United States

2006 guidelines from the Centers for Disease Control and Prevention¹ urge all people aged 13 to 64 to undergo HIV antibody testing as a routine medical screening test. Everyone should be tested at least once, and people at high risk of HIV infection should take an HIV test at least once every year.

The change in stance on testing had been under discussion for several years, and was broadly supported by doctors, HIV advocacy groups and public health officials as a way of reducing the number of people diagnosed late in the course of HIV disease, when treatment may be less effective.

Proponents of the policy highlight that there has been limited progress in preventing sexual HIV transmission, while when routine testing has been applied (blood donations, antenatal screening) the approach has been effective in limiting further HIV transmission. The CDC approach places the emphasis on public health and departs from years of a testing strategy based on civil rights, driven by informed consent and pre- and post-test individual counselling. The CDC also argues that routine testing reduces stigma associated with testing that requires assessment of risk behaviour.

In order to make testing more straightforward, pre-test counselling is kept to a minimum, and instead of signing a separate consent form for the HIV antibody test, patients are considered to have given consent when they sign a standard medical consent form covering all routine procedures. CDC says that patients should be specifically informed that HIV testing is part of routine care and have the opportunity to decline testing. Before making this decision, patients should be provided with basic information about HIV and the meanings of positive and negative test results, and should have the opportunity to ask questions.

However, prevention counselling should be offered when feasible, “especially when the healthcare visit is related to substance abuse, sexual health, family planning, or comprehensive health assessments.”

Patients at high risk of HIV infection, who will be encouraged to test at least once a year, are defined as all heterosexuals and men who have sex with men, who have had more than one sexual partner since their last HIV antibody test, or whose sexual partners have had more than one sexual partner since their last test. Injecting drug users and their partners, persons who exchange sex for money or drugs, and sexual partners of HIV-positive people are also included in this category.

Healthcare providers should encourage patients and their prospective sexual partners to be tested before initiating a new sexual relationship, the guidelines state.

The guidelines also emphasise the need for increased vigilance during pregnancy, with the recommendation that repeat HIV testing should be provided in the third trimester not only for women at high risk for HIV, but also for women in areas with high HIV prevalence among women of childbearing age or in facilities with at least one HIV diagnosis per 1000 pregnant women screened. They also specify that a rapid HIV test should be used during labour for all women whose HIV status remains unknown at the time of delivery.

The CDC’s recommendations have not been universally implemented. For example, a 2009 survey found that only 22% of emergency departments had any kind of systematic testing programme.²

One barrier to the implementation of routine testing has been that a number of US states have had laws which require pre-test counselling, disclosure of information and patient informed consent. However in recent years, 24 states have changed such laws and now only Massachusetts, Nebraska, New York, Pennsylvania and Rhode Island have laws which conflict in some respect with the CDC’s recommendations.³

1987: HIV testing recommended for people at risk and people seeking STI treatment.

1989: Pre- and post-test counselling recommended.

1993: Routine HIV testing recommended in hospital settings with an HIV prevalence above 1%.

1994: Counselling focussing on risk behaviours and prevention goals recommended.

1995: Antenatal screening recommended.

1998: Rapid testing recommended for high-risk groups.

2001: Routine HIV testing where HIV prevalence is above 1%, and targeted risk behaviour testing in lower prevalence settings. Also, simplification of consent and counselling requirements in antenatal services.

2003: New recommendations for more routine testing, including counselling not always being necessary. Rapid testing to be used in outreach projects.

2006: Routine testing, as described above.⁴