Routine HIV Testing and Screening in Healthcare Settings

Despite seeing a provider, many people at high risk for HIV are not getting tested every year. An estimate from 2014-2016 National HIV Behavioral Health Surveillance data showed that approximately 75% of people at increased risk for HIV who were not tested for HIV in the last year, despite having seen a provider, had not been offered an HIV test during their visit. Results from an international study funded by the National Institutes of Health (NIH) highlight the importance of early diagnosis and screening, showing that individuals with HIV benefit from antiretroviral therapy (ART) sooner rather than later to reduce the risk of developing AIDS and the risk of passing HIV on to partners. HIV infection is diagnosed through conventional and rapid HIV antibody tests. These tests are highly accurate.

The U.S. Preventive Services Task Force (USPSTF) recommends that providers screen individuals between the ages of 15 to 65 for HIV and the Centers for Disease Control and Prevention (CDC) recommends providers screen individuals between the ages of 13 and 64. In addition, the USPSTF also recommends that both younger adolescents and older adults should be screened if they are at an increased risk for acquiring HIV. All pregnant women with an unknown HIV status should be tested when present in a healthcare setting.

CDC provides guidance for HIV screening for gay, bisexual, and other men who have sex with men (MSM). CDC recommends that MSM complete an HIV screening at least once per year, and for some individuals at an increased risk of HIV, screening once every 3 or 6 months may be beneficial.

Healthcare settings where HIV screening can occur include places like:

Primary and specialty care clinics
Mental health facilities
Substance use disorder treatment settings
Dental clinics
Emergency departments
Community health centers
Pharmacies
Urgent care clinics

Like many other kinds of routine screenings for conditions such as high blood pressure, the CDC recommends HIV screening be provided on an “opt-out” basis. This means that testing will be performed after the person is informed of the test unless he or she specifically declines. It also means that general consent for medical care includes HIV screening and that providers do not need to obtain separate written consent before the test. CDC reports that opt-out screening has been found to be cost-effective when used in clinical settings, including emergency or urgent care centers, primary care, and STI clinics.

Rural areas continue to have low rates of HIV testing. Novel screening strategies are needed to reach this population in clinical settings. Examples of novel or promising approaches to increase access to HIV testing include integrating HIV screening with sexual health screenings, promoting pharmacist-led screenings, integrating screening with mental health and/or substance use treatment, screenings in urgent care clinics or emergency rooms and promoting distribution of HIV self-tests.

Testing all pregnant women for HIV is an important step in preventing mother-to-child transmission. The CDC recommendations for HIV testing in healthcare settings report that routine screening instead of risk-based testing for pregnant women is more effective in preventing perinatal transmission. Partners of all pregnant women should be referred for HIV testing when their status is unknown. Furthermore, the rates of HIV testing in pregnant women are much higher in states where “opt-out” policies exist. Once HIV-positive pregnant women are identified, providers can work with mothers to identify the best way to prevent transmission to their babies. Clinical guidance is available on the management of infants born to women with HIV.

Implementing elements of trauma informed care would benefit providers and the clients they serve. People living with HIV experience a disproportionate rate of trauma compared to the general population. Studies indicate how a trauma-informed approach may inform HIV testing services and treatment.

Examples of HIV Testing in Healthcare Settings:

The North Carolina Department of Health and Human Services supports a number of programs designed to integrate routine HIV testing into healthcare settings across the state. These include Federally Qualified Health Centers, substance use disorder facilities, and emergency departments. The Communicable Disease Branch provides training, funding, and free testing kits to participating sites.
Oklahoma has been classified by the Department of Health and Human Services as one of the seven states with a high rural HIV burden. Test-and-treat protocols are feasible within high-volume HIV clinics which serve rural and underserved communities to minimize the time to the first appointment to decrease time to viral load suppression.
The Cherokee Nation Health Services Ending the HIV Epidemic project was launched in September 2019 and focuses on diagnoses and prevention. The Cherokee Nation Health Services (CNHS) has screened over 11,000 individuals for HIV and more than doubled the number of persons receiving HIV PrEP. Of the 35% of CNHS patients screened for HIV so far, less than one percent are HIV positive. Also, 90% of people diagnosed with HIV through CNHS are receiving care, and of those people, 90% are considered virally suppressed.

Considerations for Implementation

Approximately 36,400 people become newly infected with HIV in the U.S. each year. The U.S. Preventive Services Task Force recommends clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. However, there are still barriers to testing in rural communities such as access to care, provider and patient attitudes, access to technology, and stigma.

Although rapid HIV antibody tests can now provide results in less than an hour, most test results are verified with additional lab testing, which can take up to several days. People may feel rushed during a routine visit with their provider and may feel that there is not sufficient time for testing. Also, confidentiality is a concern and people may not feel comfortable testing close to home for fear that someone in the community may find out the results.

In addition, reaching populations at highest risk and those who may be infrequently seen by a primary care doctor can be a challenge. In particular, adolescents and young adults make up a significant portion of new HIV cases in the U.S. each year and are often one of the most difficult populations to reach for testing. Targeted screening strategies and innovative outreach methods are necessary to reach high-risk populations. Health departments and clinics can partner with community organizations conducting testing at various sites to reach some of these populations. Community health centers provide primary care services to underserved populations and are especially important in rural communities. Implementing routine HIV testing in community health centers is another way to reach populations at high risk for contracting HIV.

Resources to Learn More

Sexual Health History: Techniques and Tips
Website
Offers guidance for family physicians to help them identify their biased behavior when discussing sexual healthcare and sexual history with their patients. Describes several key points and interventions useful for physicians when developing a patient-centered approach to identifying disease and treatment relative to sexual health.
Organization(s): American Academy of Family Physicians (AAFP)

HIV Nexus: CDC Resources for Clinicians
Website
Repository of information, tools, resources, and guidance for clinicians and their patients that spans the HIV care continuum.
Organization(s): Centers for Disease Control and Prevention (CDC)

HIV Testing Overview
Website
Describes the differences between HIV testing in a healthcare setting or lab, HIV testing outside of a healthcare setting or lab, and the self-testing option allowing people to take the test in their own home. Includes discussion on the types of HIV tests and the time it takes for accurate results, and how quickly after exposure a test can detect HIV.
Organization(s): HIV.gov, U.S. Department of Health & Human Services

Understanding HIV Test Results
Website
Discusses the meaning of positive and negative HIV test results, confidential and anonymous testing, and importance of disclosing HIV status.
Organization: HIV.gov, U.S. Department of Health & Human Services

HIV Testing Sites & Care Services Locator
Website
A search tool for organizations wishing to provide easy access to HIV testing information on their website. Instructions are provided on how to insert the widget into a website allowing the user to enter zip code or city name in the search field to find nearby HIV testing sites.
Organization(s): HIV.gov, U.S. Department of Health and Human Services