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Clinical Crossroads |

Screening for HIV Infection:  A Healthy, “Low-Risk” 42-Year-Old Man

Howard Libman, MD, Discussant
JAMA. 2011;306(6):637-644. doi:10.1001/jama.2011.1016.
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Human immunodeficiency virus (HIV) infection meets many, if not all, of the established criteria that justify routine screening, and screening for HIV infection can be cost-effective depending on the population studied. In 2006, the Centers for Disease Control and Prevention recommended that HIV screening be included as part of routine care for most of the adult US population, but implementation of this policy has been slow. Mr Y is a 42-year-old man at relatively low risk of HIV infection who was offered testing by his primary care physician but declined it. He does not consider HIV infection to be a realistic possibility given his behavioral history and does not understand the purpose of being tested. The discussion that follows addresses the rationale for HIV screening, its potential benefits and risks, current testing options, and barriers to incorporating it into routine care.

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Routine HIV Testing: Changing the Paradigm
Posted on August 7, 2011
Maggie Czarnogorski, MD
Department of Veterans Affairs
Conflict of Interest: None Declared
For decades, risk-based HIV testing has failed at reducing the number of new HIV diagnosis annually in the US (50,000-60,000 every year) (1,2). Restricting HIV testing to only those individuals who admit to risk factors ignores two important facts: most patients are not completely honest with healthcare providers and/or may not be aware of their risk. Studies have shown that it is likely that those who are unaware of their infection are likely transmitting it to others (3). Currently, there is no cure for HIV. There is no vaccine. But there are highly effective medications that can significantly improve health outcomes and reduce transmission rates. (4,5) Even so, it is only those individuals who are aware of their HIV status can benefit from these life- saving treatments. There is no medical benefit, or societal benefit, to not knowing one's HIV status. Furthermore, the risk of not knowing your HIV status can be devastating. Since 2006, the CDC has recommended routine HIV screening for all adults and adolescents in all healthcare setting for communities where the HIV prevalence is above 0.1%. (6) Studies have shown that it is as cost- effective to conduct routine HIV screening as breast cancer or colon cancer screening (7). The HIV test is cheap and easy. Rapid testing technology even allows for results to be available in 20 minutes, eliminating the need to follow-up on results days later. The CDC also recognized that written informed consent was a significant barrier to routine HIV testing; It is a time-consuming, cumbersome process for providers and has exceptionalized the test(6). Recently, the Department of Veterans Affairs (VA) recognized the benefit for eliminating written informed consent. In 2009, after Federal law change (8), VA revised HIV testing policy to ensure that the test was be offered as a part of routine medical care for all Veterans (regardless of risk) and aligned more closely with CDC recommendations by eliminating the requirement for written informed consent and prescribed pre and post test counseling. Verbal consent is still required and must be documented in the medical record and written educational material must be provided to the patient (9,10). Living in New York City, with HIV prevalence much above the 0.1% CDC threshold, Mr. Y should absolutely be offered an HIV test by any provider who believes in offering high, quality comprehensive healthcare. Mr. Y has no reason to decline the test, even if he believes he is not at risk. It is a simple, cost-effective procedure with enormous benefit for himself and his sexual partners. If it is positive, Mr. Y should be notified in- person and linked to care in a timely manner. HIV is no longer a death sentence. Anyone can live a long, healthy life HIV positive as long as they receive appropriate medical care. If he is HIV negative, he will have reassurance.
References:
1. CDC. HIV Prevalence Estimates 2006. MMWR, Vol. 57, No. 39; 2008.
2. CDC. HIV/AIDS Surveillance Report. Vol. 19; 2009.
3 Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS 2006;20:1447--50.
4 Dieffenbach, C. and Fauci A. Universal Voluntary Testing and Treatment for Prevention of HIV Transmission. JAMA. 2009;301(22):2380-2382
5 Cohen MS. Prevention of HIV-1 Infection with Early Antiretroviral Therapy. NEJM. July 18 2011.
6 CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 2006;55
7 Walensky RP. Cost-effectiveness of HIV testing and treatment in the United States. Clinical Infectious Diseases. 2007 Dec 15:45.
