Human Immunodeficiency Virus (HIV) Infection Screening-Adult

Summary of Recommendations and Evidence

Population	Recommendation	Grade (What's This?)
Adolescents and Adults 15-65 Years Old	The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. Go to the Clinical Considerations for more information about screening intervals.	A
Pregnant Women	The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown.	A

Population

Recommendation

Adolescents and Adults 15-65 Years Old

The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened.

Go to the Clinical Considerations for more information about screening intervals.

A

Pregnant Women

The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown.

A

Importance

Approximately 1.1 million persons in the United States are currently living with HIV, and more than 700,000 persons have died of AIDS since the first cases were reported in 1981. The estimated prevalence of HIV infection among persons 13 years and older in the United States is 0.4% (0.7% in males and 0.2% in females), and data from the Centers for Disease Control and Prevention (CDC) 2017 HIV Surveillance Report show a significant increase in HIV diagnoses starting at age 15 years (compared with ages 13-14 years).2 The annual number of new cases of HIV infection diagnosed in the United States has decreased slightly in recent years, from about 41,200 new cases in 2012 to 38,300 in 2017. Approximately 15% of persons living with HIV are unaware of their infection. It is estimated that persons unaware of their HIV status are responsible for 40% of transmission of HIV in the United States.

An estimated 8700 women living with HIV give birth each year in the United States. HIV can be transmitted from mother to child during pregnancy, labor, delivery, and breastfeeding. The incidence of perinatal HIV infection in the United States peaked in 1992 and has declined significantly following the implementation of routine prenatal HIV screening and the use of effective therapies and precautions to prevent mother-to-child transmission. Nearly 22,000 perinatal infections were prevented between 1994 and 2010 because of screening and preventive measures.

Detection

The USPSTF found convincing evidence that conventional and rapid HIV antibody tests are highly accurate in diagnosing HIV infection.

Benefits of Detection and Early Intervention

The USPSTF found convincing evidence that identification and early treatment of HIV infection is of substantial benefit in reducing the risk of AIDS-related events or death. The USPSTF found convincing evidence that the use of antiretroviral therapy (ART) is of substantial benefit in decreasing the risk of HIV transmission to uninfected sex partners. The USPSTF also found convincing evidence that identification and treatment of pregnant women living with HIV infection is of substantial benefit in reducing the rate of mother-to-child transmission. The overall magnitude of the benefit of screening for HIV infection in adolescents, adults, and pregnant women is substantial.

Harms of Detection and Early Intervention

The USPSTF found adequate evidence that individual antiretroviral drugs, ART drug classes, and ART combinations are associated with some harms, including neuropsychiatric, renal, and hepatic harms and an increased risk of preterm birth in pregnant women. The overall magnitude of the harms of screening for and treatment of screen-detected HIV infection in adolescents, adults, and pregnant women is small.

USPSTF Assessment

The USPSTF concludes with high certainty that the net benefit of screening for HIV infection in adolescents, adults, and pregnant women is substantial.

Patient Population Under Consideration

This recommendation applies to adolescents, adults, and all pregnant persons regardless of age. Based on the age-stratified incidence of HIV infection and data on sexual activity in youth, the USPSTF recommends screening for HIV infection beginning at age 15 years. Adolescents younger than 15 years and adults older than 65 years should be screened if they have risk factors for HIV infection.

Assessment of Risk

Although all adolescents and adults aged 15 to 65 years should be screened, there are a number of risk factors that increase risk. Among adolescents younger than 15 years and adults older than 65 years, clinicians should consider the risk factors of their patients, especially those with new sex partners, and offer testing to patients at increased risk.

Most (67%) new diagnoses of HIV infection are attributed to male-to-male sexual contact,2 and the estimated prevalence of HIV infection among men who have sex with men is 12%.3 Injection drug use is another important risk factor for HIV infection; the estimated prevalence of HIV infection among persons who inject drugs is 1.9%.3 In 2017, male individuals 13 years and older accounted for 81% of new diagnoses of HIV infection.2 Most (83%) of these new diagnoses of HIV infection were attributed to male-to-male sexual contact, while 9% were attributed to heterosexual contact, 4% to injection drug use, and 4% to both male-to-male sexual contact and injection drug use.2 Among female individuals 13 years and older, 87% of all new diagnoses were attributed to heterosexual contact and 12% to injection drug use.2

Additional risk factors for HIV infection include having anal intercourse without a condom, having vaginal intercourse without a condom and with more than 1 partner whose HIV status is unknown, exchanging sex for drugs or money (transactional sex), having other sexually transmitted infections (STIs) or a sex partner with an STI, and having a sex partner who is living with HIV or is in a high-risk category. Persons who request testing for STIs, including HIV, are also considered at increased risk.

The USPSTF recognizes that these risk categories are not mutually exclusive, that the degree of risk exists on a continuum, and that persons may not be aware of the HIV or risk status of their sex partner or the person with whom they share injection drug equipment. Patients may also be reluctant to disclose risk factors to clinicians.

