What are the guidelines for HIV screening and management?

HIV Screening Guidelines

Primary Recommendation

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

Universal Screening Approach

The most recent guidelines strongly support routine screening over risk-based approaches because:

• Risk-based screening has failed to identify 10-25% of HIV-positive individuals who report no high-risk behaviors 2
• Even when risk factors are clearly documented in medical records, only one-third of at-risk patients actually receive testing 2
• Approximately half of patients are diagnosed late in disease when they cannot receive maximum benefit from antiretroviral therapy 2
• Routine opt-out screening has been highly successful for prenatal HIV screening, with high acceptance rates and near-elimination of mother-to-child transmission 2

Screening Frequency for High-Risk Populations

High-risk individuals require HIV testing every 3 months as long as risk continues. 1 This includes:

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

Optimal Testing Method

Fourth-generation HIV antigen/antibody combination assays should be used for screening, as they detect both HIV antibodies and p24 antigen, allowing detection of recent infection. 1

Confirmation Algorithm

All reactive screening tests must be confirmed before diagnosis using: 1

• HIV-1/HIV-2 antibody differentiation immunoassay
• HIV RNA testing if the differentiation assay is indeterminate or negative

Post-Diagnosis Management

Immediate Laboratory Assessment

Before starting antiretroviral therapy (ART), obtain: 1

• HIV RNA level (viral load)
• CD4 cell count
• HIV genotype resistance testing

Treatment Initiation

All persons diagnosed with HIV should be offered ART immediately, regardless of CD4 count or viral load. 1, 3 Ideally, ART should be started within 7 days of diagnosis for improved viral suppression rates and retention in care. 3

Monitoring During Treatment

Viral load monitoring schedule: 2, 1

• Measure at 4-6 weeks after starting or changing ART regimen
• Every 3 months until HIV RNA <50 copies/mL for at least 1 year
• Every 6 months after achieving 1 year of viral suppression with consistent adherence

CD4 count monitoring: 2, 1

• Every 6 months until counts are >250/μL for at least 1 year with concomitant viral suppression
• Can be discontinued once this threshold is maintained

Response to Detectable Viral Load

If viral load >50 copies/mL is detected: 2

• Repeat measurement within 4 weeks
• Reassess medication adherence and tolerability
• If adherence appears sufficient and viral load persists, obtain genotype resistance testing

Screening for Co-Infections and Complications

Age- and risk-appropriate screening is required every visit for: 2

• Sexually transmitted infections at various anatomical sites
• Anal or cervical dysplasia
• Tuberculosis
• Depression (routine screening and treatment recommended) 2, 1
• General health and medication toxicity

Engagement in Care Strategies

Critical interventions to improve outcomes include: 2, 1

• Brief, strengths-based case management after HIV diagnosis to facilitate linkage to care
• Personal telephone and interactive text reminders before scheduled appointments and within 24-48 hours after missed appointments
• Systematic monitoring of missed clinic visits with rapid intervention
• Screening for and addressing housing instability, food insecurity, ongoing substance use, psychiatric disorders, medication adverse effects, and pill burden

Common Pitfalls to Avoid

• Do not rely solely on patient-reported risk behaviors - many infected individuals either don't recognize their risk or won't disclose behaviors 2
• Do not delay testing in low-prevalence settings - screening is cost-effective even at prevalence as low as 0.1-0.2% 2
• Do not skip confirmation testing - all reactive screening tests require confirmation before diagnosis 1
• Do not delay ART initiation - waiting for "readiness" or specific CD4 thresholds is outdated and harmful 1, 3