Screening Recommendations for HIV and Risk Stratification

Segment Description: Ian Frank, MD, reviews current US Preventive Services Task Force screening recommendations that prompt testing and factors to identify high-risk groups.

Transcript (modified slightly for readability):

Joseph Eron, MD: Ian, what about screening? What does the US Preventive Services Task Force [USPSTF] recommend? What are we supposed to be doing? Screening? What would you recommend to the generalists, community physicians, and family medicine physicians?

Ian Frank, MD: Well, the recommendations are that every person aged 15 to 65 be tested for HIV at least once in their life. It doesn’t mean you shouldn’t be testing younger individuals who may be sexually active. It doesn’t mean you shouldn’t be testing older individuals, older than 65, who are sexually active. Maybe they’re divorced or their partners have died, or they have new sexual partners. Everybody should be tested at least once.

Pregnant women should be tested during their pregnancy at least once. And then individuals should be tested again, depending upon their risk group. For men who have sex with men, individuals with a sexually transmitted illness, or individuals who are injecting drugs, they should be tested at least on an annual basis if not more often. Pregnant women who may come in contact with HIV because of sexual risk should be tested during their third trimester if they’ve been tested earlier. Because women who acquire acute HIV infection during their pregnancy are at more likely risk of transmitting their infection to their fetus or the newborn. Those are the general recommendations.

Joseph Eron, MD: Julia, you’ve really thought about this, in part identifying people for pre-exposure prophylaxis. But really it’s about identifying people who are at high risk and probably should be tested more frequently. We can use this as a way to start talking about PrEP [pre-exposure prophylaxis]. But talk a little about treatment in a general practice or in any kind of practice. How do we find these high-risk people?

Julia Marcus, MD, MPH: It’s a challenge, and it’s 1 that the USPSTF actually identified in their systematic review. When they put out their PrEP recommendations, they said there’s really a lack of effective HIV risk-assessment tools out there. There are some that exist based on the criteria for what constitutes a good candidate for PrEP, which is similar to the USPSTF criteria for HIV screening. But those tools have some limitations. For one, they’re really developed for men who had sex with men, for the most part. A provider already has to know that a patient was in that risk group before they’re going to use 1 of these tools. They’re hard to use in a busy clinical practice, and they also underestimate HIV risk in black men who have sex with men. But HIV risk for that community is much more driven by network factors.

Joseph Eron, MD: Network factors and who you have been exposed to. I think the first step is to talk about sex, right? Allison, you have to deal with adolescents. You probably talk about sex a lot.

Allison L. Agwu, MD, ScM: Well, you would be surprised. I happen to talk about sex a lot in my practice. But there are studies that showed the average provider, even the adolescent provider, spends only 30 seconds talking to adolescents about sex. That just accounts for the adolescent population. Imagine what’s happening in the over-55 age group. Some physicians and patients may be uncomfortable and we may not even bring it up. Essentially, we have a whole problem talking about sex.