Primary health care providers should incorporate HIV testing into routine patient care for all sexually active individuals

Primary health care providers should incorporate human immunodeficiency virus (HIV) testing into routine patient care for all sexually active individuals, regardless of risk factors, say a group of physician/researchers at Emory University School of Medicine, Brown Medical School, and the Johns Hopkins School of Medicine.

HIV testing also should be offered routinely in emergency departments, jails and substance abuse centers, the researchers say. The proposal for routine testing, which was published electronically February 28 and will appear in the April 1 issue of the journal Clinical Infectious Diseases, is based on a review of surveillance reports from the CDC and recent research data.

Current guidelines from the Centers for Disease Control and Prevention (CDC) recommend that HIV testing be based on risk assessment. Routine HIV testing is recommended in settings where the prevalence of HIV infections is greater than one percent. In settings where the prevalence is less than one percent, testing is based on individual risk assessment by health care providers. HIV tests are offered to patients who report risky behavior, such as unprotected sex, injection drug use, or intercourse with a partner of the same sex. Tests also are offered to patients when clinical findings indicate the possibility of HIV infection or to patients who request testing. "For anybody who is sexually active, this should be a routine part of primary care," says lead author Curt G. Beckwith, MD, an infectious disease physician at The Miriam Hospital and Brown Medical School in Providence, RI. "We see people diagnosed for the first time every month. It's astonishing that opportunities have been missed to diagnose the patient previously. Either the physician or the patient doesn't think of it."

The number of people living with HIV infections in the United States continues to increase, according to recent CDC data, and 35 percent of new cases of HIV diagnosed from 1999 to 2002 were acquired heterosexually. Since the early 1980s, the proportion of people acquiring HIV infection through heterosexual transmission has continued to increase relative to other methods of transmission. Approximately 250,000 people in the United States infected with HIV do not know they are infected, according to the Foundation for Retrovirology and Human Health.

"Based on an extensive review of the current state of HIV infection, we believe an immediate change to routine voluntary testing is a necessary and critical step to reduce HIV infection and prevent AIDS in this country," says Carlos del Rio, professor of medicine at Emory University School of Medicine, chief of medical services at Atlanta's Grady Memorial Hospital and one of the study authors. "We are missing opportunities to diagnose HIV infection before individuals develop AIDS, when we can offer counseling about secondary prevention and risky behaviors, begin antiretroviral therapy and help prevent opportunistic infections."

Current recommendations for testing in high-prevalence areas (where HIV infection is greater than one percent) and testing based on risk assessment are impractical and inaccurate, the research team reports. Most health care providers do not have access to estimates about prevalence in their particular area, and often it is difficult to determine the risk of HIV infection in individual patients. Smaller social networks with a high prevalence of infection also can be part of a larger community where prevalence is low, making accurate risk assessment more difficult.

"Many people who engage in risky behaviors are reluctant to tell their healthcare providers and may not request HIV testing," says del Rio. "People infected through heterosexual transmission, particularly adolescents, often do not consider themselves to be at risk and do not seek testing on their own. Health care providers also may not elicit accurate information about risk. Routine testing would decrease the stigma of requesting or accepting an HIV test."

Two studies in the New England Journal of Medicine in February showed that routine HIV testing is cost effective, and costs less than many other diagnostic tests. This current recommendation reinforces the need for routine tests.

"Now that we know that HIV testing is cost effective, even when the prevalence of HIV is low, we need a new approach," says Timothy P. Flanigan, MD, chief of infectious diseases at The Miriam Hospital and a professor of medicine at Brown Medical School.

The researchers recommend that routine testing be covered by private medical insurance and by Medicare and Medicaid. They also recommend changes in current counseling practices for HIV. Minimal counseling could be performed during the consent process for the test, followed by in-depth counseling for persons who receive a positive test result, for patients who request counseling, or when the health care provider believes counseling is appropriate.