According to the Centers for Disease Control and Prevention (CDC), one in five human immunodeficiency virus (HIV)-infected individuals are currently living without knowledge of their diagnosis.1 In 2006, the cost of a rapid HIV test with pre/post-test HIV counseling was anywhere between 48-64 US dollars (USD). The majority of the cost incurred was for HIV counseling, with the cost of the rapid HIV test being between 8-25 USD.2 Research looking at the cost-effectiveness of HIV screening shows that it is more cost-effective than routine screening for breast cancer with mammography yearly or even routine screening for diabetes mellitus with a one-time fasting blood glucose.3 With the cost of testing reasonably low and prevalence of undiagnosed infection high, why are our rates of HIV screening not maximized?
The following is an example of a patient who would have benefitted from HIV screening as per national guidelines. Ms. C is a 48-year-old female who presented at her gynecologist’s office for a routine examination and PAP smear. The patient had never been offered HIV screening in the past. She had a positive HIV test at that visit and was sent to the Infectious Disease clinic for follow-up care. Ms. C denied any active symptoms. Her past medical and surgical history included syphilis, treated with a short course of penicillin G, lower back pain, depression, hypothyroidism, gastroesophageal reflux disease (GERD), asthma, tubal ligation, and lipomectomy. She has had multiple Emergency Department (ED) visits in the last three years for various unrelated complaints. Yearly mammograms had been performed for health maintenance and were all within normal limits. She denied history of tuberculosis, pneumonia, or other opportunistic infections. Her social history was positive for a history of non-intravenous drug use in the past and tobacco abuse. She had no recent travel and no current HIV risks or exposures. She has been married for twenty years and stated that she was sexually active and monogamous with her husband. Her vital signs were within normal limits, and there were no abnormalities noted on physical exam.
Based on national guidelines, her positive HIV enzyme immunoassay (EIA) screen was followed by a confirmatory HIV Western Blot.4 Her baseline HIV viral load was 1090 copies/mL, and her CD4 count was 230 cells/μL. Although this patient had been treated in the ED numerous times, she remained compliant with health maintenance and had surgical procedures. However, she had never been screened for HIV. Screening for HIV at any of these points in time may have led to earlier diagnosis and treatment.
Broad screening is important, as earlier treatment of HIV has been studied compared to deferred treatment and has been shown to increase survival.5 A study compared the risk of death in patients who were started on anti-retrovirals at a higher vs. lower CD4 counts. Those started with the higher CD4 count had improved outcomes with a reduction in number of deaths. Studies have also shown that the risk of transmission of HIV is directly related to viral load, which can be treated if addressed sooner.6 The patients who are generally screened are "high risk" patients, such as people who engage in sex without protection, sharing of drug-use equipment, occupational hazards, men who have sex with men, and youths.7
This paper will review the current HIV screening guidelines from multiple national organizations (Table 1), which emphasize the importance of screening those individuals who are not necessarily "high risk".
Ganesh, MD, Anusha
"HIV Screening: A Review of Nationally Recommended Guidelines and Specific Instances in which HIV Screening is Often Overlooked,"
The Medicine Forum: Vol. 15
, Article 12.
Available at: http://jdc.jefferson.edu/tmf/vol15/iss1/12