8 Public Law 100-387. Veteran Mental Health and Other Care Improvements Act. 110th Congress. Oct. 10, 2008.
9 VHA Directive 2009-036. Testing for Human Immunodeficiency Virus in Veterans Health Administration Facilities. August 14, 2009.
10 VHA Handbook 1004.01. Informed Consent for Clinical Treatments and Procedures. August 17, 2009.
Conflict of Interest: None declared
Significant advantages of HIV screening
Posted on August 5, 2011
Alisdair A MacConnachie, MBChB MRCP PhD
Consultant Physician Infection Unit, Brownlee Centre, Gartnavel General Hospital, Glasgow, Scotland.,
Conflict of Interest: None Declared
1. For whom is HIV testing indicated? This is simple to answer from a cost-effectiveness perspective: test anyone from a population with HIV prevalence greater than 0.5/1000 (Sanders GD et al NEJM 2005; 352: 570-85). But, as Mr. Y would likely agree, this is not a compelling answer from an individual patient perspective. In the consulting room we know that population level analyses are hard to apply to individuals and assumptions about individual risk and behaviour are capricious. But results of cost effectiveness models of HIV testing diverge rapidly as their assumptions are modified (ibid).
Another seemingly simple answer is to test anyone who is "high-risk". But doctors and patients are poor assessors of individual risk. In HIV testing a common error is to think anachronistically about risk factors. We would argue that, in 2011, HIV might say little about an individual's sexual practices. Heterosexually acquired HIV accounted for 32% of new HIV diagnoses in the USA, and 54% in the UK, in 2008 (CDC, 2010; HPA, 2010). Further, blinded HIV seroprevalence studies have suggested that a majority of people who don't know they are HIV positive may also report no HIV risk factors (Fehrs et al. Am J Public Health 1991; 81: 619-22). Consequently, an increasing evidence base shows that universal, "opt-out" testing strategies can be highly successful (Rayment et al. 2011. 18th Conference on Retroviruses and Opportunistic Infections. Abstract W-156; Poster #1054).
From an individual patient point of view, there is no simple answer to the question "who should be tested for HIV?". But the decision should not rest on out-dated assessments of perceived risk, and routine screening has many advantages.
2. What is the rationale for routine screening?
HIV testing meets all of the Wilson-Jungner criteria for appraising validity of a screening program (WHO, 1968). Specifically, despite availability of highly effective treatment, HIV remains an important health problem with a significant QALY burden in high resource countries. The natural history is well understood with an early stage detectable by a highly sensitive and specific test.
RCT data suggests starting treatment earlier in the natural history of HIV confers a better prognosis (Severe et al. NEJM 2010; 363: 257-65). Unsurprisingly, late diagnosis is associated with increased morbidity and mortality (Sabin et al. AIDS 2004; 18: 2145-51), poorer response to treatment (Walters L et al HIV Medicine 2011; 12: 289-98), and increased health care costs (Krentz HB et al HIV Medicine, 2004; 5: 93-8).
Patients that present late are often found to have had missed opportunities for diagnosis at previous clinical presentations (Sullivan AK et al BMJ 2005; 330: 1301-2). When routine (universal, "opt-out") screening is introduced, testing rates and rate of positive diagnoses rise, and the CD4 count at time of diagnosis increases (Haukoos et al. JAMA 2010; 304: 284-92).
3. What are the risks?
The benefits of testing this gentleman are therefore significant. But what are the risks? Clinicians often worry about inducing anxiety by testing for HIV. It should be remembered that, if treated early, HIV has near-normal life expectancy (Hogg et al Lancet 2008; 372: 293-9) -- a much better prognosis that most illnesses we screen for. Patients respond to an offer of a test with minimal anxiety when it is well explained and not exceptionalised (Simpson BMJ 1998; 316: 262-7).
Other implications of testing vary by geographical setting. In the UK, HIV care is free at the point of delivery, and an insurance industry moratorium precludes asking about previous testing in applications for life insurance (ABI, 1994).
