Is routine opt‑out HIV (human immunodeficiency virus) screening recommended for all individuals aged 13–64, with particular emphasis on African‑American patients?

HIV Screening for African American Patients

Routine opt-out HIV screening should be offered universally to all patients aged 13–64 years regardless of race, but African American patients warrant particular clinical attention because they have higher rates of undiagnosed infection (22.2% unaware of their status) and present later to care compared to other racial groups. 1

Universal Screening Applies Equally Across All Races

The CDC explicitly recommends routine opt-out HIV screening for all patients aged 13–64 years in all healthcare settings, without distinction by race or ethnicity. 1 This universal approach is designed to:

• Remove stigma associated with risk-based testing 1
• Identify infections earlier in the disease course 1
• Eliminate the need for time-consuming risk assessments that miss substantial numbers of infected individuals 1

The American College of Physicians reinforces this universal approach, recommending routine screening for all adolescents and adults aged 15–65 years regardless of perceived risk. 1

Why African American Patients Require Enhanced Clinical Focus

While screening recommendations are universal, epidemiologic data reveal critical disparities that demand heightened clinical vigilance:

Undiagnosed infection rates: African Americans have 22.2% undiagnosed HIV infections compared to 18.8% in White patients, 21.6% in Hispanic/Latino patients, and higher rates in Asian/Pacific Islanders (29.5%). 1

Late presentation to care: The median CD4 count at first presentation increased only modestly from 235 cells/µL in 1996 to 327 cells/µL by 2007, with African Americans disproportionately affected by late diagnosis. 1

Higher testing yield: Recent data show that testing rates remain low overall (4.0% with commercial insurance, 5.5% with Medicaid in 2019), but testing rates are appropriately higher among Black persons, reflecting both higher prevalence and targeted public health efforts. 2

Practical Implementation Strategy

For all patients aged 13–64 years (including African Americans):

• Offer HIV testing as part of routine care using opt-out screening (inform patients testing will be performed unless they decline) 1
• Use fourth-generation antigen/antibody combination assays that detect both HIV antibodies and p24 antigen 3
• Incorporate consent into general medical consent without requiring separate written consent 4
• Document if patient declines testing 4

Enhanced frequency for high-risk patients (regardless of race):

• Test at least annually for: injection drug users and their partners, persons exchanging sex for money/drugs, sexual partners of HIV-infected persons, MSM, and heterosexual persons with multiple partners 1
• Test during each pregnancy for all women 1
• Test at every visit for new complaints in STD clinic settings 1

Critical Clinical Pitfalls to Avoid

Do not use risk-based screening alone: Targeted testing based on perceived risk behaviors fails to identify substantial numbers of infected persons because many do not perceive themselves at risk or do not disclose risk behaviors. 1 This approach perpetuates late diagnosis, particularly in African American communities. 1

Do not assume younger or older patients are low-risk: While CDC guidelines specify ages 13–64 years, approximately 20% of HIV patients are older than 50 years, and adolescents represent new at-risk cohorts with 79% of young HIV-infected MSM unaware of their infection. 1

Physician recommendation is the strongest predictor of testing: Having a regular doctor recommend HIV testing was the strongest predictor of testing among African American men (OR=7.38). 5 Simply offering testing without a clear recommendation significantly reduces uptake.

The Evidence Behind Universal Screening

The shift from risk-based to universal screening reflects multiple converging lines of evidence:

• Opt-out screening consistently achieves higher testing rates than opt-in programs requiring extensive pretest counseling and explicit written consent 1
• Routine testing identifies infections earlier than targeted approaches 1
• Patients express less anxiety with opt-out screening and do not find it difficult to decline 1
• Cost-effectiveness analyses support screening in populations with HIV prevalence >0.1%, a threshold met in most U.S. healthcare settings 1

Current Testing Rates Are Insufficient

Mathematical modeling indicates that current annual testing rates (4-5%) would need to increase at least threefold and be sustained over several years to achieve the Ending the HIV Epidemic goal of ≥95% of persons with HIV being aware of their infection by 2025. 2 This gap is particularly concerning for African American patients who already face higher rates of undiagnosed infection. 1

The recommendation is clear: offer routine opt-out HIV screening to all patients aged 13–64 years without racial distinction, while recognizing that African American patients statistically have higher undiagnosed infection rates and benefit from consistent implementation of these universal guidelines. 1