home hiv test, hiv test kitApplying HIV testing guidelines in clinical practice is reviewed in an article published in the December 15 issue of the American Family Physician.
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“Nearly 1 million persons in the United States are living with human immunodeficiency virus (HIV), of which an estimated 25 percent are not aware they are infected,” write Megan R. Mahoney, MD, from University of California, San Francisco, and colleagues. “Primary care physicians, however, have been found to experience several real and perceived barriers to HIV testing. These include insufficient time, competing priorities, lack of knowledge and training, perceived burden of consent and counselling requirements, lack of patient acceptance, and inadequate reimbursement.”
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Adults who do not know they are infected with HIV account for more than half of new sexual transmissions of HIV each year. After being notified that they are HIV positive, men and women reduce the frequency of unprotected vaginal or anal intercourse by 64%, according to the results of a meta-analysis.
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Regardless of risk factors, the Centers for Disease Control and Prevention (CDC) now recommend routine HIV testing in all persons aged 13 to 64 years, as do guidelines of the American College of Obstetricians and Gynecologists and the American College of Physicians. The CDC position is that all patients aged 13 to 64 years should be offered HIV testing at least once. Although the American Academy of Family Physicians and the US Preventive Services Task Force do not recommend routine HIV testing in low-risk populations, they also mandate increased HIV testing.
Because early diagnosis of HIV may limit viral transmission and optimize outcomes for infected persons, testing for HIV in the primary care setting is important. However, time constraints, reimbursement concerns, and lack of patient acceptance may hinder HIV testing by clinicians.
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To reduce these barriers to HIV testing, current guidelines attempt to streamline the testing process and make it less stigmatizing. Evidence has shown that test acceptance is improved by the opt-out consent process.
Although the CDC no longer recommends formal pretest counseling and written consent, clinician-patient discussions before HIV testing may be useful. Specifically, counseling in this setting offers an opportunity to provide information about HIV, to reassure patients regarding fears of discrimination, and to identify and reduce ongoing high-risk activities.
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The CDC recommends that persons at increased risk for HIV infection be tested at least once. Persons at increased risk include injection drug users and their sexual partners, sex trade workers, sexual partners of individuals who are infected with HIV or at high risk for infection, and men who have sex with men.
Increased HIV screening in the primary care setting could result in earlier identification of more persons with HIV, allowing them to be managed and treated early and appropriately to prevent transmission and clinical progression.
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“Primary care physicians have been identified as a group that has the potential to perform broader testing with the goal of decreasing new transmissions and facilitating early linkage to care,” the review authors write. “National data indicate that more than one half of HIV tests and 38 percent of positive tests are conducted in primary care settings.”