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Near-universal screening for HIV recommended in the U.S.

The U.S. Preventive Services Task Force now recommends HIV screening for those aged 15-65 and increased use of PrEP, a pill that helps prevent infection.

I was surprised to learn the U.S. has more people with new HIV diagnoses each year than any high-income nation. There is this widespread misconception out there that we've got it under control; that the drug cocktails are so effective that HIV is no longer a leading threat.

"Unfortunately, HIV remains a major public health problem in the U.S.," Stanford Health Policy's Douglas Owens, MD, told me. He is chair of the U.S. Preventive Services Task Force, which issued two influential recommendations on the prevention and treatment of HIV in the Journal of the American Medical Association.

The task force now recommends clinicians screen everyone aged 15 to 65 and all pregnant women for HIV and offer pre-exposure prophylaxis (PrEP) -- a pill that helps prevent HIV -- to people at high risk of contracting the potentially fatal infection.

"There are highly effective preventive interventions that can help us toward the goal of ending the HIV epidemic in the U.S.," said Owens, who is also an investigator at VA Palo Alto Health Care System "However, we know not enough people receive these interventions."

Owens said an estimated 1.1 million people are currently living with HIV in this country -- and more than 700,000 people have died of AIDS since the first cases were reported in 1981. Of the 38,281 new diagnoses of HIV reported in 2017, 81% were among men and 19% among women.

"Each year, almost 40,000 people acquire HIV," he said. "It's not acceptable and requires our urgent attention."

In this short video, Stanford's Douglas Owens explains the recommendations.

The task force is an independent, volunteer panel of national experts in prevention and evidence-based medicine who work to improve the health of all Americans by making recommendations. They typically give letter grades to its recommendations, and this time issued its highest grade, an A.

The benefit of this endorsement could be substantial, according to one of the accompanying editorials in JAMA, because under the Affordable Care Act, grade A and B recommendations made by the USPSTF should be covered by private insurance without patient cost sharing.

"How this recommendation will be implemented is of critical importance because cost is a major barrier for people both to start and to stay on PrEP," wrote Diane Havlir, MD, and Susan Buchbinder, MD, both from the University of California, San Francisco, in their editorial. At present, they wrote, the average monthly retail cost for PrEP without insurance is nearly $2,000.

The task force members concluded "with high certainty" that while there are some potential harms, the magnitude of benefit with PrEP, or oral tenofovir disoproxil fumarate-based therapy, to reduce the risk of HIV infection in people at high risk is substantial.

"Clinicians can make a real difference toward reducing the burden of HIV in the United States," Owens said in the task force statement. "HIV screening and HIV prevention work to reduce new HIV infections and ultimately save lives."

Fewer than half of all adults have ever been tested for HIV in the U.S. and many of those requiring more frequent testing are not receiving it. The task force emphasized that clinicians should make testing routine and ensure patients are given an environment that is free of judgment during discussions of sexual health.

Screening is the only way to know if a person has been infected with HIV because, after initial flu-like symptoms, HIV is not apparent for several years.

In addition to screening, people need to prevent getting HIV by using condoms during sex, the task force said, and, for those who inject drugs, using clean needles and syringes.

Photo by Michelle Ramos

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