HIV Screening as an Example of the Continuum of Care

By Frances S. Margolin

HIV screening is inexpensive, noninvasive and critical for prevention and treatment.

Frances S. Margolin

In September 2006, the Centers for Disease Control and Prevention (CDC) issued new recommendations for screening adults for HIV. The bottom line is that CDC now recommends that everyone aged 13 through 64 be screened for HIV at least once, and that screening take place in all health care settings, including hospitals as well as physicians' offices and clinics. Furthermore, patients at high risk for HIV infection should be screened at least annually.

There is a clear rationale for this recommendation. While the annual number of cases of AIDS and related deaths has decreased, cases among African-Americans, other minority groups and people exposed through heterosexual contact continue to increase. CDC estimates that nearly a quarter of those with HIV in the United States are unaware of their infection. This has implications for HIV-infected individuals, and for everyone else. In fact, researchers believe that HIV-infected people who do not know their status are responsible for more than half of new HIV infections.

Why Screening is Necessary

First, individuals who do not know they are infected cannot be treated. The latest studies show that earlier treatment—in terms of the T-cell count at which antiretroviral therapy (ART) is begun—produces better results. Second, studies also show that once individuals know they are HIV-positive, they substantially reduce risky behavior, thus presumably lowering the risk of transmitting the virus to their partners.

Third, as the epidemic has spread beyond the first populations of AIDS patients, risk-based screening has become less effective. And fourth, data show that the prevalence of HIV in population groups is not related to the amount of risky behavior in those groups—that is, high-prevalence racial/ethnic groups have the same level of almost all risky behavior as groups with lower HIV prevalence.

Still, many HIV-infected people have had contact with the health care system but have not been tested for HIV. Even patients presenting at STD clinics are not always screened for HIV. There's no excuse for this failure to screen. As the CDC recommendations note, HIV infection is consistent with the criteria we use to justify medical screening. Providers can diagnose HIV before a patient has symptoms. Screening tests are reliable, inexpensive and noninvasive. Treatment can increase the years and quality of a patient's life.

In addition, screening costs are reasonable compared with the benefits that accrue from diagnosis. Even in populations that have a low prevalence of HIV, HIV screening is as cost-effective as screenings commonly conducted for conditions such as colon cancer and high blood pressure.

Perinatal Screening

There are several different venues in the hospital where HIV screening might be located, but the strongest case to make is in labor and delivery, and the nursery. Determining that a mother is HIV-positive during any stage of pregnancy—including labor—or immediately after birth provides the catalyst for prophylactic treatment.

The best chance of reducing mother-to-child transmission of the HIV virus comes when providers administer ARTs at each stage—pre-pregnancy, pregnancy, labor, neonate—and take other precautions against transmission. But the chances of the baby seroconverting are also reduced when ARTs are given only to the baby and breastfeeding is avoided. Perinatal HIV screening is strongly recommended because it can prevent the development of disease, and it is being adopted as policy in more and more U.S. hospitals.

HIV Screening in the ED

Hospital emergency departments (EDs) see patients who do not have a medical home for primary care, but few EDs do widespread risk-based testing. Some EDs provide referrals to confidential HIV testing sites, but this has not proved effective because too many patients do not follow up. When hospital EDs screen for HIV, they find patients who test positive—often at higher rates than found at HIV testing sites or STD clinics that serve high-risk populations. In addition, patients who receive rapid HIV tests in the ED before being admitted to the hospital have shorter lengths of stay and better entry into outpatient care.

Other Hospital Venues for Screening

Screening inpatients and screening in outpatient clinics provide opportunities for screening in hospital-based venues. A study published in May in the American Journal of Public Health suggests that people whose main contact with the health care system is through hospitalization may benefit from hospital services, such as brief case management, that help them link to follow-up care. Overall, the idea is that any adult who has contact with the health care system but does not have his or her HIV status documented in their personal health record should be screened.

As hospitals evaluate their role in the continuum of care, they should consider establishing programs of non-risk-based HIV screening. The imperative to identify HIV infection early and link patients to life-extending treatment is too great to ignore.

Frances Margolin, M.A., is director, education and fellowships, with the American Hospital Association Quality Center. She has been working with hospitals to help them institute HIV screening programs since 2003.

This article 1st appeared on August 24, 2009 in HHN Magazine online site.

To respond to this article, please click here.