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Screening for HIV: Systematic Review to Update the U.S. Preventive Services Task Force Recommendation
Evidence Syntheses, No. 95
Investigators: Roger Chou, MD, Shelley Selph, MD, MPH, Tracy Dana, MLS, Christina Bougatsos, MPH, Bernadette Zakher, MBBS, Ian Blazina, MPH, and P Todd Korthuis, MD, MPH.
Author Information and AffiliationsStructured Abstract
Background:
A 2005 U.S. Preventive Services Task Force (USPSTF) review found good evidence that HIV screening tests are accurate and that identification of undiagnosed HIV infection and treatment of immunologically advanced disease is associated with substantial clinical benefits. However, it found insufficient evidence to estimate effects of diagnosis and subsequent interventions on transmission risks, or to estimate clinical benefits of antiretroviral treatment in patients with less immunologically advanced disease.
Purpose:
To systematically update the 2005 USPSTF review on benefits and harms of screening for HIV infection in adolescents and adults, focusing on research gaps identified in the prior review.
Data Sources:
We searched the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through the second quarter of 2012) and Ovid MEDLINE (2004 through June 2012) and manually reviewed reference lists.
Study Selection:
We selected randomized trials and observational studies that compared different HIV screening strategies and reported clinical outcomes; the uptake, yield, or harms of screening; CD4 counts at diagnosis; or rates of linkage to care. We also selected randomized trials and observational studies that reported the effects of starting antiretroviral therapy (ART) at different CD4 count thresholds and long-term harms associated with ART, and randomized trials and observational studies that reported the effects of screening and subsequent interventions on risky behaviors and transmission risk.
Data Extraction:
One investigator abstracted data and a second investigator checked data abstraction for accuracy. Two investigators independently assessed study quality using methods developed by the USPSTF.
Data Synthesis (Results):
No study directly evaluated effects of screening for HIV infection versus no screening on clinical outcomes, or compared effects of repeat screening versus one-time screening. Evidence from studies comparing effects of different HIV screening strategies on the uptake or yield of screening, CD4 count at diagnosis, linkage to care, or harms associated with screening is too limited to draw reliable conclusions. New evidence provides strong evidence for effectiveness of earlier initiation of ART, including a subgroup analysis from a randomized trial that found initiation of ART at CD4 counts <0.250 × 109 cells/L associated with markedly increased risk of death or acquired immunodeficiency syndrome (AIDS) events compared with initiation at CD4 counts >0.350 × 109 cells/L after a mean of 18 months (hazard ratio, 5.3 [95% CI, 1.3 to 9.6]). Large, fair-quality cohort studies also consistently found initiation of ART at CD4 counts of 0.350 to 0.500 × 109 cells/L associated with decreased risk of mortality and clinical events compared with delayed initiation. New evidence from good-quality cohort studies confirm a small increase in risk of long-term cardiovascular events associated with certain antiretroviral drugs. Although direct clinical evidence showing that changes in risky behaviors as a result of screening or subsequent interventions reduces transmission risk remains unavailable, there is now strong evidence from a randomized trial as well as consistent evidence from multiple observational studies that ART use is associated with an approximately 10- to 20-fold reduction in risk of sexual transmission of HIV infection.
Limitations:
Only English-language articles were included. Observational studies were included. Studies conducted in resource-poor or high-prevalence settings were included, but might be of limited applicability to general screening in the United States.
Conclusions:
Prior studies have shown that HIV screening is accurate, targeted screening misses a substantial proportion of cases, and treatments are effective at improving clinical outcomes in patients with advanced immunodeficiency. New evidence indicates that ART reduces risk of AIDS-defining events and mortality in persons with less advanced immunodeficiency and reduces sexual transmission. More research is needed to understand effects of different screening strategies on the uptake and yield of screening, harms, CD4 count at diagnosis, and linkage to care.
Contents
- 1. INTRODUCTION
- 2. METHODS
- 3. RESULTS
- Key Question 1 What Are the Benefits of Universal or Targeted HIV Screening Versus No Screening or Each Other in Asymptomatic, Nonpregnant Adolescents and Adults on Disease Transmission, Morbidity, Mortality, and Quality of Life?
- Key Question 2a What Is the Yield (Number of New Diagnoses) of HIV Screening at Different Intervals in Nonpregnant Adolescents and Adults?
