What are the current HIV screening guidelines for individuals aged 13–64 and high‑risk groups, including recommended testing methods and screening frequency?

Current HIV Screening Guidelines

All adolescents and adults aged 15–65 years should undergo routine opt-out HIV screening at least once, regardless of perceived risk, with high-risk individuals screened at least annually or every 3 months depending on specific risk factors. 1, 2, 3

Universal Screening Recommendations

Age-Based Screening

• Screen all patients aged 15–65 years at least once in their lifetime using opt-out screening in all healthcare settings, including primary care, emergency departments, urgent care clinics, inpatient services, STD clinics, tuberculosis clinics, and correctional facilities. 4, 3
• The CDC recommends screening starting at age 13–64 years, while USPSTF recommends 15–65 years; use the broader 13–65 year range to capture all at-risk adolescents. 4, 3
• Younger adolescents (<15 years) and older adults (>65 years) should be screened if they have any increased risk for HIV infection. 3

Opt-Out Screening Approach

• Inform patients orally or in writing that HIV testing will be performed as part of routine care unless they decline, without requiring separate written consent or extensive pre-test counseling. 4, 1
• This approach removes stigma, eliminates time-consuming risk assessments that miss many infections, and achieves significantly higher testing rates than traditional opt-in programs. 1, 5
• If a patient declines testing, document this decision in the medical record and re-offer testing at subsequent visits. 5

High-Risk Populations Requiring Frequent Screening

Annual Screening (Minimum)

• Test at least annually for persons likely to be at high risk, including: 4, 2
  • Injection drug users and their sexual partners
  • Persons who exchange sex for money or drugs
  • Sexual partners of HIV-infected persons
  • Men who have sex with men (MSM)
  • Heterosexual persons who themselves or whose partners have had more than one sex partner since their most recent HIV test

Every 3-Month Screening

• Screen every 3 months for the highest-risk individuals as long as risk continues: 2, 6
  • MSM with multiple or anonymous partners
  • Transfeminine persons
  • Persons newly diagnosed with sexually transmitted infections or hepatitis C
• While CDC's 2006 guidance recommended annual screening for MSM, more recent expert consensus supports offering screening every 3–6 months to individual MSM at increased risk, though evidence remains insufficient to mandate this frequency universally. 6

Special Populations

• All pregnant women should be screened during each pregnancy, ideally at the first prenatal visit. 4, 2, 3
• Pregnant women at high risk should be rescreened in the third trimester (preferably before 36 weeks gestation). 3
• All patients initiating treatment for tuberculosis should be screened routinely. 4
• All patients seeking STD treatment should be screened at every visit for a new complaint, regardless of known or suspected risk behaviors. 4

Recommended Testing Methods

Fourth-Generation Combination Assays

• Use fourth-generation HIV antigen/antibody combination assays that detect both HIV antibodies and p24 antigen, allowing detection of infection approximately 2 weeks earlier than antibody-only tests. 2
• These tests have sensitivity and specificity >99.5%. 5

Confirmatory Testing Algorithm

• All reactive screening tests must be confirmed before diagnosis using: 2
  • HIV-1/HIV-2 antibody differentiation immunoassay
  • HIV RNA testing if the differentiation assay is negative or indeterminate
• This algorithm distinguishes HIV-1 from HIV-2 and identifies acute infections when antibody tests are negative but viral load is detectable. 2

Alternative Testing Options

• Rapid HIV tests provide results in 5–40 minutes and can use less invasive specimens such as oral fluid or finger-stick blood, which may increase acceptance. 5

Screening Frequency in Average-Risk Populations

• One-time screening is the minimum standard for all persons aged 15–65 years. 3
• Repeat screening of persons not at high risk should be based on clinical judgment, considering new sexual relationships, changes in relationship status, or patient request. 4
• Encourage patients and prospective sex partners to be tested before initiating a new sexual relationship. 4

Prevalence Thresholds for Implementation

• Routine screening should be performed unless the prevalence of undiagnosed HIV infection is documented to be <0.1% in the patient population. 4
• In the absence of prevalence data, initiate voluntary screening until diagnostic yield is established to be <1 per 1,000 patients screened. 4
• Cost-effectiveness analyses demonstrate screening is justified at prevalence ≥0.1%, a threshold met in most U.S. healthcare settings. 1

Critical Implementation Pitfalls to Avoid

Limitations of Risk-Based Screening Alone

• Risk-based screening fails to identify 10–25% of HIV-positive individuals who report no high-risk behaviors, and many patients do not perceive themselves at risk or will not disclose behaviors. 4, 2
• Even when risk factors are documented in medical records, only one-third of at-risk patients actually receive testing under risk-based approaches. 2
• This contributes to delayed diagnosis, with approximately half of patients diagnosed late in disease when they cannot receive maximum benefit from antiretroviral therapy. 2

Disparities in Diagnosis

• Undiagnosed HIV infection is present in 22.2% of African American patients, higher than White (18.8%) and Hispanic/Latino (21.6%) populations, making universal opt-out screening especially critical for reducing disparities. 1
• African American patients experience later presentation to care, with median CD4 counts at first presentation of approximately 327 cells/µL. 1

Insufficient Testing Rates

• Current annual testing rates of 4–5% are insufficient; mathematical models indicate rates must increase at least threefold and be sustained to reach the goal of ≥95% of persons with HIV aware of their infection. 1

Clinical Benefits of Early Detection

• Early identification and treatment with antiretroviral therapy substantially reduces AIDS-related events, death, and sexual transmission to uninfected partners. 4, 3
• Treatment reduces viral load and infectivity, and early diagnosis allows for behavioral counseling and other interventions. 4
• Routine prenatal screening combined with antiretroviral therapy has nearly eliminated mother-to-child transmission in the United States. 2, 3