to be < 0.1%. In the absence of existing data for HIV prevalence, health care providers should initiate voluntary HIV screening until they establish that the diagnostic yield is < 1 per 1,000 patients screened, at which point such screening is no longer warranted.
  • All patients initiating treatment for TB should be screened routinely for HIV infection.
  • All patients seeking treatment for STDs, including all patients attending STD clinics, should be screened routinely for HIV during each visit for a new complaint regardless of whether the patient is known or suspected to have specific behavior risks for HIV infection.

Repeat screening

  • Health care providers should subsequently test all persons likely to be at high risk for HIV at least annually. Persons likely to be at high risk include injection drug users and their sex partners, persons who exchange sex for money or drugs, sex partners of HIV-infected people, and men who have sex with men or heterosexual persons who themselves or whose sex partners have had more than one sex partner since their most recent HIV test.
  • Health care providers should encourage patients and their prospective sex partners to be tested before initiating a new sexual relationship.
  • Repeat screening of persons not likely to be at high risk for HIV should be performed on the basis of clinical judgment.
  • Unless recent HIV test results are immediately available, any person whose blood or body fluid is the source of an occupational exposure for a health care provider should be informed of the incident and tested for HIV infection at the time the exposure occurs.

Consent and pretest information

  • Screening should be voluntary and undertaken only with the patient's knowledge and understanding that HIV testing is planned.
  • Patients should be informed orally or in writing that HIV testing will be performed unless they decline (opt-out screening). Oral or written information should include an explanation of HIV infection and the meanings of positive and negative test results, and the patient should be offered an opportunity to ask questions and to decline testing. With such notification, consent for HIV screening should be incorporated into the patient's general informed consent for medical care on the same basis as other screenings or diagnostic tests; a separate consent form for HIV testing is not recommended.
  • Easily understood informational materials should be made available in the languages of the commonly encountered populations within the service area. The competence of interpreters and bilingual staff to provide language assistance to patients with limited English proficiency must be ensured.
  • If a patient declines an HIV test, this decision should be documented in the medical record.

(Editor's note: The CDC's HIV testing recommendations are available at www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm.)