The federal government this summer has taken a two-pronged approach to reinvigorating its efforts in addressing HIV/AIDS.
In June, the Centers for Disease Control and Prevention launched an initiative aimed at helping physicians make HIV testing a routine part of medical care. The initiative, known as “HIV Screening. Standard Care.” aims to increase the use of opt-out screening strategies over risk-based screening, which previously has been the more common practice.
In an interview, Dr. Jonathan Mermin, director of the CDC's division of HIV/AIDS prevention, Atlanta, said the goal of the new initiative is to increase implementation of the CDC's 2006 HIV screening guidelines, which recommend that all patients aged 13-64 years be tested for HIV at least once in their lives—regardless of perceived risk of infection—and that individuals at high risk be tested at least annually (MMWR 2006;55[RR-14]:1-17).
“In the end, HIV testing is one of the most important interventions we have, both for HIV care and HIV prevention,” Dr. Mermin said.
“The need for HIV screening is an ongoing issue,” said Dr. Amir Qaseem, senior medical associate at the American College of Physicians, which recently published a guidance statement for HIV screening (Ann. Intern. Med. 2009;150:125-31). “It's a major public health problem worldwide, even within the United States, where almost 1 million people are living with HIV. Almost 25% of these people are unaware of their HIV infection.”
He acknowledged certain challenges to providing routine screening in primary care, including addressing multiple issues in a limited amount of time during the office visit.
“Risk-based screening has been an unsuccessful strategy and has failed to identify a substantial number of patients with HIV,” Dr. Qaseem said. “Routine HIV screening is easier to implement in busy practice settings.”
Yet few physicians do it. A 2009 Web-based survey from the public relations firm Porter Novelli found that only 17% of primary care physicians routinely screen their patients for HIV.
And in a study from 2007, investigators from the bureau of HIV/AIDS prevention and control in the New York City Department of Health and Mental Hygiene reviewed published and unpublished literature on HIV testing barriers.
They divided studies into three categories: prenatal, emergency department, and other medical settings (AIDS 2007;21:1617-24). Several barriers were identified in all three settings: lack of knowledge/training, lack of patient acceptance, pretest counseling requirements, competing priorities, and inadequate reimbursement.
“Some providers [feel] awkward raising issues about HIV testing or sexuality with their patients, because they think someone who's 55 years old may not be at risk,” Dr. Mermin said. “But in fact, people of all ages are at risk for HIV infection. Some of that is because it's a chronic disease and people can live with HIV for many years without showing symptoms. Some of it is that the majority of Americans are sexually active throughout their life, and can acquire HIV regardless of age.”
Laws and regulations in some states pose another challenge to adoption of routine HIV screening. In a recent study, researchers led by Dr. John G. Bartlett of Johns Hopkins University, Baltimore, reported that at the time of the CDC's 2006 HIV screening guidelines, 20 states had laws or regulations that required separate written consent for HIV testing of nonpregnant adults (JAMA 2008;300:945-51).
“Legislation or regulations to remove these barriers have been enacted in 11 states (Arizona, California, Illinois, Indiana, Iowa, Louisiana, Maine, Maryland, New Hampshire, New Mexico, and North Carolina),” the researchers wrote. Since publication of that article, Connecticut, Hawaii, Rhode Island, and Wisconsin have changed laws to remove these barriers, according to Dr. Bernard M. Branson of the CDC, one of the study's authors. Similar legislation has been introduced but not enacted in Massachusetts, Michigan, Nebraska, and New York.
Routine HIV screening is supported in the government's National HIV/AIDS Strategy for the United States—the summer's other major federal HIV/AIDS effort.
Released in July, the national strategy is a 45-page blueprint with three main goals: reducing the number of people who become infected with HIV, increasing access to care and optimizing health outcomes for people living with HIV, and reducing HIV health-related disparities.
The strategy emphasizes reduction of new HIV infections by intensifying prevention efforts in communities where HIV is most prevalent, expanding targeted efforts to prevent HIV infection using a combination of effective, evidence-based approaches, and educating all Americans about the threat of HIV and how to prevent it.
“This has been a long time coming,” said Dr. Donna Sweet, professor of internal medicine at the University of Kansas–Wichita. “It reflects, I think, what we all think needs to be done. It really is about reducing new HIV infections, improving care for the people living with HIV/AIDS, and perhaps even most importantly, narrowing the health disparities, because this epidemic has moved into corners of our country where there are very little resources and a lack of education.