HIV Screening and Treatment Guidelines

HIV Screening Recommendations

All persons aged 15-65 years should be screened for HIV at least once in their lifetime, with routine opt-out screening recommended in primary care settings, emergency departments, and for all pregnant women. 1, 2

Universal Screening Populations

Adolescents and adults aged 15-65 years should undergo routine HIV screening regardless of perceived risk 1, 2
All pregnant women must be screened during each pregnancy, including those who present in labor with unknown HIV status 1, 2
Younger adolescents (<15 years) and older adults (>65 years) should be screened if they have any risk factors for HIV 1, 2

High-Risk Populations Requiring Frequent Screening

High-risk individuals should be tested every 3 months as long as risk continues 1:

Men who have sex with men (MSM) 1
Transfeminine persons 1
People who inject drugs outside needle sharing programs 1
Persons newly diagnosed with sexually transmitted infections (STIs) or hepatitis C 1
Sexual partners of HIV-infected persons 1
Persons who exchange sex for money or drugs 1

Optimal Testing Methods

Screening should be performed with fourth-generation HIV antigen/antibody combination assays that detect both HIV antibodies and p24 antigen, allowing detection of recent infection 1, 3, 4

Combined HIV antibody and antigen tests are preferred over antibody-only tests because they detect infection earlier 1
Rapid HIV tests can be used when immediate results are needed, but oral rapid tests have higher false-positive rates and should be confirmed with whole blood testing 1, 5
Third-generation antibody-only tests are acceptable for persons without access to better testing, but miss early infections 1

Critical Testing Algorithm

All reactive screening tests must be confirmed before diagnosis 1, 3:

Initial screening with fourth-generation antigen/antibody combination assay 3
If reactive, perform HIV-1/HIV-2 antibody differentiation immunoassay 3
If differentiation assay is positive, HIV infection is confirmed 3
If differentiation assay is negative, perform HIV RNA testing to rule out acute HIV-1 infection 3

Common Pitfall: Never diagnose HIV based on screening test alone—false-positive results can occur with devastating psychological consequences 3

Window Period Considerations

HIV antibody is detectable in ≥95% of patients within 6 months of infection 1
Antibody tests cannot exclude infection that occurred less than 6 months before testing 1
Fourth-generation tests detect infection earlier than antibody-only tests by identifying p24 antigen 3, 4
Approximately 14.5% of new HIV diagnoses in emergency departments represent acute infection detectable only with antigen/antibody tests 4

Special Populations

Pregnant women require specific screening protocols 1, 2:

Screen during each pregnancy, even if previously tested negative 1
Repeat screening in third trimester for women at ongoing risk 1
Offer rapid HIV testing during labor for women with unknown or undocumented status 1

Infants born to HIV-positive mothers 1, 3:

Standard antibody tests are unreliable due to maternal antibody transfer 1
Definitive diagnosis requires two positive HIV RNA PCR or viral culture tests on separate specimens 3
Passively acquired maternal antibody becomes undetectable by 15-18 months of age 1

HIV-2 testing considerations 1, 3:

Test persons from West Africa (endemic region) or their sexual partners 1
Consider when clinical evidence suggests HIV disease but HIV-1 tests are negative 1

Post-Diagnosis Evaluation

Immediate Laboratory Assessment

Before starting antiretroviral therapy (ART), obtain the following tests, but do not delay ART initiation while waiting for results 1:

HIV staging and monitoring 1:

HIV RNA level (viral load) 1
CD4 cell count and percentage 1
HIV genotype resistance testing 1

General health assessment 1:

Complete blood count with differential 1
Comprehensive metabolic panel (kidney and liver function, electrolytes) 1
Fasting lipid profile 1
Fasting blood glucose 1
Urinalysis 1
Pregnancy test (if applicable) 1

Co-infection screening 1:

Hepatitis A, B, and C serologies 1
Tuberculosis screening 1
Sexually transmitted infection screening 1
Toxoplasma gondii serology 1
Cytomegalovirus (CMV) serology for patients at low risk 1

Additional baseline tests 1:

HLA-B*5701 testing (required before prescribing abacavir) 1
CCR5 tropism testing (if considering maraviroc) 1
Glucose-6-phosphate dehydrogenase (G6PD) in appropriate racial/ethnic groups 1
Cervical Pap test; consider anal Pap test if indicated 1

Special consideration for severely immunocompromised patients 1:

Serum cryptococcal antigen test for patients with CD4 count <100/μL, even without symptoms 1

Antiretroviral Therapy Initiation

When to Start Treatment

All persons diagnosed with HIV should be offered ART immediately, regardless of CD4 count or viral load 1, 2

Early treatment substantially reduces risk of AIDS-related events and death 1, 2
ART substantially decreases risk of HIV transmission to uninfected sex partners 2
Treatment should not be delayed for laboratory results unless there is preexisting kidney/liver damage or high likelihood of transmitted drug resistance 1

Initial ART Regimens

ART must consist of combination therapy—never add a single active drug to a failing regimen 1, 6, 7, 6

FDA-approved regimens include 6, 7, 6:

