If HIV treatment is perceived as an effective and durable medical intervention by people at risk of infection, will this lead to an increased uptake of HIV testing? At the moment it's not possible to tell what impact the new treatments will have on HIV testing rates, because the countries where they have had the greatest impact are also the countries which have most strongly encouraged widespread HIV testing in any case. There is no indication from UK testing centres that increasing numbers of people are choosing to take an HIV test because of advances in medical care.

Regular HIV testing for 18-65 year olds?

United States' health providers should have a policy of routine HIV testing, according to a letter published in the 15^th March 2003 edition of the Journal of Infectious Diseases.

Such a policy would mean a shift in emphasis from the current risk-based approach to HIV testing in the US (and for most people in the UK).

The letter’s authors, from Brown University, Providence, Rhode Island, point out that the average heterosexual women testing HIV-positive in Rhode Island would be traditionally considered “low-risk” for HIV, as her median number of sexual partners in the last ten years was less than three.

Routine testing for HIV would also be advantageous as it would eliminate the need to obtain sexual and risk histories prior to taking blood samples, which both health provider and patients can find embarrassing. Indeed, the authors suggest that embarrassment may cause some people seeking HIV testing to lie about their HIV risk behaviour.

A knock-on advantage of routine testing would be the destigmatisation of HIV testing, and the authors suggest “offering routine HIV testing would be analogous to the current standard of care that indicates routine offering of Pap smear tests to women between the ages of 18 and 65 years, irrespective of risk.” All sexually active people aged 18-65 would be tested for HIV as a matter of course under the authors' proposals.

Cost-effectiveness of routine testing has been demonstrated, say the Brown University investigators. Routine testing would also lead to the early detection of undiagnosed HIV infections, enabling anti-HIV therapy to be offered before CD4 cell count falls below 200 cells/mm³. A third of cases of HIV in the US and UK are estimated to be undiagnosed and late presentation often occurs, frequently in an in-patient setting when a person may already have become severely ill with HIV, and may not be able to fully benefit from anti-HIV treatments.

Reduced rates of HIV transmission could also be a desirable consequence of routine testing, add the authors.

Routine testing should, the authors recommend, consist of brief pre- and post-test counselling, with patients required to positively opt out. They also suggest that reduced rates of HIV transmission could also be a desirable consequence of routine testing.

In the UK all pregnant women are offered an antenatal HIV test as part of their routine care.

US moves to make HIV testing routine

The US Centers for Disease Control has announced a major shift in its HIV prevention strategy with the launch of a new initiative, Advancing HIV Prevention: New Strategies for a Changing Epidemic.

The initiative consists of five key strategies, says the CDC:

• Making HIV testing a routine part of medical care.

Health care providers will be encouraged to make HIV testing as routine as testing for other chronic medical conditions such as hepatitis B or diabetes in settings where HIV prevalence is high, or where clinics serve populations at high risk of HIV infection (such as GUM clinics).

• Implement new models for diagnosing HIV infections outside medical settings.

The CDC will fund new demonstration projects using a rapid, saliva-based HIV antibody test (OraQuick), and will move HIV testing into non-medical settings, as well as placing more emphasis on partner notification and testing.

• Prevent new infections by working with persons diagnosed with HIV and their partners.

In 2003, CDC, in collaboration with the Health Resources and Services Administration (HRSA), the National Institutes of Health, and the HIV Medical Association of the Infectious Diseases Society of America, will publish Recommendations for Incorporating HIV Prevention into the Medical Care of Persons with HIV Infection.

The CDC will also fund demonstration projects using peer-led counseling to reach the partners of people diagnosed with HIV infection.

• Routine perinatal HIV testing.

CDC will promote recommendations for routine HIV testing of all pregnant women, and, as a safety net, for the routine screening of any infant whose mother was not screened.

• National surveillance.

Reporting of HIV infections to public health authorities is now required in 49 states. In 2002, CDC initiated a pilot system to monitor HIV incidence. To track the impact of the new initiative, beginning in 2003, CDC is expanding this surveillance system by implementing a national behavioral surveillance system.