Screening Intervals

The USPSTF found insufficient evidence to determine appropriate or optimal time intervals or strategies for repeat HIV screening. Repeat screening is reasonable for persons known to be at increased risk of HIV infection, such as sexually active men who have sex with men; persons with a sex partner who is living with HIV; or persons who engage in behaviors that may convey an increased risk of HIV infection, such as injection drug use, transactional sex or commercial sex work, having 1 or more new (ie, since a prior HIV test) sex partners whose HIV status is unknown, or having other factors that can place a person at increased risk of HIV infection (see the Assessment of Risk section). Repeat screening is also reasonable for persons who live or receive medical care in a high-prevalence setting, such as a sexually transmitted disease clinic, tuberculosis clinic, correctional facility, or homeless shelter. The CDC recommends annual screening in persons at increased risk10 but recognizes that clinicians may wish to screen high-risk men who have sex with men more frequently (eg, every 3 or 6 months) depending on the patient’s risk factors, local HIV prevalence, and local policies.11 Routine rescreening may not be necessary for persons who have not been at increased risk since they last tested negative for HIV.

The USPSTF found no evidence on the yield of repeat prenatal screening for HIV compared with 1-time screening during a single pregnancy. The CDC10 and the American College of Obstetricians and Gynecologists (ACOG)12 recommend repeat prenatal screening for HIV during the third trimester of pregnancy in women with risk factors for HIV acquisition and in women living or receiving care in high-incidence settings, and the CDC notes that repeat screening for HIV during the third trimester in all women who test negative early in pregnancy may be considered. Women screened during a previous pregnancy should be rescreened in subsequent pregnancies.

Screening Tests

Current CDC guidelines recommend testing for HIV infection with an antigen/antibody immunoassay approved by the US Food and Drug Administration that detects HIV-1 and HIV-2 antibodies and the HIV-1 p24 antigen, with supplemental testing after a reactive assay to differentiate between HIV-1 and HIV-2 antibodies.8,9 If supplemental testing for HIV-1/HIV-2 antibodies is nonreactive or indeterminate (or if acute HIV infection or recent exposure is suspected or reported), an HIV-1 nucleic acid test is recommended to differentiate acute HIV-1 infection from a false-positive test result.8,9

Antigen/antibody tests for HIV are highly accurate, with reported sensitivity ranging from 99.76% to 100% and specificity ranging from 99.50% to 100%, and results can be available in 2 days or less.8 Rapid antigen/antibody tests are also available.9

When using a rapid HIV test for screening, positive results should be confirmed. Pregnant women presenting in labor with unknown HIV status should be screened with a rapid HIV test to get results as soon as possible.

Treatment

No cure for chronic HIV infection currently exists. However, appropriately timed interventions in HIV-positive persons can reduce risks for clinical progression, complications or death from the disease, and disease transmission. Effective interventions include ART (specifically, the use of combined ART, defined as ≥3 antiretroviral agents used together, usually from ≥2 classes), immunizations, and prophylaxis for opportunistic infections.

Other Approaches to Prevention

The USPSTF recognizes that the most effective strategy for reducing HIV-related morbidity and mortality in the United States is primary prevention or avoidance of exposure to HIV infection. Condom use can also substantially decrease the risk for transmission of HIV and other STIs.

The USPSTF recommends high-intensity behavioral counseling to prevent STIs for all sexually active adolescents and for adults at increased risk for infection. More information can be found at www.uspreventiveservicestaskforce.org//Page/Topic/recommendation-summary/sexually-transmitted-infections-behavioral-counseling1.

The Community Preventive Services Task Force has made several recommendations related to the prevention of HIV, AIDS, and other STIs, including person-to-person behavioral interventions (information and skill building to change knowledge, attitudes, beliefs, and self-efficacy) for men who have sex with men that can be implemented at the individual, group, or community level. It also recommends health provider notification and encouragement for HIV testing for sexual or needle-sharing partners of individuals diagnosed with HIV, as well as comprehensive risk reduction interventions in adolescents. More information can be found at www.thecommunityguide.org/hiv/index.html This link goes offsite. Click to read the external link disclaimer.

Other Resources

More information about HIV and AIDS is available at www.aids.gov This link goes offsite. Click to read the external link disclaimer& and www.cdc.gov/hiv/default.htm This link goes offsite. Click to read the external link disclaimer.

The CDC's recommendations on HIV testing in adults, adolescents, and pregnant women in health care settings are available at www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm This link goes offsite. Click to read the external link disclaimer. More information on HIV testing is available at www.cdc.gov/hiv/topics/testing/index.htm This link goes offsite. Click to read the external link disclaimer and www.fda.gov/ForConsumers/ByAudience/ForPatientAdvocates/HIVandAIDSActivities/ucm117922.htm This link goes offsite. Click to read the external link disclaimer.

Antiretroviral treatment guidelines are regularly updated and available at http://aidsinfo.nih.gov/guidelines This link goes offsite. Click to read the external link disclaimer.

Information about state-based HIV and AIDS hotlines is available at http://hab.hrsa.gov/gethelp/statehotlines.html This link goes offsite. Click to read the external link disclaimer.