September 21, 2006 (AIDSmeds)—HIV antibody testing should be a regular part of the medical care of all adolescents, adults, and pregnant women, according to new federal guidelines published by the U.S. Centers for Disease Control (CDC). The new guidelines, released September 21st, highlight a number of important recommendations to increase awareness among those who are infected with the virus but do not yet know they are positive and, as a result, lacking the benefits of counseling and care.

The CDC estimates that, despite ongoing prevention efforts, the number of people being infected in the U.S. has lingered at 40,000 annually. Moreover, nearly 40% of HIV-positive people do not learn of their infection until they have AIDS or advanced HIV disease, meaning that they likely remained unaware of their HIV status – and were potentially exposing others to the virus – for several years. By increasing access to testing using rapid and highly sensitive assays, the CDC argues, counseling and care can be promptly provided to reduce the risk of transmission and to protect patients’ health before they progress to AIDS.

“We’re very happy that CDC is taking this important step,” said Daniel R. Kuritzkes, MD, Chair of the Infectious Disease Society of America’s HIV Medical Association (HIVMA). “We see far too many patients who were never tested for HIV before they became sick with AIDS. Routine testing will help identify more people with HIV who don’t know they are infected.”

One of the most significant revisions to the guidelines involves who should be tested. Past guidelines stressed counseling and testing people perceived to be at risk for HIV infection, notably men who have sex with men and intravenous drug users. The guidelines now recommend routine testing all U.S. residents between 13 and 64 years of age, regardless of their reported risks.

The new CDC guidelines also take steps to remove barriers to testing. Until now, testing for HIV has been treated differently than for any other disease, requiring a separate written consent form and extensive pre-test counseling. The new guidelines suggest that these steps are no longer required. The new guidelines also call for the testing of patients in all healthcare settings, including primary care doctors’ offices (e.g., during routine physical exams), public health clinics, emergency rooms, and prison hospitals.

While the guidelines no longer require written consent by the patient before testing, the CDC strongly emphasizes that HIV testing be voluntary and undertaken only with the patient’s knowledge. The guidelines advise that patients be informed that HIV testing is now part of routine care and that they 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.

“Patients go to their doctors expecting to be screened for heart disease, cancer, sexually transmitted diseases, or other conditions,” said Michael Saag, MD, of the University of Alabama. “But no one signs a form to get a prostate exam. We need to make sure that patients are informed about the HIV test, but we should not put obstacles in the way of testing.”

While recommendations to increase HIV testing are being heralded as a vital public health strategy, there are also concerns that the U.S. healthcare system is already overburdened and not readily prepared to deal with an increased number of people diagnosed with HIV in need of treatment and expert medical care. “The programs they rely on to provide them with care are already bursting at the seams,” Dr. Saag said. “Providers are overworked and burning out. Funding is too short to hire more staff, even as the caseload keeps increasing all the time. We’re on the brink of a crisis in HIV care in this country.”

Increased testing is the right thing to do, Dr. Kuritzkes added. “But Congress absolutely must back up increased testing with funding to match.” Overburdened HIV-care providers, people living with HIV, and advocates need to make this a priority issue, he said. “Tell Congress to reauthorize and adequately fund the Ryan White CARE Act and expand access to Medicaid to ensure that those who are newly identified with HIV receive the care and services they need.”