Integrase strand transfer inhibitors (INSTIs) in combination with other antiretrovirals 7
- Dolutegravir-based regimens for treatment-naïve or treatment-experienced adults and pediatric patients ≥4 weeks and ≥3 kg 7
Non-nucleoside reverse transcriptase inhibitors (NNRTIs) in combination with protease inhibitors and/or nucleoside analogue reverse transcriptase inhibitors (NRTIs) 6
- Efavirenz 600 mg orally once daily for adults 6
- Efavirenz for pediatric patients ≥3 months and ≥3.5 kg with weight-based dosing 6

Dosing Considerations

Efavirenz should be taken on an empty stomach, preferably at bedtime 6:

Food increases efavirenz concentrations and may increase adverse reactions 6
Bedtime dosing improves tolerability of nervous system symptoms 6

Dosage adjustments required for drug interactions 6:

When coadministered with voriconazole: decrease efavirenz to 300 mg once daily and increase voriconazole maintenance dose to 400 mg every 12 hours 6
When coadministered with rifampin in patients ≥50 kg: increase efavirenz to 800 mg once daily 6

Monitoring During Treatment

Viral Load Monitoring

Measure viral load 4-6 weeks after starting or changing ART regimen 1:

If viral load has not declined and adherence appears sufficient, obtain genotype resistance testing 1
Once HIV RNA <50 copies/mL, monitor every 3 months until suppressed for at least 1 year 1
After 1 year of viral suppression with consistent adherence, monitoring can be reduced to every 6 months 1

If viral load >50 copies/mL is detected 1:

Repeat measurement within 4 weeks 1
Reassess medication adherence and tolerability 1
If adherence is sufficient, obtain genotype resistance testing 1

CD4 Cell Count Monitoring

Measure CD4 counts every 6 months until counts are >250/μL for at least 1 year with concomitant viral suppression 1

CD4 counts have substantial variation, especially during acute illness 1
Some experts recommend obtaining 2 baseline measurements before treatment decisions 1
CD8 cell count and CD4:CD8 ratio should not be used in clinical decision making 1

Ongoing Screening and Monitoring

At each visit, screen for 1:

High-risk sexual or drug-use behaviors 1
Symptoms of sexually transmitted infections 1
Depression (routine screening and treatment recommended) 1
Age- and risk-appropriate STI screening at various anatomical sites 1
Anal or cervical dysplasia 1
Tuberculosis 1
Medication toxicity 1

Treatment of Multidrug-Resistant HIV

Salvage Therapy Options

For patients with extremely limited treatment options due to multidrug resistance 1:

Ibalizumab (anti-CD4 monoclonal antibody, IV every 2 weeks): approximately 50% of adults with virological failure and multidrug-resistant HIV achieved undetectable viral loads at 12 months when combined with at least 1 other active drug 1
Fostemsavir (attachment inhibitor): 60% of patients achieved HIV RNA <40 copies/mL at 96 weeks when combined with at least 1 fully active agent; approximately one-third achieved undetectable viral loads without other fully active agents 1

Optimization of the ART regimen to keep viral load as low as possible is essential when resistance is suspected 1

Engagement in Care and Adherence

Linkage to Care After Diagnosis

Brief, strengths-based case management after HIV diagnosis facilitates linkage to care 1

Systematic monitoring of time to care linkage, retention, and viral suppression is recommended in all care settings 1
Rapid HIV test algorithms allow same-day referral to treatment from nonclinical settings 1
Data-driven risk stratification should identify high-acuity patients for combination intervention strategies 1

Retention Strategies

Systematic monitoring of missed clinic visits with rapid intervention is essential 1:

Personal telephone and interactive text reminders before scheduled appointments 1
Contact within 24-48 hours after missed appointments 1
Use public health surveillance with clinic-level data to guide individual-level reengagement 1

Adherence Monitoring and Support

Monitor adherence using validated self-report instruments and pharmacy refill data 1

For specific populations 1:

Integrate directly observed ART in methadone maintenance programs 1
Consider directly observed therapy for persons with substance use disorders 1
Provide opioid substitution therapy for opioid-dependent patients 1

Cash financial incentives for appointment attendance and viral suppression are generally not recommended 1

Psychosocial Support

Behavioral and psychosocial services are integral to HIV care and should be available on-site or through referral 1

Patients require support for 1:

Accepting potential life implications 1
Coping with stigma and others' reactions 1
Developing strategies for maintaining physical and emotional health 1
Initiating behavioral changes to prevent HIV transmission 1
Making reproductive choices 1
Gaining access to health services and insurance 1
Confronting employment discrimination 1

Routine screening and treatment for depression is recommended 1

Prevention Counseling

Post-Exposure Prophylaxis (PEP)

For persons with high-risk exposure within the previous 72 hours 1:

Screen with rapid HIV antibody test 1
If negative, offer PEP immediately—do not delay for confirmatory testing 1
At time of prescribing PEP, obtain: creatinine level, hepatitis B surface antigen, STI screening, combined HIV antibody/antigen test or HIV RNA assay 1

Pre-Exposure Prophylaxis (PrEP)

For persons with ongoing high risk for HIV infection 1:

Screen with rapid HIV antibody test or combined antibody/antigen test 1
If initial test is negative, offer PrEP without waiting for confirmatory or safety testing results 1

Special Considerations for Hepatic Impairment

Monitor hepatic function before and during efavirenz treatment 6

Efavirenz is not recommended in patients with moderate or severe hepatic impairment (Child-Pugh B or C) 6

What are the guidelines for screening and treatment of Human Immunodeficiency Virus (HIV)?

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