4. What are the barriers to testing?
Mr. Y presciently highlights the biggest barrier to HIV testing: stigma. Routine testing, which doesn't discriminate on the basis of ethnicity or lifestyle factors, is one way to potentially reduce this problem. No stigma is attached to routine antenatal HIV testing. High prevalence countries like South Africa, Uganda and Botswana have demonstrated how universal testing strategies can diminish stigma (Weiser et al PLoS 2006; 3:e261).
5. Is informed consent necessary?
Absolutely, if Mr. Y does not want the test then that decision should be respected.
6. How should results be communicated?
Our experience is that a face to face appointment is preferable when giving the results of a HIV test. The patient is likely to have follow-up questions. Some would suggest that those who are low risk can be given their results by phone. However, as discussed earlier, our opinion is that this maintains the artificial distinction between subsets of the patients.
7. What would you recommend?
We would recommend HIV testing for all of the reasons above.
Conflict of Interest: None declared
Decreasing HIV-associated stigma, one patient at a time
Posted on August 5, 2011
Ronald J. Lubelchek, MD
John H. Stroger, Jr. Hospital of Cook County & Ruth M. Rothstein CORE Center
Conflict of Interest: None Declared
Mr Y, would benefit from education on the role of disease screening in general, and screening for HIV in particular. Explaining the rationale for HIV screening may represent an effective response to a reluctant Mr. Y. You could start by telling Mr. Y. about the 1968 World Health Organization white paper entitled 'Principles and Practices of Screening for Disease' that outlined justifications for disease screening, including(1):
1) The disease represents a serious health disorder that can be detected before symptoms develop. 2) Treatment is more beneficial when begun before symptoms develop. 3) Reliable, inexpensive, acceptable screening tests are available. 4) The costs of screening are reasonable in relation to anticipated benefits. 5) Treatment for the disease must be accessible.
HIV satisfies each of these criteria.
Highlighting reasons for HIV screening presented in the CDC's 2006 HIV testing guidelines could help inform Mr. Y's decision (2). Recent data estimate that approximately 50,000 people become infected annually in the US (3). Further, one in five remain unaware of their HIV infection (3). While identifying HIV early decreases mortality, employing risk- based HIV testing often diagnoses patients late. South Carolina HIV surveillance data showed that of the state's 4000 plus cases diagnosed between 2001 - 2005, 41% proceeded to AIDS within one year of diagnosis. Most late testers had multiple prior healthcare visits during which HIV testing had not been offered (4).
Importantly, we have real world data showing that HIV screening can work. In the US, screening pregnant women for HIV has drastically reduced the incidence of pediatric HIV (5). In addition, multiple modeling studies have documented the cost-effectiveness of HIV screening (6).
Emphasizing the great strides made in HIV treatment could also erode Mr Y's ambivalence. The HIV Outpatient Study demonstrated a dramatic decline in HIV mortality coincident with the inception of combination anti -retroviral therapy (7). Walensky et al. estimated that anti-retroviral therapy has saved two million person-years in the US alone (8). Treatment is so good now that life-expectancy for someone started early on HIV treatment approximates that of a HIV uninfected person (9).
Despite these justifications, I suspect Mr. Y. just does not perceive his own risk. Mr. Y. reports 10 lifetime sexual partners. How many partners has each of those 10 people had? Have any of his partners' partners had HIV, used intravenous drugs or traded sex for drugs? The instinctual nature of our sexuality often clouds our self-assessment of risk.
While self-assessment has intrinsic shortcomings, the sexual histories volunteered to physicians are likely more deficient. One study comparing sexual histories obtained by audio computer assisted self- interview (ACASI) vs. clinicians found significant discrepancies. People more often reported oral sex, transactional sex, same sex behavior and sex with amphetamine use to ACASI vs. clinicians (10).
The inherent limitations of both physicians' and patients' risk assessments underscore the need to de-stigmatize HIV disease and its screening. By telling Mr. Y that HIV screening is equally justified as screening for high cholesterol, we start to take down the roadblock of stigma, allowing our patients access to a clear path toward better health.
