Institute of Medicine Issues Guidelines on Expanded HIV Screening and Access to Care

The Institute of Medicine (IOM) Committee on HIV Screening and Access to Care has issued guidelines concerning HIV testing and access to treatment. Information in their report, which was released September 16, should be useful to policymakers at all levels who hope to facilitate expanded HIV testing and screening as a critical component of the nation’s response to HIV/AIDS.

“The White House Office of National AIDS Policy (ONAP) is tasked with coordinating government efforts to reduce the number of HIV infections in the United States,” Committee Chair Paul D. Cleary, PhD, dean of public health at the Yale School of Public Health, Yale School of Medicine, in New Haven, Connecticut, told Medscape Medical News. “These efforts have included the development of a National HIV/AIDS Strategy, released July 13, 2010, the primary objectives of which are to (1) reduce HIV incidence, (2) increase access to care and optimize health outcomes for people living with HIV, and (3) reduce HIV-related health disparities. To supplement other efforts to inform the development and implementation of the [National HIV/AIDS Strategy], in the fall of 2009 ONAP commissioned an IOM committee to evaluate barriers to implementation of an expanded HIV testing and treatment program.”

Despite the increasing prevalence and public health burden of HIV in the United States, with about 56,300 new infections annually, approximately one fifth of the 1.1 million US residents with HIV/AIDS are unaware that they are infected. Knowledge of HIV serostatus is critical for timely medical intervention, reduction of HIV transmission, and achieving better clinical outcomes.

“Identification of the approximately 20% of individuals in the United States who are unaware that they have HIV infection will provide them immediate benefit, since they could potentially take advantage of life-saving treatment,” Paul E. Sax, MD, clinical director, Division of Infectious Diseases and HIV Program at Brigham and Women’s Hospital, and associate professor of medicine at Harvard Medical School, Boston, Massachusetts, told Medscape Medical News when asked for independent comment. “Furthermore, research shows that once a person finds out he or she is HIV-infected, they diminish high risk behaviors that could spread the virus to others.”

Targeting the aforementioned goals, ONAP commissioned the 15-member Committee on HIV Screening and Access to Care to develop 3 reports on the delivery of HIV screening and care, the first of which is entitled HIV Screening and Access to Care: Exploring Barriers and Facilitators to Expanded HIV Testing.

“[This report] focuses on the first part of the committee’s task: the extent to which federal and state laws and policies, private health insurance policies, and other factors pose a barrier to expanded HIV testing,” Dr. Cleary said. “It is based on a review of available research literature and a public workshop during April 15 to 16, 2010, in Washington, DC, to explore the extent to which federal, state, and private health insurance policies pose a barrier to expanded HIV testing.”

Conflicting Policies Regarding HIV Screening

John G. Bartlett, MD, professor of medicine and director of the Johns Hopkins HIV Care Program at Johns Hopkins University School of Medicine in Baltimore Maryland, told Medscape Medical News that in 2006, the US Centers for Disease Control and Prevention (CDC) recommended universal HIV testing for everyone aged 13 to 64 years. However, in 2007, the US Preventive Services Task Force (USPSTF) recommended only risk-based HIV testing.

“The CDC changed the recommendations because risk-based testing didn’t work,” Dr. Bartlett said. “This is important — it means that 2 parts of the government are in conflict over this issue, and the USPSTF recommendations carry a lot of weight. Remember, the Obama health plan requires funding support for the recommendations of the USPSTF.”

Since the CDC issued their revised guidelines on HIV testing in 2006 to recommend widespread screening, most of the states have modified their HIV testing laws to align them more with these recommendations. Furthermore, several professional societies have lent their support to these changes, including the American College of Physicians, the World Health Organization, and UNAIDS.

“However, the USPSTF continues to recommend targeted testing for those perceived to be at risk, rather than widespread screening, and some people believe that the counseling component of HIV testing is critical,” Dr. Sax said.

Barriers to Expanded HIV Screening

“An additional concern is that if we identify a greater number of people with HIV, how will we link them to and pay for their care in a time when resources are constrained?” Dr. Sax noted. “I consider this last point somewhat tangential to the issue of whether we should expand HIV testing — after all, one rarely hears this as an argument against screening for conditions such as diabetes, hypertension, or colon cancer in underserved populations, and HIV already has a remarkably successful national program for treatment already in place.”

