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Press Start: Lead an Empowered Life as a Clinical Laboratorian

Universal HIV Screening

Published June 16, 2008 10:52 AM by Glen McDaniel
In September 2006, the CDC issued new guidelines recommending a wider screening of the general public for HIV.

This aggressive guideline resulted from the finding that of new HIV diagnosis, almost a half (over 40 percent)  went on to develop AIDS in about a year after diagnosis. This suggests the initial diagnosis was made late--maybe as late as 10 years after infection. The CDC still recommends screening in high risk patients, but also suggested healthcare providers screen all patients in the age group 13-64. Those considered high risk or who engage in one episode of risky behavior should be screened annually.

While well-meaning, universal screening means that many smaller sites would have to provide the personnel, equipment to perform testing, arrange for confirmatory testing and to be prepared for test interpretation and patient counseling. I am not sure many sites such as rural sites or smaller physicians' offices are ready to do even rapid testing.

Widescale testing is bound to yield a higher level of false positives than would be seen when testing a high-risk population. I am not sure how many providers are prepared to understand and explain that nuance. Imagine the trauma of telling a young mother incorrectly after a single rapid test that she has HIV?

It's been almost 2 years since the CDC guideline was published. Have you noticed increased testing in your lab from outpatients, ED patients for example? What are the pros and cons of this CDC recommendation?

3 comments

Recent reports from the CDC indicates that the incidence of HIV is significantly higher than previously thought.

http://www.cnn.com/2008/HEALTH/conditions/08/02/hiv.cdc/index.html

These alarming new statistics point up the need for continued education, early testing, counselling and initiation of treatment as early as possible.

I still feel very strongly, however, that the implications of being HIV positive are so significant that we must do everything to reduce the incidence and attendant risks of false positives (or false negatives). These incorrect results are much more likley to occur in sites where testing is performed by untrained, ill-prepared individuals.

Glen McDaniel August 4, 2008 11:43 AM
Atlanta GA

HIV is certainly a very serious illness with implications for the individual, family members and society as a whole. The diagnosis of HIV brings financial, physical and psychological burdens. It is still an incurable disease with a stigma attached. There are certainly much improved treatment options currently available making early diagnosis even more important.

The point is that HIV has such huge psychological and life changing ramifications that testing and diagnosis should not be left in the hands of inadequately prepared personnel. Widescale testing suggests that testing should be available almost wherever patients might present. In many cases the individuals doing the testing would be untrained -or minimally trained.

Data from CMS indicates that in many cases nonlaboratorians are not cognizant of the need for proper storage of reagents, conducting QC or following directions exactly as stated.

http://www.medscape.com/viewarticle/525098_3

In many physicians' offices testing is done by nurses, medical assistants, receptions or even volunteer lay persons. These should not be the persons entrusted with performing a test with such significance as HIV.

There is also the issue of counselling. Those who perform HIV testing should ideally have a resource for appropriate patient counselling. My point in the original post is that this might not be the case in many areas.

The case of false positives is just a statistical reality. Whenever a low risk population is screened for anything, the probability of false positives increases. Again, this is not a reason NOT to screen, it's simply another warning that the testers should be competent and individuals who understand the process should be available for putting the results in context and providing sound, valid answers.

We all, hopefully, agree on the need for early testing and appropriate intervention. I was simply raising a cautionary note about the possible ramifications of incompetent testing and inappropriate or inaccurate counselling.

Glen McDaniel June 26, 2008 7:20 PM
Atlanta GA

Are you implying that VDRL shouldn't be tested for either?  There is an increase of syphillis cases also.

This is linked to sexual exposure.

HIV is a treatable disease, is it not?  If diagnosed at a time when intervention by drug therapy, and if needed behavioral counseling, then the patient may live many years.  HIV could be transmitted still by non sexual contact.  Wouldn't a young mother want to know so that her children would be treated.  Get with it, we need to get out of the Victorian age.

M June 19, 2008 9:58 AM

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