Nearly everyone ages 15 to 64 should be screened for HIV even if they're not at great risk for contracting the virus, according to new guidelines proposed by an influential panel of medical experts. If the panel ultimately adopts those recommendations, Medicare and most private health insurers will be required to pay for the tests.
The draft guidelines were written by the U.S. Preventive Services Task Force, an independent group that operates under the auspices of the Department of Health and Human Services to advise the government and the nation's physicians on the medical evidence for preventive health measures.
Posted online Monday on the task force website for a four-week period of public comment, the guidelines also recommend that doctors offer HIV tests to people under 15 or over 64 if they are at high risk for contracting HIV and — in advice that has not changed — to all pregnant women.
The recommendations, which would apply to all but very-low-risk populations, are a clear shift toward broader testing for HIV, the virus that causes AIDS. The task force's 2005 guidelines suggested routine HIV screening only for adolescents and adults at increased risk, including men who have sex with men, injection drug users, people who trade sex for drugs and those who have multiple sexual partners.
But studies published since that time offer strong evidence that HIV-infected individuals — along with their intimate partners and the public — are better served by near-universal screening, said task force member Dr. Douglas K. Owens, a general internist and director of the Center for Primary Care and Outcomes Research in the School of Medicine at Stanford University.
Some of those reports found that people who were treated earlier for HIV infections fared better than those who started treatment later, and routine screening improved the chances that patients would learn of their infections sooner, Owens said. Studies also show that when people learn they are HIV-positive, they are more likely to adopt safe-sex behaviors.
A landmark clinical trial last year involving 1,763 couples, most of them heterosexual, showed that when HIV-positive partners were treated early with antiretroviral medications, transmission of the virus to uninfected partners was reduced by 96%.
The 15-to-64 age range was suggested for such tests — which could be offered to patients visiting their doctors or hospitals for any reason — because government health statistics show this would capture the majority of Americans who contract the virus every year, Owens said.
Still, he added, "We want to emphasize that the best way to reduce HIV-related disease and death is to avoid getting infected in the first place."
Experts have also known for some time that treating pregnant women who have HIV can greatly reduce the risk of infecting their babies, which is why the task force continues to recommend universal screening for this group.
About 50,000 new cases of HIV infections occur in the United States each year. Since today's medications allow HIV-infected people to live longer, the number of people living with HIV will steadily increase unless ways are found to lower the rate of new infections, said Dr. Bernard M. Branson, an epidemiologist in the Centers for Disease Control and Prevention's Division of HIV/AIDS Prevention. Every infection that is averted saves $367,000 in lifetime medical costs, he said.
The agency's own guidelines, released in 2006 and co-written by Branson, are largely in line with the ones now proposed by the task force — although the CDC recommended that testing begin at age 13 instead of 15. As is the case with the task force proposal, testing is optional but is the default, conducted unless patients decline or they belong to a group in which HIV-positive rates are 1 in 1,000 or lower.
The American College of Physicians, the American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics, among other groups, also recommend widespread HIV tests, with slight differences.
Doctors said that making the HIV test routine for all but the lowest-risk groups removes the stigma associated with getting a test and increases the likelihood of an early diagnosis. Conversations to assess a patient's risk status are time-consuming and awkward, and patients are often not truthful about their sexual behavior, they said.
The issue is especially complicated in the case of adolescents, said Dr. Patricia J. Emmanuel, a pediatric infectious disease specialist at the University of South Florida in Tampa who co-wrote the 2011 American Academy of Pediatrics guidelines that recommend testing for teens ages 16 and older. When tests are done only for high-risk patients, the very fact someone had a test is a betrayal of confidentiality, she said. A routine HIV test "helps to create an environment where HIV testing is another medical screening test, not something so special," she said.
Despite the growing list of endorsements, surveys show that many doctors are not performing the tests routinely, said Dr. Jeffrey D. Klausner, a professor of medicine and infectious diseases at UCLA.
"On a daily basis, people come into the hospital and are not offered an HIV test. They go to the doctor for a checkup and are not offered an HIV test," Klausner said. "As an AIDS provider, I regularly see people who have missed the opportunity to be diagnosed, and so they present to me with end-stage cancers and infections" related to AIDS.
The task force based its draft report on two reviews of the science conducted by independent groups of scientists, one focused on HIV screening for the population at large and one on pregnant women. Those reviews were published online Monday by the Annals of Internal Medicine.
The panel listed its recommendations as Grade A, meaning that there is high certainty of substantial benefit. As such, most insurers would be required to pay for the HIV tests under the new Patient Protection and Affordable Care Act if the advice is finalized.