References:
1. Taege A. Seek and treat: HIV update 2011. Cleve. Clin. J. Med. 2011; 78(2): 95-100.
2. Branson B, Handsfield H, Lampe M, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Morb. Mortal. Wkly. Rep. 2006; 55(RR-14): 1-17.
3. Prejean J, Song R, Hernandez A, et al. Estimated HIV Incidence in the United States, 2006-2009. PLoS ONE. 2011; 6(8): e17502.
4. Duffus W, Kettinger L, Stephens T, et al. Missed opportunities for earlier diagnosis of HIV infection -- South Carolina, 1997-2005. Morb. Mortal. Wkly. Rep. 2006; 55(47): 1269-1272.
5. Lubinski C, Aberg J, Bardeguez AD, et al. HIV policy: The path forward - a joint position paper of the HIV Medicine Association of the Infectious Diseases Society of America and the American College of Physicians. Clin. Infect. Dis. 2009; 48(10): 1335-1344.
6. Walensky R, Freedberg K, Weinstein M, Paltiel A. Cost- effectiveness of HIV testing and treatment in the United States. Clin. Infect. Dis. 2007; 45(S4): 248-254.
7. Palella FJ, Baker RK, Moorman AC, et al. Mortality in the highly active antiretroviral therapy era: changing causes of death and disease in the HIV outpatient study. J Acq Immun Def Synd. 2006; 43(1): 27-34.
8. Walensky R, Paltiel A, Losina E, et al. The survival benefits of AIDS treatment in the United States. J Inf Dis. 2006; 194(1): 11-19.
9. van Sighem A, Gras L, Reiss P, Brinkman K, de Wolf F. Life expectancy of recently diagnosed asymptomatic HIV-infected patients approaches that of uninfected individuals. AIDS. 2010; 24(10): 1527-1535.
10. Kurth AE, Martin DP, Golden MR, et al. A comparison between audio computer-assisted self-interviews and clinician interviews for obtaining the sexual history. Sex Trans Dis. 2004; 31(12): 719-726.
Conflict of Interest: None declared
Mr Y's Volition
Posted on August 4, 2011
Bhavna Seth, Third Year Medical Student
Lady Hardinge Medical College, New Delhi, India,
Conflict of Interest: None Declared
For whom is HIV screening indicated? Recommended for all patients aged 13-64 years, in all health-care settings. After notifying the patient, the test is performed unless the patient opts-out screening, in a setting with background rate of HIV>1%. Also recommended for all high-risk groups, patients with Tuberculosis, and at STD clinics; as part of routine antenatal care for all pregnant women (1).In 2007, WHO and UNAIDS issued guidelines on provider-initiated HIV testing and counseling (PITC) in health facilities (2)
What is the rationale for routine HIV screening?
Anti-retroviral therapy can be initiated in HIV patients and this will delay progression of disease. People who are infected with HIV but unaware of status will unknowingly spread the disease(3).
What are its benefits and risks?
1) HIV /AIDS can be diagnosed before symptoms develop; 2) infected patients gain years of life with early treatment; 3) costs of screening are reasonable in relation to the anticipated benefits. 4) Better control of spread of HIV. 5) More patients accept recommended HIV testing when it is offered routinely to everyone, without pejorative risk assessment.6) Screening assists health care providers to plan healthcare, screening and surgery for patients. Risks of routine screening can include stress related to potentially false positive results and social stigmatization of positive cases.
What are the testing options for HIV infection?
Besides conventional HIV enzyme immunoassay tests (ELISA),FDA has now approved 4 Rapid HIV Antibody tests for on-spot screening -OraQuick, Reveal, Multispot and aUni-Gold Recombigen. (4). These MUST be supplemented with confirmatory tests like Western Blot, Indirect Flourescent Antibody tests or PCR (Polymerase Chain Reaction).
What are the barriers to incorporating HIV screening into routine care?
