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Level II – Human Immunodeficiency Virus (HIV) Screening

Level II Services: Preventive services for which clinicians and care systems should assess the need. These services should be recommended to each patient as they have value, but less than those in Level I.

The USPSTF recommendations are fully endorsed by the ICSI Preventive Services work group.
Grade of Recommendation and Level of Certainty as Evaluated by USPSTF
  1. “Clinicians screen for HIV infection in adolescents and adults ages 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened.”
  2. “Clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown.”
(USPSTF Last Revised 2013)
Grade of Recommendation:
  1. A
  2. A

Level of Certainty:

  1. High
  2. High
“Benefits:
The USPSTF found convincing evidence that identification and treatment of HIV infection is associated with a markedly reduced risk for progression to AIDS, AIDS-related events and death in individuals with immunologically advanced disease (defined as a CD4 count < 0.200 × 10 cells/L). Adequate evidence shows that initiating combined antiretroviral therapy (ART) earlier (that is, at CD4 counts between 0.200 and 0.500 × 10 cells/L) – when individuals are more likely to be asymptomatic and detected by screening rather than clinical presentation – is also associated with reduced risk for AIDS-related events or death. The USPSTF found convincing evidence that the use of ART is associated with a substantially decreased risk for transmission from HIV-positive persons to uninfected heterosexual partners. Convincing evidence also shows that identification and treatment of HIV-positive pregnant women dramatically reduces rates of mother-to-child transmission. The overall benefits of screening for HIV infection in adolescents, adults and pregnant women are substantial.
Harms:
The USPSTF found convincing evidence that individual antiretroviral drugs, drug classes and combinations are all associated with short-term adverse events; however, many of these events are transient or self-limited, and effective alternatives can often be found. Although the long-term use of certain antiretroviral drugs may be associated with increased risk for cardiovascular and other adverse events, the magnitude of risk seems to be small. The overall harms of screening for and treatment of HIV infection in adolescents, adults and pregnant women are small.
Benefit-Harms Assessment:
The USPSTF concludes with high certainty that the net benefit of screening for HIV infection in adolescents, adults and pregnant women is substantial.
Assessment of Risk:
According to estimates from the Centers for Disease Control and Prevention (CDC), men who have sex with men account for about 60% of HIV-positive persons in the United States. Among men living with HIV infection who were diagnosed at age 13 years or older, 68% of infections are attributed to male-to-male sexual contact, 8% are attributed to male-to-male sexual contact and injection drug use, and 11% are attributed to heterosexual contact. Among women living with HIV infection, 74% of infections are attributed to heterosexual contact and the remainder to injection drug use. According to the CDC, heterosexual contact accounted for an estimated 25% of new HIV infections in 2010 and 27% of existing infections in 2009.
On the basis of HIV prevalence data, the USPSTF considers men who have sex with men and active injection drug users to be at very high risk for new HIV infection. Behavioral risk factors for HIV infection include having unprotected vaginal or anal intercourse; having sexual partners who are HIV-infected, bisexual or injection drug users; or exchanging sex for drugs or money. Other persons at high risk include those who have acquired or request testing for other sexually transmitted infections (STIs). Patients may request HIV testing in the absence of reported risk factors. Individuals not at increased risk for HIV infection include persons who are not sexually active, those who are sexually active in exclusive monogamous relationships with uninfected partners, and those who do not fall into any of the aforementioned categories. The USPSTF recognizes that these categories are not mutually exclusive, the degree of sexual risk is on a continuum, and individuals may not be aware of their sexual partners' risk factors for HIV infection. For patients younger than 15 years and older than 65 years, it would be reasonable for clinicians to consider HIV risk factors among individual patients, especially those with new sexual partners. However, clinicians should bear in mind that adolescent and adult patients may be reluctant to disclose having HIV risk factors, even when asked.
Screening Intervals:
The evidence is insufficient to determine optimum time intervals for HIV screening. One reasonable approach would be one-time screening of adolescent and adult patients to identify persons who are already HIV-positive, with repeated screening of those who are known to be at risk for HIV infection, those who are actively engages in risky behaviors, and those who live or receive medical care in a high-prevalence setting. According to the CDC, a high-prevalence setting is a geographic location or community with an HIV seroprevalence of at least 1%. These settings include sexually transmitted disease (STD) clinics, correctional facilities, homeless shelters, tuberculosis clinics, clinics serving men who have sex with men, and adolescent health clinics with a high prevalence of STDs. Patient populations that would more likely benefit from more frequent testing include those who are known to be at higher risk for HIV infection, those who are actively engages in risky behaviors, and those who live in a high-prevalence setting. Given the paucity of available evidence for specific screening intervals, a reasonable approach may be to rescreen groups at very high risk for new HIV infection at least annually and individuals at increased risk at somewhat longer intervals (for example, three to five years). Routine rescreening may not be necessary for individuals who have not been at increased risk since they were found to be HIV-negative. Women screened during a previous pregnancy should be rescreened in subsequent pregnancies.”
Relevant Resources:
http://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm
Implementation Tools and Strategies:
Screening for Human Immunodeficiency Virus (HIV)