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Guideline title

Screening for HIV: US Preventive Services Task Force Recommendation Statement

Guideline developer

US Preventive Services Task Force

Guideline year

2013

Year appraised

2013

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OVERVIEW

This guideline focuses on screening for HIV in adolescents, adults and pregnant women1.

At the end of 2009, the number of people with HIV in the United States who were aged 13 years and older was an estimated 1,148,2002, representing a prevalence of 0.45%. In Canada, the number of people with HIV (including AIDS) was an estimated 71,300 in 20113, representing a prevalence of 0.21%. Similarly, the incidence rate in the United States is nearly twice that of Canada (19.0 vs. 9.9 per 100,000 in 20094 5). Although the proportion of undiagnosed cases is higher in Canada than in the United States (25%3 vs. 18%6), over 50% of some populations in the United States are likely to be unaware of their HIV infection7.

The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen all adolescents and adults aged 15 to 65 years for HIV infection. Younger adolescents and older adults who are at increased risk should also be screened.

In addition, the USPSTF recommends that clinicians screen all pregnant women for HIV, including those presenting in labour who have not been tested and whose HIV status is unknown.

 

RELEVANCE TO CTFPHC MANDATE

All sections of this guideline are applicable to the CTFPHC mandate of prevention in primary care.

 

POPULATION

The target populations for screening are adolescents and adults aged 15 to 65 years, younger adolescents and older adults at increased risk for infection, and pregnant women.

 

EVIDENCE REVIEW METHODS

The USPSTF searched Ovid MEDLINE for the period 2004 to June 2012 and the Cochrane Library through the second quarter of 2012, and reviewed reference lists to identify relevant articles published in English. The search for evidence relevant to adults and adolescents resulted in a total of 10,297 abstracts; 876 full-text articles were reviewed for relevance, of which 25 were included in the evidence synthesis. The search for evidence relevant to pregnant women resulted in a total of 1,636 abstracts; 387 full-text articles were reviewed for relevance, of which 38 studies from 43 publications were included in the evidence synthesis.

 

GRADING SYSTEM

The USPSTF assigns 1 of 5 letter grades to each recommendation: A, B, C, D, or I8. These grades are based largely on the level of certainty and magnitude of the net benefit associated with providing the service.

 

METHODOLOGICAL QUALITY

The CTFPHC assessed the methodological quality of this guideline using the Appraisal of Guidelines Research & Evaluation (AGREE II) criteria (Table 1).

This guideline scored above 60% on the domains of Scope and Purpose, Rigour of Development, and Editorial Independence; therefore, the CTFPHC has classified it as a high-quality guideline. Concordance among reviewers, as measured through standard deviation (SD) of AGREE II scores, was high (SD < 1.5) for the majority of domains.

Table 1. AGREE II domain scores
AGREE II domain Domain score Standard deviation
Scope and purpose 93% 0.8
Stakeholder involvement 82% 1.7
Rigour of development 88% 0.8
Clarity of development 90% 0.8
Applicability 67% 1.5
Editorial independence 83% 1.1
Overall assessment 92% 1.0

COMMENTARY

The scope and purpose of this guideline are clearly outlined, with age-specific recommendations for adolescents and adults and no age limitations for pregnant women. All relevant professional groups were represented in the development process, and public opinion was sought before release. Further, the recommendations are specific, the methods used were rigorous, and there was no concern about editorial independence.

Although the indirect evidence presented in the USPSTF guideline is strong and logical (demonstrating that screening tests can detect HIV and that treatment of identified HIV will improve outcomes), there is no direct evidence on the effectiveness of screening on clinical outcomes.

In addition, the substantially higher prevalence of HIV in the United States relative to Canada makes this guideline of uncertain relevance to Canadian practice.

