AETC-NMC | Curricula

Rationale Underlying the 2006 Recommendations

Implementation difficulties were associated with previous HIV testing guidelines:

Costs of HIV screening are often not reimbursed by third-party payers.
Practitioners in busy settings may not have the time needed to conduct risk assessments and may perceive the counseling requirements in previous recommendations as a barrier to testing.

In most areas, clear information about HIV prevalence is not available to
guide selection of specific settings in which screening should be offered. [Frieden 2005, Walensky 2005, Paltiel 2005, Rothman, 2004, Lyons,
2005]

The characteristics of HIV infection are consistent with other conditions that typically justify screening:

A serious health condition that can be diagnosed before the development of symptoms
A condition detectable by reliable, inexpensive, noninvasive screening procedures
Significant potential for increased survival if treatment is initiated before symptoms develop
Reasonable costs of screening in relation to the anticipated benefits [Wilson 1968]

Increased Detection

Many HIV-infected persons who are unaware of their status use healthcare services (eg, hospitals, emergency departments, and STI clinics) for years without being tested for HIV disease. [Klein 2003, Alpert 1996, Liddicoat 2004] With the evolution in the demographics of the US HIV epidemic since the 1980s, increasing proportions of infected persons are < 20 years of age, women, members of racial or ethnic minority populations, not residents of a metropolitan area, and heterosexual men and women are unaware that they are at risk for HIV infection.[IOM 2001] This evolution means that risk-based screening to identify HIV-infected individuals is no longer as effective as in earlier years. [Klein 2003, Alpert 1996, Jenkins 2006, Chen 1998]

Inclusion of routine HIV screening in prevention programs has been shown to be highly effective. For example, screening blood donors for HIV has virtually eliminated transfusion-associated HIV transmission in the United States. [Dodd 2002] In addition, since the recommendation in the 1990s for routine screening of pregnant women—and the use of prophylactic antiretrovirals and other measures when HIV infection is detected—the US incidence of pediatric HIV has declined significantly. [CDC 1995, CDC 1999, Public Health Service Task Force, pregnant; Cooper 2002]

In contrast, the prevention of sexual transmission of HIV has met with more limited success. Detection of new HIV infections has remained relatively level since the 1990s, and some data indicate possible increases in certain populations in recent years. [Karon 2001, CDC Trends]

Risk Reduction

In a meta-analysis of findings from 8 studies, the prevalence of unprotected anal or vaginal intercourse with uninfected partners was on average 68% lower for HIV-infected persons who knew their status vs HIV-infected persons who did not know their status. [Marks 2005] The Institute of Medicine and other groups of healthcare professionals [Karon 2001, IOM 2001, Bozette 2005, CDC Pregnant] have encouraged routine HIV testing in all healthcare settings as a strategy to:

Increase the numbers of HIV diagnoses
Remove any stigma from the testing process
Link clinical care with prevention
Provide immediate access to care for individuals who have been newly diagnosed

Increased ED Screening

The numbers of at-risk individuals who receive HIV screening in emergency departments (EDs) has remained low, despite repeated recommendations supporting routine risk-based testing in health-care settings. [Klein 2003, Fincher 2002] A survey of 154 healthcare providers in 10 hospital EDs reported that the providers cared for an average of 13 patients per week who were suspected to have STIs, but only 10% of them encouraged such patients to be tested for HIV while in the ED and an additional 35% referred patients to confidential HIV testing sites in the community. [Fincher 2002] Such referrals, however, have proven ineffective because of poor compliance by patients. [Coil 2004]

At some hospitals and emergency departments that employ routine screening, the percentages of positive results (2% to 7%) often are greater than those reported at publicly funded HIV counseling and testing sites (1.5%) and STI clinics (2%). [CDC Mass., CDC MSM 2005, CDC Atlanta, Kelen 1999, CDC Anonymous] These earlier diagnoses of HIV infection were identified because few of the patients were seeking testing when offered screening at these hospitals. [Lyons 2005] Targeted testing based on risk behaviors does not detect a substantial number of HIV infected persons. [Klein 2003, Alpert 1996, Chen 1998] One reason for such undetected cases is the large number of individuals, including some who are at increased risk for HIV infection, fail to perceive themselves as at risk or fail to disclose their risks. [CDC Mass., CDC MSM 2005, CDC Anonymous]

