HIV Screening Underutilized, Particularly in Physicians’ Offices

Universal HIV screening has been endorsed by the U.S. Centers for Disease Control and Prevention (CDC) and other groups, but has not been widely adopted by hospitals and outpatient health care providers. New data shows that the vast majority of young men seeking care in physicians’ offices are not screened. Experts are simultaneously exploring barriers to screening and possible mechanisms to routinize HIV testing and improve testing coverage.

In a clinical review and education piece published July 12 in the Journal of the American Medical Association (JAMA), infectious disease experts cite insurance barriers, difficulty in assessing risk factors, and provider uncertainty regarding best practices and/or national testing recommendations as possible explanations for why HIV screening is not routinely conducted. This confusion could be due to the fact that in 2006, the CDC recommended HIV testing of adults and adolescents, but a systematic literature review conducted as part of the 2013 U.S. Preventive Services Task Force HIV screening recommendations found inconclusive benefit of universal screening versus targeted screening. Additionally, no single universal screening strategy (opt in versus opt out; standard laboratory testing versus point-of-care testing) proved superior.

“Clinical and risk factor–based testing is inferior to routine testing for identifying infected patients unaware of their diagnosis,” writes co-author Moira McNulty, M.D., from University of Chicago, in JAMA. “Automatic testing with voluntary opting out is a strategy that should be more seriously considered. It is important to realize that the clinical and public health benefits of screening are achieved only by ensuring engagement in care at other points in the continuum of care cascade.”

Opportunity to Increase HIV Testing in Physicians’ Offices
Young men aged 15 to 39 years frequently visited physicians’ offices from 2009 to 2012, but HIV testing was only performed at one percent of those visits, according to a study published June 24 in Morbidity and Mortality Weekly Report (MWWR). Opportunities such as opt-out testing, standing laboratory orders for HIV testing, and electronic medical record reminders need to be explored to increase HIV testing coverage at visits to physicians’ offices, the CDC researchers say.

Young men (aged 20 to 29 years of age) accounted for the highest number of new HIV infection diagnoses in 2014, with even higher rates seen among young, male racial and ethnic minorities. To estimate the rates of health care visits among young men (aged 15 to 39 years) and the rates of HIV testing at these encounters, the CDC researchers analyzed data from the 2009–2012 National Ambulatory Medical Care Survey (NAMCS) and U.S. Census data.

The researchers found that overall, from 2009 to 2012, young males had an average of 1.35 visits to physicians’ offices each year, but only one percent of the visits included an HIV test. While black males (2.7 percent) and Hispanic males (1.4 percent) had higher testing rates among compared with white males (0.7 percent), minority males had fewer office visits overall (0.9 and 0.8 visits per person among black and Hispanic males, respectively, versus 1.6 visits per person for white males).

“CDC recommends repeat testing at least annually for persons at high risk for HIV infection, and although the optimal annual percentage of visits with an HIV test to achieve universal testing is unknown, these results indicate there are opportunities to improve HIV testing rates,” writes lead author D. Cal Ham, M.D., in MWWR. “A systems-level approach to increase HIV testing rates that does not rely on individual providers could use interventions to routinize HIV testing such as electronic medical records reminders, opt-out testing policies, provider education campaigns, and removal of barriers to HIV testing (i.e., special consent forms).”

In JAMA, McNulty similarly calls for identifying new research to inform future testing strategies, including determining the optimal screening interval, different testing methods (standard laboratory testing versus point-of-care testing), different processes for obtaining patient consent (opt in or opt out), and different strategies for test result notification and linkage to care for HIV-infected patients.

“There is little evidence to suggest that one universal screening strategy is superior to another,” McNulty writes. “While the cost-effectiveness and sustainability of disparate models is unknown, parallel programs with dedicated point-of-care testers and patient navigators are likely to be more costly than incorporating HIV testing and linkage to care into routine medical care.”

Takeaway: New strategies are needed to improve rates of HIV screening, particularly among young men and in physicians’ offices.