Routine HIV Testing, Public Health, and the USPSTF — An End to the Debate (New Eng Jour Med)

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Routine HIV Testing, Public Health, and the USPSTF — An End to the Debate

Ronald Bayer, Ph.D., and Gerald M. Oppenheimer, Ph.D., M.P.H.

The U.S. Preventive Services Task Force (USPSTF) is poised to release recommendations on screening for human immunodeficiency virus (HIV) infection that will endorse the routine testing of adults and adolescents, a position first adopted by the Centers for Disease Control and Prevention (CDC) in 2006. Based on an exacting systematic examination of the new evidence on clinical and public health benefits of early identification of HIV infection that has emerged since 2005, when the initial USPSTF review led to rejection of routine screening, the new recommendations will be a critical guide to clinical practice. They will also carry important policy implications, since the Affordable Care Act (ACA) mandates that all public and private health plans provide coverage for USPSTF-recommended preventive services without patient copayments.

In recent years, USPSTF decisions have sometimes attracted widespread attention, stirring sharp controversy when the task force has challenged well-established clinical practices after determining that there was insufficient evidence of benefit. Most notably, such a controversy occurred in 2009, when the USPSTF recommended against annual mammographic screening for women 40 to 50 years of age. More recently, a recommendation against routine prostate-cancer screening provoked acrimony and denunciations from urologic societies and the National Medical Association.

In the case of HIV screening, the anticipated recommendations, rather than challenging prevailing consensus, will offer what many believe is a long-overdue acknowledgment of the evidence as interpreted by the CDC, the American College of Physicians, the Infectious Diseases Society of America, and the American Congress of Obstetricians and Gynecologists.

Approximately 56,000 people in the United States become infected with HIV each year. Many will not be identified for years. It is widely accepted that 20 to 25% of the estimated 1.1 million Americans living with HIV are unaware of their status. They consequently lose a critical opportunity to initiate antiretroviral therapy (ART) early, and they pose a public health hazard as sources of ongoing transmission. That gap and its consequences have haunted public health discussions of HIV testing for years, raising fundamental questions. Were the exacting consent procedures for HIV testing too burdensome? Were demands for pretest counseling incompatible with the routinization of screening?

http://www.nejm.org/doi/full/10.1056/NEJMp1214535?query=TOC