Cost of screening is a major barrier in addition to the implication of a positive screening result. Because HIV and AIDS are still stigmatized, a positive result changes the life of person.
Is informed consent necessary? How should test results be communicated?
According to current CDC guidelines, a separate written consent for HIV testing is not required; general consent for medical care should be considered sufficient to encompass consent.HIV-positive test results should be communicated confidentially through personal contact by a clinician, nurse or counselor. Family or friends should not be used as interpreters to disclose HIV-positive test results. Active efforts are essential to ensure HIV-infected patients receive their positive test results and linkage to clinical care, counseling, support services. Persons known to be at high risk for HIV infection should also be advised of the need for periodic retesting and should be offered prevention counselling.
What would you recommend for Mr. Y?
Since Mr. Y is visiting the physician for the first time it is the duty of the physician to offer HIV screening as part of his initial panel of investigations. The physician is not offering the test because he suspects that Mr. Y is infected or at high risk, but solely because the guidelines recommend screening in his age group; and even though his behavior does not put him at risk, his past sexual history may. My Y is free to opt-out of this screening as per the CDC 2006 guidelines. The doctor can counsel the patient and allay his fear of giving an additional blood sample, but cannot force the test on the patient. In this case Mr. Y does not seem too eager to undergo testing. The doctor should explain the potential benefits and public health responsibility of testing to Mr. Y, and repeat the request on subsequent healthcare visits. However, the final call is with Mr Y.
REFERENCES:
1) http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm
2) http://www.who.int/hiv/topics/vct/about/en/index.html
3) http://www.cdc.gov/hiv/topics/testing/
4) http://www.cdc.gov/hiv/topics/testing/resources/journal_article/pdf/rapid_review.pdf
Conflict of Interest: None declared
Dr
Posted on August 1, 2011
Patrick O Oben, MD
John H Stroger Hospital, Chicago, IL, USA
Conflict of Interest: None Declared
I think the major problem in Mr Y's case is really not what to do but what to tell him in response to his thoughtful reasons for refusal. HIV screening should be voluntary and without coercion. The only appropriate intervention should be to have an informed discourse with him and then let him have a third chance following the "expert" opinion, after his intuition and initial thoughts. Therefore the general approach will be to try to confidently provide informed answers and let him make the final decision. If he refuses, then as his physician, I would note it in his record and plan to discourse it with him later down the road when the relationship has been more established. The embryonal doctor-patient relations is the first issue at stake here. He would likely think "my first visit and the doctor wants to screen for HIV. What does he think of me?" He runs the risk of perceiving the Physician as judgmental and his relationship with this physician at least will be strained or terminated at worse.
Other issues at stake here include the risk of progression of an unidentified infection and spread to his sexual partner(s). Nevertheless, these issues at stake in his case do not seem to make his screening HIV an emergency. We assume the HIV prevalence in the facility is above 0.1% to warrant routine screening in the first place.
His first concern was that he believes the absence of symptoms mean no disease. Though this seems to challenge the very rationale for screening, it should easily be addressed by explanation of the different phases of HIV infection, especially the asymptomatic phase which made take up to 10 years before symptoms appear. The very fact that he has no symptoms makes him even more suited for an HIV screening test, as this is the ultimate aim of screening in the first place.(2)
He worries about screening a patient at low risk for the infection. The CDC guidelines however do not take into consideration the risk of the patient. Most importantly, recent evidence shows that many persons at risk of infection might not be aware of their risk or even perceive it(1). However, given that Mr Y is not a "research paper", the results should be presented as justification of the CDC's recommendations and not reflective of his specific case.
He also presents with some traces of worries with regards to stigma and receiving an HIV test result, even by mail where they would be no one looking at him, maybe. That is definitely the reason why screening at the healthcare setting, where everyone is screened, without need for a separate consent for testing and the proximity of resources to immediately handle a positive results, is a better option.
1. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. 2006;55(RR14):1-17.
2. Wilson JM, Jungner G. Principles and practice of screening for disease. Geneva, Switzerland: World Health Organization; 1968.
Conflict of Interest: None declared
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