Specific barriers to HIV testing identified by the committee included state legal requirements for HIV testing, discordant federal HIV testing recommendations, public and private health insurance policies, policies inhibiting use of rapid HIV tests, and policies and practices in corrections settings.

“In my opinion, the biggest barrier [to the use of expanded HIV testing] is the perception by both the public and the medical community that HIV is somehow different from other infectious diseases, or different from other conditions for which screening strategies have been well established — in other words, that testing for HIV remains an example of ‘HIV exceptionalism,’ ” Dr. Sax said. “This is understandably a holdover from the 1980s, when HIV was both highly stigmatized and untreatable. While some stigma surrounding the disease persists, it has dramatically diminished, and of course the treatment of HIV has been one of the great success stories in medicine over the past 20 years.”

The committee also recognized that more programs and policies are needed to improve clinician education and training, to release constraints on practice settings, and to reduce stigma and discrimination associated with HIV-positive serostatus, which may impede expanded HIV testing.

“Studies have already shown that in areas where HIV screening is broadly adapted, a greater number of people find out their status, and for those who are HIV-positive, the CD4 cell count at the time of diagnosis is higher — clearly a net benefit for personal and public health,” Dr. Sax said. “This has been most starkly demonstrated in the Washington, DC, area, which has a very high HIV prevalence. Ongoing research in lower-prevalence settings will also be important, as the rate of false-positive results will invariably be higher. Thus far, I am not aware of any studies demonstrating harm arising from an expanded HIV testing strategy, but conceivably this could arise due to issues of cost or poor provider–patient communication.”

Recommendations to Increase HIV Testing

“The committee identified several strategies to increase HIV testing and identification of HIV-infected individuals as well,” Dr. Cleary said. “The research reviewed by the committee indicates that opt-out HIV testing, where an individual is told that testing will be performed unless he or she declines, may facilitate HIV testing, although there is still debate about the ethics of opt-out HIV testing.”

Other recommendations proposed by Dr. Bartlett include having Medicare use the CDC guideline for HIV testing as a performance indicator and having the joint commission make HIV testing policy a part of their review process.

“Either of these would change testing policy immediately because hospital practice changes immediately based on requirements of these 2 groups,” Dr. Bartlett said. “Also note that this type of testing, when diagnostic tests and treatment became available, is what worked to decrease syphilis rates by 95%.”

Finally, Dr. Bartlett suggested that another strategy to expand rates of HIV screening would be to obtain funding for this testing in emergency departments that have high rates of HIV.

“HIV physicians know this is very important for both life-saving treatment and prevention,” Dr. Bartlett concluded. “The problem is that it is not generally well-known to primary care providers, and they are the ones who need to do the testing. Many are living by the pre-[highly active antiretroviral therapy] concepts, when we needed to get signed consent.”

In their closing remarks, the IOM committee reiterated that expanded HIV testing would help lower the number of HIV-infected individuals in the United States who are unaware of their status, thereby promoting earlier intervention, better outcomes, and lower rates of HIV transmission.

“The committee did not specifically assess the need for, or priorities of, research in different areas,” Dr. Cleary said. “Committee members were struck, however, about the lack of research on many of the critical implementation issues raised.”

Barriers to expanded HIV testing include specific laws, policies, and procedures in settings where HIV tests are administered, and the lack of programs and policies to support clinician education and training on HIV testing and to reduce HIV-related stigma and discrimination.

“There are evidence-based approaches to facilitate HIV testing that may be considered as part of an expanded HIV testing strategy,” the committee concluded. “Before implementation of a program of expanded HIV testing, consideration should be given to whether individuals who are diagnosed as HIV-positive can be provided timely access to care. Federal and state policies and private health insurance policies/practices that inhibit entry into clinical care or the provision of continuous and sustained clinical care for individuals with HIV will be explored in the committee’s second report.”

The IOM report was supported by the National Academy of Sciences and the White House Office of National AIDS Policy. Dr. Cleary has disclosed no relevant financial relationships.

HIV Screening and Access to Care: Exploring Barriers and Facilitators to Expanded HIV Testing. Published online September 16, 2010.