US HIV screening guidance shifts to a population-based approach

The updating of important US guidelines on HIV testing by the US Planning Services Task Force (USPSTF) (http://annals.org/article.aspx?articleid=1682314) confirms a shift from a risk-based to a population-based approach to HIV testing.   The USPSTF guidelines are now in line with the most recent (2006) guidelines of the Communicable Diseases Centre (CDC)  http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm).  The option for risk-based screening has now been superseded in the guidance of both bodies by a policy of population-based testing for 15–65 (USPSTF)/13-64 (CDC) year olds.  The USPSTF advocates screening on an “opt-out” basis, while the CDC guidelines have relaxed earlier requirements for written consent and pre-/post- test counselling.  Universal screening of pregnant women was already a recommendation in both sets of guidelines.

The new consensus follows important trends in policy with regard to HIV testing that can be observed both in the US and internationally.  Earlier guidance reflected concerns around the toxicity of antiretroviral drugs and the possibility of psychological harm from testing.  However, current antiretroviral therapies have proved safe and effective, and are perceived to allow HIV infected individuals to enjoy a normal life expectancy.  Any harm to the asymptomatic individual from adverse side effects of the therapy is far outweighed by the potential health benefits of early diagnosis and treatment, as well as reducing the risk of further transmission, while the “psychological” implications of testing are less apparent, now HIV is perceived to be a “chronic” and potentially treatable condition (http://annals.org/article.aspx?articleid=1682313).  Yet, for all this positive change in perception of the benefits of testing, an estimated 20% of the infected population in the US remain undiagnosed, and beyond the reach of what is now recognized to be life-extending treatment (http://sti.bmj.com/content/87/Suppl_1/A98.3.abstract?sid=345955f4-7eb8-4ea4-be62-89230052756a).

Guidelines for HIV testing issued by national authorities will clearly reflect local factors, such as the size and character of the untreated HIV-infected populations, and what is cost-effective in a particular setting.  A large recent study of untargeted HIV screening in Paris hospital emergency departments, for example, reached largely negative conclusions as to its effectiveness as a strategy (https://blogs.bmj.com/sti/2011/11/28/non-targeted-hiv-testing-in-health-settings-worthwhile/?preview=true&preview_id=536&preview_nonce=d2ce801784 ).  Public Health England advocates that population-based routine testing should be commissioned in areas where prevalence is ≥2 per 1000 of 15-59 year olds http://www.hpa.org.uk/web/HPAweb&Page&HPAwebAutoListName/Page/1272032270566). Yet the updating of the US guidelines reminds us there remain certain factors – such as the development of safe and efficacious anti-retroviral therapy and the recent demonstration of its potential contribution to HIV prevention – that are relevant to the value of HIV-testing in any setting.  These more general factors will doubtless influence public health opinion in the direction of a less hesitant and more pro-active attitude to screening, increasingly liable to favour routinization.

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