HIV Screening in Health Care Settings: Title and subTitle BreakSome Progress, Even More Questions

In 2006, the US Centers for Disease Control and Prevention (CDC) issued revised recommendations for HIV diagnostic testing and screening in health care settings.¹ With these recommendations, the CDC advised that all 13- to 64-year-old patients in US health care settings undergo nontargeted screening for HIV—that is, be tested without regard to their actual or perceived risk for HIV and without regard to signs or symptoms of HIV infection. To facilitate large-scale screening, the CDC proposed fundamental changes to HIV testing methods. The CDC recommended that (1) an opt-out approach should be used to introduce HIV testing (patients are informed that they will be tested for HIV unless they decline); (2) patient permission for HIV testing should not be given through a separate signed consent form but can be considered part of the general medical consent for care (either implicitly or explicitly stated); and (3) HIV prevention counseling does not need to be performed at the time of testing.²

The CDC further proposed that HIV screening should be incorporated in a battery of screening tests that have been considered over time to be routine and without special processes or procedures that might make HIV testing seem different from other medical tests. Although the revised CDC HIV testing recommendations are often referred to as opt-out testing, this is an oversimplification, as the opt-out approach represents just 1 component of a much more comprehensive modification of HIV testing practices and procedures.

In this issue of JAMA, 2 articles provide information relevant to implementation of the CDC's 2006 HIV screening recommendations. In their article on HIV screening in oncology patients, Chiao et al³ argue for widespread or universal HIV screening for patients with cancer and cite evidence that suggests oncology patients are not typically screened for HIV,⁴ even though HIV-infected patients represent a population at increased risk for malignancies.^{5 - 8} The authors further note that the hazards associated with undiagnosed HIV among patients with cancer are particularly high when immunosuppressive treatments are administered,⁹ and that HIV-infected cancer patients may benefit from highly active antiretroviral therapy.^{10 - 12} It is surprising that a group of patients who are usually meticulously evaluated and monitored may lack a routine assessment that is simple and inexpensive yet could have profound implications for care. Oncologists should consider embracing the CDC's suggestion that HIV screening be a part of a routine screening battery. Perhaps needed change for routine HIV screening can occur in stages, including the oncology setting, to promote HIV screening as normative behavior for clinicians and as having benefits for patients.

In another study in this issue of JAMA, Haukoos et al¹³ report findings of a CDC-funded investigation of an HIV screening model in an emergency department setting. The authors compared the yield of HIV testing when an opt-out approach without separate signed consent and prevention counseling was used vs clinician-initiated HIV diagnostic testing and screening. As expected, significantly more patients were tested during the nontargeted, opt-out screening phase than during the clinician-initiated testing phase. The nontargeted, opt-out screening phase yielded few more previously undiagnosed HIV-infected patients than were identified during the clinician-initiated testing phase. The yield of screening was expected to be low, because this approach included more patients who did not appear to be at risk. In contrast, clinicians traditionally test patients who have reported risk factors for or show signs or symptoms of HIV infection, and accordingly, the yield for detecting previously undiagnosed HIV infection should be higher in that context.

However, the uptake of HIV screening was low in this emergency department–based HIV screening model.¹³ Only 24% of patients did not opt out of rapid HIV testing. This finding seems to challenge the hope for the opt-out approach in the emergency medicine setting. Prior emergency department–based studies using an opt-in approach (ie, patients are asked if they want to be tested) have reported a wide range of proportions for testing uptake.^{14 - 15} In one study involving a random sample of 18- to 55-year-old patients using an opt-in approach, approximately 40% agreed to be tested for HIV.¹⁶

The specific manner in which testing is presented to patients can be a crucial determinant of the yield of testing. The opt-out approach is intended to bypass patients' fear of actively accepting HIV testing and instead to allow for passive acceptance. Nevertheless, patients often decline testing based on the belief that they are not at risk for HIV, even if they are.^{16 - 17} The disconnect between perceived and actual risk is important and may reflect a patient's fear of coming to terms with risk and lack of knowledge about HIV transmission. In the study by Haukoos et al,¹³ HIV screening was initiated by a registration clerk, not by a clinician, and not in the context of a personalized discussion of the merits, rationale, or justifications for screening. As a result, patients could easily dismiss the need for screening and not be asked to provide reasons for declining. Questions remain regarding which models provide the best uptake and are the most efficient. For instance, it is possible that uptake might have been greater if clinicians had suggested screening instead of registration clerks. However, clinicians do not initiate HIV screening on a routine or sustained basis. Because of this limitation, perhaps a model in which external staff screen emergency department patients might improve uptake and save costs in the long run.

The optimal models for HIV screening in health care settings are not yet known and most likely will not be a one-size-fits-all approach. Research is needed to determine who should initiate screening, as well as how, and when screening should be conducted during medical care. The current CDC recommendations might not be the optimal methods for all settings, but they offer suggestions from which models can be tailored to a setting's and patients' needs. New tools are available for HIV testing; it is up to clinicians to use them and find those that work best. The next greatest challenge will be to identify which HIV screening models are most effective and efficient and can be self-sustaining after research funding has been removed.