Cost-Effectiveness

Studies have demonstrated that voluntary HIV screening is cost-effective even in healthcare settings where HIV prevalence is low. [Walensky 2005, Paltiel 2005, Sanders 2005] In populations having undiagnosed HIV infection prevalence of > 0.1%, HIV screening is as cost-effective as routine screening programs for other conditions (eg, hypertension and colon and breast cancer). [Paltiel 2005, Sanders 2005] Survival gains associated with early initiation of HAART are comparable to conventional benchmarks for cost-effectiveness, even without considering the public-health benefits of fewer HIV transmissions. [Sanders 2005] Furthermore, HIV screening without such linkage to care confers little or no patient benefit. The substantial costs of screening and providing HIV care are balanced by the associated survival benefits. [Walensky 2005, Paltiel 2005, Weinhardt 1999]

However, the benefit of providing prevention counseling along with HIV testing is less clear. That approach is associated with reductions in risky behavior among HIV-infected participants but with little effect on the behavior of HIV-negative participants. [Weinhardt 1999] However, carefully controlled, theory-based prevention counseling has been associated with reductions in risky behaviors among HIV-negative participants vs participants who received only a didactic prevention messages. [Kamb 1998] A more intensive, 3-month intervention in HIV-negative MSM at high risk was found to be associated with reductions in unprotected sex with partners whose status was positive or unknown vs MSM who received structured prevention counseling twice yearly. [EXPLORE]

