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Expanded HIV Testing: Implementing the CDC Recommendations

The findings and conclusions described in this article are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention. On September 22, 2006 the Centers for Disease Control and Prevention (CDC) published recommendations for a major change in the approach to testing for HIV infection in the United States: expanded screening in healthcare settings with streamlined procedures for consent and pretest information,[1] available at http://www.cdc.gov/mmwr/PDF/rr/rr5514.pdf.

The CDC's specific recommendations for healthcare settings, outlined in Table 1, included: * expanded HIV screening for patients regardless of risk; * revisions to procedures for separate, written informed consent; * indications for diagnostic testing; and * decreased emphasis on prevention counseling.

Table 1. Summary: CDC Recommendations for HIV Testing of Adults and Adolescents in Healthcare Settings Screening All persons aged 13-64, regardless of risk, should receive routine, voluntary screening for HIV in all healthcare settings in which the prevalence of undiagnosed HIV infection is at least 0.1%. All patients initiating treatment for TB should be screened for HIV. All patients seeking treatment for STDs should be screened for HIV each time they seek such treatment.

Healthcare providers should encourage patients and their prospective sex partners to be tested before initiating a new sexual relationship. Repeat HIV screening should be performed for patients with known risk at least annually. Persons likely to be at high risk include injection-drug users and their sex partners, persons who exchange sex for money or drugs, sex partners of HIV-infected persons, and men who have sex with men (MSM) or heterosexual persons who themselves or whose sex partners have had more than one sex partner since their most recent HIV test.

Table 1. Summary: CDC Recommendations for HIV Testing of Adults and Adolescents in Healthcare Settings

Screening
All persons aged 13-64, regardless of risk, should receive routine, voluntary screening for HIV in all healthcare settings in which the prevalence of undiagnosed HIV infection is at least 0.1%.
All patients initiating treatment for TB should be screened for HIV.
All patients seeking treatment for STDs should be screened for HIV each time they seek such treatment.
Healthcare providers should encourage patients and their prospective sex partners to be tested before initiating a new sexual relationship.
Repeat HIV screening should be performed for patients with known risk at least annually.
   Persons likely to be at high risk include injection-drug users and their sex partners, persons who exchange sex for money or drugs, sex partners of HIV-infected persons, and men who have sex with men (MSM) or heterosexual persons who themselves or whose sex partners have had more than one sex partner since their most recent HIV test.

This type of screening, known as opt-out testing, is carried out after notifying the patient that an HIV test will be performed and that the patient may elect to decline or defer testing. Thus, consent is inferred unless the patient declines testing. Opt-out testing is sometimes referred to as "routine testing," but the two are not synonymous. In opt-out testing, patients are notified that an HIV test is a routine part of the encounter and as such there is no requirement for formalized counseling or separate written informed consent.

Patients must specifically decline testing, either orally or in writing, to be exempt from having an HIV test. Routine testing, on the other hand, is the routine offer of an HIV test, followed by whatever protocol is required in that setting or state.

Rationale for the CDC's Revised Recommendations

The revised recommendations came from several observations. First, effective treatment with highly active antiretroviral therapy (HAART) has substantially changed the risk-benefit ratio associated with HIV testing, transforming AIDS from a fatal disease to a highly treatable chronic condition. Get tested, it's that simple.



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