to the editor: I was pleased to see the article by Dr. Mahoney and colleagues regarding the application of the Centers for Disease Control and Prevention (CDC) human immunodeficiency virus (HIV) testing guidelines in clinical practice, which were first released in September 2006. Routine opt-out HIV testing was recommended after repeated studies showed that risk-based screening failed to identify a significant number of adults with HIV infection (20 to 25 percent), and that patients continue to present in advanced stages of disease despite the availability of multiple effective HIV therapies.¹

Unlike the American Congress of Obstetricians and Gynecologists and the American College of Physicians, the American Academy of Family Physicians (AAFP) has yet to endorse the CDC guidelines. The AAFP cites level C evidence based on the U. S. Preventive Services Task Force (USPSTF) 2005 statement on HIV screening, which states that the USPSTF makes no recommendation for or against routine screening in patients who are not at increased risk of infection.² Physicians who provide care to a large number of patients with HIV infection are constantly reminded of the many missed opportunities to diagnose patients at an early stage of this disease because their clinician did not perceive them to be “at risk.” My hope is that the AAFP and the USPSTF will reevaluate newer evidence regarding HIV screening in adults and ultimately endorse routine opt-out testing as the standard of care.

Historically, written informed consent has been a major barrier to HIV testing. This is slowly changing, and there are now only five states that require this before testing is performed.³ Dr. Mahoney and colleagues also cite a lack of reimbursement as a barrier to testing. Fortunately, since their article was published, the Centers for Medicare and Medicaid Services has approved coverage for HIV screening, noting that they will cover screening tests for “persons who request an HIV test despite reporting no individual risk factors, since this group is likely to include individuals not willing to disclose high-risk behaviors.”⁴

in reply: The differences between the AAFP/USPSTF recommendations for risk-based HIV screening and the CDC recommendations for routine (universal) HIV screening are described in several previous family medicine articles.^1–3 Our article tried to emphasize that increased testing to identify patients who are unaware of their HIV status is essential, regardless of which recommendations are followed.

As Dr. Kirchner points out in his letter, the barrier of requiring written informed consent for HIV testing has diminished substantially. Currently, only five states (Massachusetts, Michigan, Nebraska, New York, and Pennsylvania) require written informed consent per the Compendium of 2010 State HIV Testing Laws. Some of these states, however, have large numbers of persons with HIV infection and, presumably, large numbers of persons with undiagnosed HIV infection.

Inconsistent reimbursement for HIV screening by public and private insurers continues to be a major barrier. The Centers for Medicare and Medicaid Services memorandum mentioned by Dr. Kirchner included the approval of reimbursement for HIV tests performed in patients who request the test, but do not declare risk factors.⁴ This, however, is still considered risk-based (not routine) testing. Routine testing is designed to screen even those who do not identify themselves as being at risk of HIV infection. Even so, this benefit only applies to Medicare patients. A higher percentage of patients at risk of HIV infection are Medicaid patients. Although federal law permits, but does not require, state Medicaid programs to cover routine HIV screening, it is ultimately the prerogative of states to provide that coverage, and many state Medicaid programs have not opted to do so.⁵ Mandating coverage of routine screening would require Congress to change Medicaid law, or states to pass legislation, requiring all insurers to cover routine HIV testing, as California did in 2008.⁶

The reasons persons do not get tested for HIV are complex. Recognizing the central role of primary care, the CDC has launched a new initiative, called HIV Screening. Standard Care. (http://www.cdc.gov/hiv/testing/HIVStandardCare/), aimed at internists and family physicians. The common goal of this program, as well as the various differing recommendations, is to encourage primary care physicians to implement broader HIV testing, engage newly identified patients in potentially lifesaving care, and prevent further HIV transmission.