« BACK

	3. Promoting HIV Testing in Diverse Populations Curricula 1 2 3 4 AETC-NMC Home Curricula Home Glossary Feedback

	About Curriculum 3 Module 1: U.S. HIV Epidemiology Learning Objectives & Pretraining Assessment The HIV Epidemic in the United States The HIV Epidemic, cont. By Risk Group Key Events in the US HIV Epidemic (early 1980s - late 1990s) (2000 - present) African American Populations Hispanic/Latino Populations MSM Populations Asian and Pacific Islander Populations American Indian/Native Alaska Populations Summary References Assessment Questions Module 2: Recommendations for Routine HIV Testing Learning Objectives & Pretraining Assessment Development of HIV Screening Recommendations Rationale Underlying the 2006 Recommendations Revised Recommendations for HIV Testing Summary References Assessment Questions Module 3: Benefits of Early Testing and Risks of Delayed Testing Learning Objectives & Pretraining Assessment Timing of Initiation of HAART Guidelines on Starting Antiretroviral Therapy Benefits Associated With Early Therapy Initiation Diagnosis in the ED Risks of Delayed HIV Diagnosis and Treatment Summary References Assessment Questions Module 4: Barriers to Testing and Strategies to Improve Rates of Routine HIV Testing Learning Objectives & Pretraining Assessment Discovering Barriers to Wider Use of HIV Screening Provider-Related Barriers Impact of State and Local Laws and Regulations Population-Specific Barriers Factors That Impede HIV Testing Among Latinos Factors That Impede HIV Testing Among American Indians/Alaska Natives Factors That Impede HIV Testing Among Asian/Pacific Islanders Strategies to Improve Routine HIV Testing Working With Community Organizations Summary References Assessment Questions Module 5: HIV Testing Technologies Learning Objectives & Pretraining Assessment Point-of-Care Testing vs Laboratory-Based Testing Confirmatory Tests Availability of Results Point-of-Care Testing Issues Key Resources for Understanding and Employing HIV Testing Technologies Summary References Assessment Questions Case Studies Suggested Activities	Rationale Underlying the 2006 Recommendations Implementation difficulties were associated with previous HIV testing guidelines: Costs of HIV screening are often not reimbursed by third-party payers. Practitioners in busy settings may not have the time needed to conduct risk assessments and may perceive the counseling requirements in previous recommendations as a barrier to testing. In most areas, clear information about HIV prevalence is not available to guide selection of specific settings in which screening should be offered. [Frieden 2005, Walensky 2005, Paltiel 2005, Rothman, 2004, Lyons, 2005] The characteristics of HIV infection are consistent with other conditions that typically justify screening: A serious health condition that can be diagnosed before the development of symptoms A condition detectable by reliable, inexpensive, noninvasive screening procedures Significant potential for increased survival if treatment is initiated before symptoms develop Reasonable costs of screening in relation to the anticipated benefits [Wilson 1968] Increased Detection Many HIV-infected persons who are unaware of their status use healthcare services (eg, hospitals, emergency departments, and STI clinics) for years without being tested for HIV disease. [Klein 2003, Alpert 1996, Liddicoat 2004] With the evolution in the demographics of the US HIV epidemic since the 1980s, increasing proportions of infected persons are < 20 years of age, women, members of racial or ethnic minority populations, not residents of a metropolitan area, and heterosexual men and women are unaware that they are at risk for HIV infection.[IOM 2001] This evolution means that risk-based screening to identify HIV-infected individuals is no longer as effective as in earlier years. [Klein 2003, Alpert 1996, Jenkins 2006, Chen 1998] Inclusion of routine HIV screening in prevention programs has been shown to be highly effective. For example, screening blood donors for HIV has virtually eliminated transfusion-associated HIV transmission in the United States. [Dodd 2002] In addition, since the recommendation in the 1990s for routine screening of pregnant women—and the use of prophylactic antiretrovirals and other measures when HIV infection is detected—the US incidence of pediatric HIV has declined significantly. [CDC 1995, CDC 1999, Public Health Service Task Force, pregnant; Cooper 2002] In contrast, the prevention of sexual transmission of HIV has met with more limited success. Detection of new HIV infections has remained relatively level since the 1990s, and some data indicate possible increases in certain populations in recent years. [Karon 2001, CDC Trends] Risk Reduction In a meta-analysis of findings from 8 studies, the prevalence of unprotected anal or vaginal intercourse with uninfected partners was on average 68% lower for HIV-infected persons who knew their status vs HIV-infected persons who did not know their status. [Marks 2005] The Institute of Medicine and other groups of healthcare professionals [Karon 2001, IOM 2001, Bozette 2005, CDC Pregnant] have encouraged routine HIV testing in all healthcare settings as a strategy to: Increase the numbers of HIV diagnoses Remove any stigma from the testing process Link clinical care with prevention Provide immediate access to care for individuals who have been newly diagnosed Increased ED Screening The numbers of at-risk individuals who receive HIV screening in emergency departments (EDs) has remained low, despite repeated recommendations supporting routine risk-based testing in health-care settings. [Klein 2003, Fincher 2002] A survey of 154 healthcare providers in 10 hospital EDs reported that the providers cared for an average of 13 patients per week who were suspected to have STIs, but only 10% of them encouraged such patients to be tested for HIV while in the ED and an additional 35% referred patients to confidential HIV testing sites in the community. [Fincher 2002] Such referrals, however, have proven ineffective because of poor compliance by patients. [Coil 2004] At some hospitals and emergency departments that employ routine screening, the percentages of positive results (2% to 7%) often are greater than those reported at publicly funded HIV counseling and testing sites (1.5%) and STI clinics (2%). [CDC Mass., CDC MSM 2005, CDC Atlanta, Kelen 1999, CDC Anonymous] These earlier diagnoses of HIV infection were identified because few of the patients were seeking testing when offered screening at these hospitals. [Lyons 2005] Targeted testing based on risk behaviors does not detect a substantial number of HIV infected persons. [Klein 2003, Alpert 1996, Chen 1998] One reason for such undetected cases is the large number of individuals, including some who are at increased risk for HIV infection, fail to perceive themselves as at risk or fail to disclose their risks. [CDC Mass., CDC MSM 2005, CDC Anonymous] Cost-Effectiveness Studies have demonstrated that voluntary HIV screening is cost-effective even in healthcare settings where HIV prevalence is low. [Walensky 2005, Paltiel 2005, Sanders 2005] In populations having undiagnosed HIV infection prevalence of > 0.1%, HIV screening is as cost-effective as routine screening programs for other conditions (eg, hypertension and colon and breast cancer). [Paltiel 2005, Sanders 2005] Survival gains associated with early initiation of HAART are comparable to conventional benchmarks for cost-effectiveness, even without considering the public-health benefits of fewer HIV transmissions. [Sanders 2005] Furthermore, HIV screening without such linkage to care confers little or no patient benefit. The substantial costs of screening and providing HIV care are balanced by the associated survival benefits. [Walensky 2005, Paltiel 2005, Weinhardt 1999] However, the benefit of providing prevention counseling along with HIV testing is less clear. That approach is associated with reductions in risky behavior among HIV-infected participants but with little effect on the behavior of HIV-negative participants. [Weinhardt 1999] However, carefully controlled, theory-based prevention counseling has been associated with reductions in risky behaviors among HIV-negative participants vs participants who received only a didactic prevention messages. [Kamb 1998] A more intensive, 3-month intervention in HIV-negative MSM at high risk was found to be associated with reductions in unprotected sex with partners whose status was positive or unknown vs MSM who received structured prevention counseling twice yearly. [EXPLORE] « BACK NEXT »
	Accessibility · Copyright and Disclaimers © Howard University The AIDS Education and Training Center-National Multicultural Center (AETC-NMC) at Howard University website was made possible by Health Resources and Services Administration, HIV/AIDS Bureau (HAB) of the U.S. Department of Health and Human Services (grant #U2THA19645).

3. Promoting HIV Testing in Diverse Populations

Rationale Underlying the 2006 Recommendations