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New HIV testing guidelines released by the Centers for Disease Control and Prevention in Atlanta include strategies for increasing early testing of at-risk people and universal HIV testing of pregnant women. "Over the course of time, we’ve ended up with a document that describes state-of-the-art HIV testing, counseling, and referral services," says Ken Hunt, senior public health advisor in the Division of HIV/AIDS Prevention. The guidelines have been in development for nearly three years. CDC officials have taken pains to include various expert opinions and incorporate public comments into the guidelines. They also use information provided at conferences and state meetings, as well as other feedback, Hunt says. This way, both the public and providers have been actively involved in helping to frame the recommendations, he adds.
"What’s important now in the state of the epidemic is that we have better treatment, so we’re encouraging people to ensure that early testing is made available and the highest-risk people have the opportunity to be tested," Hunt says. The updated guidelines, called the Revised Guidelines for HIV Counseling, Testing and Referral and Revised Public Health Service Recommendations for HIV Screening of Pregnant Women, are available on-line at www.cdc.gov/hiv/ctr or by calling (800) 458-5231.
Here’s what’s new in each of the guidelines:
1. Pregnant women.
"The revisions really emphasize that every woman who is pregnant should be offered HIV testing," says Mary Glenn Fowler, MD, MPH, chief of the Maternal Child Transmission Section of the Epidemiology Branch of HIV/AIDS. Since the last guidelines were released, research has strongly suggested public health benefits in having every pregnant woman tested because it enables physicians to identify and treat HIV-infected women and provide prevention interventions for their infants. In recent years, there have been concerns among private practice physicians that pre-test counseling is onerous and burdensome, Fowler says.
So the guidelines suggest strategies for making pre-test counseling simpler and more flexible by providing women with the basic information they need to make an informed decision, Fowler explains. "If a woman refuses testing, we need to understand the reasons behind it," Fowler says. For example, some women were bothered by long waits for the test, and if the test had been offered at a later time they might have agreed to be tested, she says.
Another issue is that some women do not receive prenatal care, so when they are finally seen by a physician, it is when they already are in labor. For these women, the guidelines recommend that rapid testing be offered so that treatment can be offered at the time of delivery in order to prevent mother-to-child transmission. "That’s a group we’re trying to target and make testing available to them," Fowler says. "Women are approached around the time of labor and delivery, and they can be offered a rapid HIV test, which is followed up by a standard test." The CDC now is conducting tests to see how best to offer these tests to women in labor.
HIV educational material, including videos, general information, and user-friendly brochures, may be offered to women while they wait in their doctor’s office, Fowler says. "It’s different from the general guidelines where people go to counseling and testing settings and where they have much more need to know certain risk behaviors and need more advice," Fowler explains. Pregnant women simply need to know that HIV testing is important for their own treatment and to substantially reduce the risk of their babies becoming infected.
2. Adult HIV testing guidelines:
The new guidelines focus on having clinicians encourage the highest-risk people to be tested for HIV. "If you’re serving folks concerned about sexually transmitted diseases [STDs], then those same people could be at risk for HIV," Hunt says. "Some folks are more at risk than others, and the recommendations talk a lot about how a facility might provide a screening for folks so that offering testing for HIV, STDs, and hepatitis might be made available." The guidelines emphasize that once people know their serostatus, they are likely to reduce their risk behaviors. The guidelines offer detailed and technical information that is fully referenced for managers, administrators, directors, and people involved with public policy at a local level.
"We intend to make good use of the web and expand on the web presence so that we also have a one-stop shopping resource on that page," Hunt says. "As we develop links in the document, it will make it easier for providers to understand the details and the whys and wherefores." Flexibility has been added to the revised guidelines, giving clinicians several options in counseling.
The guidelines offer a best-of-all-worlds prevention intervention strategy, as well as strategies that take into account policy, resource, and financial constraints, Hunt says. "For example, some providers will say they don’t have the resources to do counseling," Hunt says. "So the recommendations acknowledge that testing is important and missed opportunities to do counseling are important, but perhaps they could refer a patient to someone who could do counseling." Therefore, even when a provider can’t do it all, the provider could at least provide testing and refer patients to networks or clinics where they could receive prevention support or psychosocial support.