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November 22nd, 2012

The U.S. Preventive Services Task Force Recommends HIV Screening — And Why is This News?

A flurry of coverage recently appeared about the U.S. Preventive Services Task Force’s recommendation for one-time HIV screening for all Americans, ages 15-64.

Some might wonder why this is news — um, hasn’t this been recommended now for years? — and I think I’ve figured it out.

Let me start by relaying that every ID/HIV specialists can tell some version of the following sad story, which is still repeated on a regular basis (including just the other day, in our very own hospital):

  • Person sees several clinicians over months-years for various medical issues (some combination of fatigue, swollen glands, anemia, thrombocytopenia, skin rashes — especially zoster).
  • Many tests (blood tests, X-rays, sometimes even biopsies) are done, but because the person is not identified as being “at risk”, no HIV test is sent; or, ironically, he/she is “known” to be HIV negative based on a test done several years ago.
  • Person eventually shows up in the hospital with some serious complication that all but screams “AIDS” — PCP, toxoplasmosis, cryptococcal meningitis, or even worse, PML or lymphoma — and the HIV test is finally done, of course returning positive.

Because the above sequence of events is all but 100% preventable with early identification of HIV — and because people who are unaware they are infected continue to spread the virus —  in 2006 (yes, it was that long ago) the CDC made a big splash by recommending one-time HIV screening for adolescent and adult patients in all health care settings.

(They also said that high risk patients should be screened annually — unfortunately this is all too rarely done, but that’s an issue for a different day.)

To say that the ID/HIV provider community (docs, nurses, PAs, social workers) supported the CDC recommendations is like saying dermatologists support wearing sunscreen and a hat in the tropical sun.

“Support” just isn’t strong enough — we were strongly, unanimously, and vociferously behind them, so much so that virtually every lecture on HIV for the next several years mentioned the guidelines. To us, this was a total no-brainer — how could anyone oppose screening?

Indeed, the American College of Physicians, the American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics all came out with guidelines that said pretty much the same thing.

But not everyone did agree — namely, on the books already were guidelines from the U.S. Preventive Services Task Force, who had come out with their recommendation in 2005 for risk-based testing only.

For the unaware, the USPSTF is “an independent group of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, or preventive medications.”

I picture these USPSTF folks with hats, T-shirts, and coffee mugs emblazoned with “Evidenced-Based Only, Please.” Nothing speaks more clearly about their mission than these slide presentations entitled “Too Much Prevention” and “What Not to Do in Primary Care“. In plain English, the presenters make the excellent case that many well-intentioned screening strategies don’t help patients — and actually hurt them by uncovering clinically silent conditions that lead inexorably to procedures and medical treatments that are harmful and expensive.

Most cancer screening (infamously PSA) falls into this category. Cardiac CT. EKGs. Regular physical exams. Spirometry as a screen for COPD. Routine urinalysis. RPR. Hepatitis C testing (ahem).

And I generally agree with them. But HIV testing? That cheap, accurate test that identifies a clinically silent, eventually deadly infection that is both treatable and can be spread to others? Don’t they realize that the “risk based” testing they favored has been a failure?

Well now they do. In the plain language so characteristic of this committee, they write:

Previous studies have shown that HIV screening is accurate, targeted screening misses a substantial proportion of cases, and treatments are effective in patients with advanced immunodeficiency. New [well, "new" since 2005!] evidence indicates that ART reduces risk for AIDS-defining events and death in persons with less advanced immunodeficiency and reduces sexual transmission of HIV.

The bottom line is if this group recommends screening, it must be the right thing to do. Because these guys are tough.

Welcome to the club, USPSTF.

6 Responses to “The U.S. Preventive Services Task Force Recommends HIV Screening — And Why is This News?”

  1. Davif Finwall says:

    Being one of those “ID/HIV specialists can tell some version of the following sad story…” people that Dr Sax was speaking about, I can only hardily and angrily agree that all medical care providers should be testing for HIV as a routine check – for the health of the patient, reduction of still too pervasive stigma, and normalization of the disease itself.

  2. Stu says:

    Should have been doing it 25 yr ago.

  3. Stephen A Wilson says:

    Yes, we should screen, but how often? Once does not seem enough for some, but is one too many for people who are zero risk.

  4. Paul Sax says:

    Yes, we should screen, but how often? Once does not seem enough for some, but is one too many …

    Stephen, for the “high risk” folks, annually is a good place to start. I’ve heard epidemiologists say this would be the highest-yield way of finding those who are infected — more so than testing everyone. But since the test is so accurate and inexpensive, testing everyone (even those apparently low risk) once isn’t so crazy — plus it will further destigmatize the process.

    Paul

  5. don’t we worry about the huge number of false positives that will occur when we screen people with no overt risk factors?

  6. Paul Sax says:

    don’t we worry about the huge number of false positives that will occur when we screen people with no overt risk factors?

    The good news is that now we have three readily available ways of confirming HIV infection — the standard ELISA or rapid test (sensitive but not specific enough), the Western blot (very specific, extremely low false-positive rate), and the HIV viral load (not FDA approved for diagnosis, but often used in conjunction with the other two as yet another confirmatory test). Bottom line is that false positives are now extremely rare (less than 1 per 250,000), and usually easily sorted out with supplemental testing.
    Paul

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HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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