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New USPSTF Guidelines on HIV Screening
These evidence-based individual recommendations are simply not enough for effective public health.
In early July, the U.S. Preventive Services Task Force (USPSTF) released updated guidelines on HIV screening. As with previous guidelines, the recommendations are rated A through I, based on the strength of the available evidence. Grade A recommendations are the strongest and indicate that there is good evidence that the service improves outcomes and that benefits substantially outweigh harms.
- The USPSTF strongly recommends that clinicians screen for HIV in all adolescents and adults at increased risk for HIV infection. Individuals are considered to be at increased risk if they report at least one risk factor or receive care in high-prevalence (defined by the CDC as
1%) or high-risk clinical settings (such as STD clinics, correctional facilities, and homeless shelters). Recommendation: Grade A
- The USPSTF makes no recommendation for or against screening individuals who are not considered to be at increased risk for HIV infection. The task force concludes that "the benefit of screening adolescents and adults without risk factors for HIV is too small relative to potential harms to justify a general recommendation." Recommendation: Grade C
- The USPSTF now strongly recommends that clinicians screen all pregnant women for HIV infection. Previous guidelines recommended screening only pregnant women who were considered to be at high risk. Recommendation: Grade A
Comment: Although the USPSTF guidelines are a step in the right direction and most of us applaud them, they unfortunately fall short of recommending routine screening for all adolescents and adults. Since 1993, the CDC has recommended routine screening of all hospitalized adults in areas with HIV prevalence 1%. Several recent studies have suggested that this approach is clinically beneficial, cost-effective, and acceptable to patients (ACC Mar 1 2005 and Mar 30 2005). However, the CDC recommendations remain largely ignored, probably because like the new USPSTF guidelines, they assume that clinicians can determine risk in brief clinical encounters and that they are aware of the seroprevalence in the populations they serve.
There appears to be strong support in the medical community for routine screening of all adolescents and adults (ACC Mar 21 2005), but the USPSTF guidelines fail to address the public health benefits of such an approach. They take into account the potential risks of screening for the individual, but they do not consider the substantial risks and harms that exist for the sexual and drug-using partners of individuals who have HIV infection without being aware of it. Although the potential harm of a false-positive result is real for the individual who gets screened, the potential benefit to society of knowing who is infected — and linking those individuals to treatment and preventive services — is also substantial.
Most major payers, such as Medicare and Medicaid, rely on USPSTF recommendations when deciding whether to reimburse for specific tests and procedures. Unfortunately, as a result of these updated recommendations, routine HIV screening will likely be reimbursable only in settings that meet the grade A criteria.
— Carlos del Rio, MD
Published in AIDS Clinical Care July 13, 2005
Citation(s):
U.S. Preventive Services Task Force. Screening for HIV: Recommendation statement. Ann Intern Med 2005 Jul 5; 143:32-7.
- Original article (Subscription may be required)
- Medline abstract (Free)
Chou R et al. Screening for HIV: A review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2005 Jul 5; 143:55-73.
- Original article (Subscription may be required)
- Medline abstract (Free)
Chou R et al. Prenatal screening for HIV: A review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2005 Jul 5; 143:38-54.
- Original article (Subscription may be required)
- Medline abstract (Free)