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May 13, 2003 — The Centers for Disease Control and Prevention (CDC) have recommended that HIV testing become a routine part of medical care, especially for pregnant women. The recommendations to state health departments, which are not legally binding, form part of a new strategy aimed at preventing HIV transmission by people who do not know they are infected. The strategy places HIV on a par with other health problems — such as high cholesterol — for which people are screened once they are suspected to be at risk.
The strategy has four main components:
1. Routinely offering HIV tests as part of medical appointments in high HIV-prevalence locations, or when personal background makes it likely patients are at high risk;
2. Making 20-minute rapid HIV tests available in non-medical settings such as prisons and homeless shelters;
3. Tracing the partners of those found to be HIV-infected and offering them testing and training in prevention; and
4. Making HIV one of the conditions for which pregnant women are checked, unless they specifically refuse to be tested, and encouraging testing of all newborn children.
Stable HIV-associated morbidity and mortality, concerns about possible increases in HIV incidence, and the recent availability of a simple, rapid HIV test combined with strong prevention collaborations among communities heavily affected by HIV support the need to reassess and refocus some of CDC's HIV-prevention activities. An emphasis on greater access to testing and on providing prevention and care services for persons infected with HIV can reduce new infections and lead to reductions in HIV-associated morbidity and mortality (2,8). In addition, simplifying prenatal and other testing procedures can lead to more effective use of resources that CDC provides to prevent perinatal and other HIV transmission.
The initiative consists of four key strategies:
· Make HIV testing a routine part of medical care. CDC will work with professional medical associations and other partners to ensure that all health-care providers include HIV testing, when indicated, as part of routine medical care on the same voluntary basis as other diagnostic and screening tests. Previously, CDC has recommended that patients be offered HIV testing in high HIV-prevalence acute care hospitals and in clinical settings serving populations at increased risk (e.g., clinics that treat persons with STDs). This initiative adds to those recommendations to include offering HIV testing to all patients in all high HIV-prevalence clinical settings and to those with risks for HIV in low HIV-prevalence clinical settings. Because prevention counseling, although recommended for all persons at risk for HIV, should not be a barrier to testing, CDC will promote adoption of simplified HIV-testing procedures in medical settings that do not require prevention counseling before testing. In 2003, CDC will support state and local health departments in conducting demonstration projects offering HIV testing to all patients in high HIV-prevalence health-care settings and referral into care, treatment, and prevention services, and will assess the outcomes of these projects.
· Implement new models for diagnosing HIV infections outside medical settings. In 2003, CDC will fund new demonstration projects using OraQuick® to increase access to early diagnosis and referral for treatment and prevention services in high-HIV prevalence settings, including correctional facilities. In addition, CBOs will pilot new models, particularly in nonmedical settings, for diagnosis and referring persons for treatment and prevention services. Also, because 8%--39% of partners tested in studies of partner counseling and referral services (PCRS) were found to have previously undiagnosed HIV infection (11), CDC will increase emphasis on PCRS. In 2004, CDC will implement these new models through health departments and CBOs.
· Prevent new infections by working with persons diagnosed with HIV and their partners. Although many persons with HIV modify their behavior to reduce their risk for transmitting HIV after learning they are infected, some persons might require ongoing prevention services to change their risk behavior or to maintain the change. In 2003, CDC, in collaboration with the Health Resources and Services Administration (HRSA), the National Institutes of Health, and the HIV Medical Association of the Infectious Diseases Society of America, will publish Recommendations for Incorporating HIV Prevention into the Medical Care of Persons with HIV Infection. CDC will work with professional associations to disseminate the new guidelines to primary care providers and infectious disease specialists and to assess their integration into medical practice. CDC will work closely with HRSA and other partners to reach persons in whom HIV infection has been diagnosed but who are not in ongoing medical or preventive care. CDC also will conduct demonstration projects through state and local health departments to provide prevention case management for persons living with HIV to reduce HIV transmission. Finally, CDC will increase emphasis on partner notification and also will support new models of partner notification, including offering rapid HIV testing to partners and using peers to conduct partner prevention counseling and referral. In 2004, acting through health departments and CBOs, CDC will implement these prevention services for persons living with HIV. CDC also will require grantees to employ standardized procedures for prevention interventions and evaluation activities.
· Further decrease perinatal HIV transmission. CDC will promote recommendations for routine HIV testing of all pregnant women, and, as a safety net, for the routine screening of any infant whose mother was not screened. CDC will work with prevention partners, including the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Nurse-Midwives, to disseminate the recommendations and support their implementation. CDC also will develop guidance for using rapid tests during labor and delivery, or post partum if the mother was not screened prenatally, and provide training for health departments and providers in conducting prenatal testing. In 2003, CDC will expand its activities to monitor the integration of routine prenatal testing into medical practice.
Reporting of HIV infections to public health authorities is now required in 49 states. In 2002, CDC initiated a pilot system to monitor HIV incidence. To track the impact of the new initiative, beginning in 2003, CDC is expanding this surveillance system by implementing a national behavioral surveillance system. In addition, CDC will monitor the implementation of these new activities through several systems, including new performance indicators for state and local health departments and CBOs.
Stable HIV morbidity and mortality, increased numbers of syphilis and HIV cases, and growing concern about increasing HIV incidence in some communities require new strategies to control the spread of HIV in the United States. Through Advancing HIV Prevention: New Strategies for a Changing Epidemic, every HIV-infected person should have the opportunity to be tested and have access to state-of-the-art medical care and to the prevention services needed to prevent HIV transmission.