Canadian practitioners should consider testing those with clinical indicators of HIV or with factors that increase the risk for exposure to HIV infection, focusing on higher-prevalence groups such as men who have sex with men, people who inject drugs and people from HIV-endemic countries3. Although some Canadian jurisdictions9 10 have moved to recommend routine screening in certain settings (e.g., primary and/or emergency care) in response to their local HIV epidemiology, it is important to note that this practice is not yet supported by direct evidence.

In the opinion of the CTFPHC, primary care practitioners in Canada should continue to offer HIV counselling and testing to individuals who may be at increased risk for exposure to HIV, given the potential benefits of timely detection. Pregnant women should continue to be screened for HIV as per existing guidelines11.

 

ORIGINAL GUIDELINE RECOMMENDATIONS

The full guideline can be found at uspreventiveservicestaskforce.org.

  • Adolescents and adults aged 15 to 65 years, younger adolescents and older adults at increased risk for infection, and pregnant women: Screen for HIV infection. (Grade A)

REFERENCES

  1. Screening for HIV. U.S. Preventive Services Task Force recommendation statement. Rockville, Maryland: U.S. Preventive Services Task Force; 2013. Available at: http://www.uspreventiveservicestaskforce.org/uspstf13/hiv/hivfinalrs.htm. Accessed 2013 Jun 16.
  2. Centers for Disease Control and Prevention. Diagnoses of HIV infection and AIDS in the United States and dependent areas, 2011. HIV Surveill. Rep. Vol. 23. Available at: http://www.cdc.gov/hiv/library/reports/surveillance/2011/surveillance_report_vol_23.html. Accessed 2013 Jun 16.
  3. Summary: estimates of HIV prevalence and incidence in Canada, 2011. Ottawa, ON: Public Health Agency of Canada; 2012. Available at: http://www.phac-aspc.gc.ca/aids-sida/publication/survreport/estimat2011-eng.php. Accessed 2013 Jun 16.
  4. Prejean J, Song R, Hernandez A, Ziebell R, Green T, Walker F, et al.; HIV Incidence Surveillance Group. Estimated HIV incidence in the United States, 2006–2009. PLoS ONE. 2011;6(8):e17502.
  5. Yang Q, Boulos D, Yan P, Zhang F, Remis RS, Schanzer D, et al. Estimates of the number of prevalent and incident human immunodeficiency virus (HIV) infections in Canada, 2008. Can J Public Health. 2010;101(6):486–490.
  6. Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 U.S. dependent areas—2010. HIV Surveill Suppl Rep. 2012;17(3, Pt A). Available at: <http://www.cdc.gov/hiv/library/reports/surveillance/2010/surveillance_Report_vol_17_no_3. html>. Accessed 2013 Nov 12.
  7. Prevalence and awareness of HIV infection among men who have sex with men—21 cities, United States, 2008. MMWR Morb Mortal Wkly Rep. 2010;59(37):1201–1207. Available at: http://www.cdc.gov/mmwr/pdf/wk/mm5937.pdf. Accessed 2014 Feb 21.
  8. Grade definitions: grade definitions after July 2012. Rockville, Maryland: U.S. Preventive Services Task Force; 2012. Available at: http://www.uspreventiveservicestaskforce.org/uspstf/grades.htm. Accessed 2013 Nov 12.
  9. Stop HIV/AIDS. Vancouver, BC: British Columbia Centre for Excellence in HIV/AIDS. Available at: http://www.cfenet.ubc.ca/stop-hiv-aids/about. Accessed 2014 Feb 21.
  10. HIV testing in Saskatchewan. SK HIV Provincial Leadership Team; 2013. Available at: http://www.skhiv.ca/SK%20HIV%20Testing%20Policy%2Final%20Dec%202012%20(2).pdf. Accessed 2014 Feb 21.
  11. Human immunodeficiency virus HIV screening and testing guide. Ottawa, ON: Public Health Agency of Canada; 2013. Available at: http://www.phac-aspc.gc.ca/aids-sida/guide/hivstg-vihgdd-eng.php>. Accessed 2013 Nov 12.