- Key Question 2b What Are the Effects of Universal Versus Targeted HIV Screening on Testing Acceptability and Uptake in Nonpregnant Adolescents and Adults?
- Key Question 2c What Is the Effect of Opt-Out Versus Opt-In Testing or Different Pre- or Post-Test HIV Counseling Methods on Screening Uptake or Rates of Followup and Linkage to Care in Nonpregnant Adolescents and Adults?
- Key Question 2d What Are the Adverse Effects (Including False-Positive Results and Anxiety) of Rapid Versus Standard HIV Testing in Nonpregnant Adolescents and Adults Not Known to Be at Higher Risk?
- Key Question 2e What Are the Effects of Universal Versus Targeted HIV Screening on CD4 Counts at the Time of Diagnosis?
- Key Question 2f What Are the Effects of Universal Versus Targeted HIV Screening on Rates of Followup and Linkage to Care in Nonpregnant Adolescents and Adults Who Screen Positive?
- Key Question 3a To What Extent Does Knowledge of HIV-Positive Status Affect Behaviors Associated With Increased Risk of HIV Transmission in Nonpregnant Adolescents and Adults?
- Key Question 3b To What Extent Does Use of Antiretroviral Therapy Affect Behaviors Associated With Increased Risk of HIV Transmission in Nonpregnant Adolescents and Adults?
- Key Question 4a How Effective Is Antiretroviral Therapy in Reducing Transmission of HIV in Nonpregnant Adolescents and Adults With Chronic HIV Infection?
- Key Question 4b How Effective Is Behavioral Counseling in Reducing Transmission of HIV in Nonpregnant Adolescents and Adults With Chronic HIV Infection?
- Key Question 4c In Asymptomatic, Nonpregnant Adolescents and Adults With Chronic HIV Infection, What Are the Effects of Initiating Antiretroviral Therapy at Different CD4 Counts or Viral Load Thresholds on Morbidity, Mortality, and Quality of Life?
- Key Question 5 What Are the Longer-Term Harms Associated With Antiretroviral Therapy in Nonpregnant Adolescents and Adults With Chronic HIV Infection?
- Key Question 6a To What Extent Are Improvements in Viremia Associated With Reductions in HIV Transmission Rates in Nonpregnant Adolescents and Adults?
- Key Question 6b To What Extent Are Improvements in Risky Behaviors Associated With Reductions in HIV Transmission Rates in Nonpregnant Adolescents and Adults?
- Contextual Question What Is the Cost-Effectiveness of Universal Versus Targeted HIV Screening in Low- or Average-Prevalence Populations?
- 4. DISCUSSION
- REFERENCES
- APPENDIX A DETAILED METHODS
- APPENDIX B EVIDENCE AND QUALITY TABLES
Acknowledgments: The authors acknowledge Laurie Hoyt Huffman, MS, for contributions to the report. The authors also thank the AHRQ Medical Officer, Jennifer Croswell, MD, MPH, as well as the U.S. Preventive Services Task Force leads, Susan Curry, PhD, Virginia Moyer, MD, MPH, Wanda Nicholson, MD, MPH, MBA, Timothy Wilt, MD, MPH, and Douglas Owens, MD, MS.
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. HHSA-290-2007-10057-I, Task Order No. 8 . Prepared by: Oregon Evidence-Based Practice Center, Oregon Health & Science University2
Suggested citation:
Chou R, Selph S, Dana T, Bougatsos C, Zakher B, Blazina I, Korthuis PT. Screening for HIV: Systematic Review to Update the U.S. Preventive Services Task Force Recommendation. Evidence Synthesis No. 95. AHRQ Publication No. 12-05173-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; November 2012.
This report is based on research conducted by the Oregon Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-02-0024). The investigators involved have declared no conflicts of interest with objectively conducting this research. The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.
This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
- 1
540 Gaither Road, Rockville, MD 20850; www
.ahrq.gov - 2
3181 SW Sam Jackson Park Road, Portland, OR 97239; www
.ohsu.edu/epc
- Review Screening for HIV: systematic review to update the 2005 U.S. Preventive Services Task Force recommendation.[Ann Intern Med. 2012]Review Screening for HIV: systematic review to update the 2005 U.S. Preventive Services Task Force recommendation.Chou R, Selph S, Dana T, Bougatsos C, Zakher B, Blazina I, Korthuis PT. Ann Intern Med. 2012 Nov 20; 157(10):706-18.
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