Resources for Care Providers

Resources for Care Providers

Q/A: HIV Testing

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Updated March 2019 by Aisha Khan, DO, and Christine Kerr, MD

Who Should be Tested for HIV?

What does the NYSDOH AIDS Institute guideline recommend for HIV screening in the general population? Healthcare providers should offer HIV testing to all individuals aged >13 years as part of routine healthcare.

What does NYS public health law require with regard to HIV testing? New York State public health law requires that all individuals aged >13 years receiving care in a primary care setting, an emergency room, or a hospital are offered an HIV test at least once and mandates that care providers offer an HIV test to any person, regardless of age, if there is evidence of activity that puts an individual at risk of HIV acquisition.

Who should be offered ongoing testing for HIV? Healthcare providers should offer an HIV test at least annually to all individuals whose behavior increases their risk for exposure to HIV (such behavior includes condomless anal sex, sex with multiple or anonymous partners, needle-sharing, or sex with partners who share needles). Since many people choose not to disclose risk behaviors, care providers should consider adopting a low threshold for recommending HIV testing.

Also, any individual who has been diagnosed with a sexually transmitted infection (STI) should be offered HIV testing.

How often should HIV screening be performed in individuals who engage in high-risk behavior? Healthcare providers should screen patients who engage in high-risk behavior every 3 months and should provide or refer these individuals for ongoing medical care, risk-reduction counseling and services, and HIV prevention, such as pre-exposure prophylaxis (PrEP). Access to care and prevention are important to maintain the health of individuals at risk and to prevent transmission by those who acquire HIV.

How often should HIV screening be performed in individuals who would not fall into a high-risk behavior category? According to data from the CDC [Dailey, et al. 2017], 1 in 2 individuals with HIV have had the virus at least 3 years before diagnosis. Many of these individuals did not acknowledge themselves to be at high risk. The U.S. Preventative Health Task Force notes that for individuals not engaged in the high-risk behavior outlined above, but are still at increased risk, a somewhat longer interval (for example, 3 to 5 years) may be adopted [U.S. Preventive Services Task Force 2016]. A change in sexual partner or marital status merits repeat HIV screening. Routine rescreening may not be necessary for individuals who have not been at increased risk since they were found to be HIV-negative. Women screened during a previous pregnancy should be rescreened in subsequent pregnancies.

Is written consent required before an HIV test is ordered? As of May 17, 2017, neither written nor oral consent is needed before ordering an HIV test; however, patients must be informed that an HIV test will be performed and they may opt out.

What is the best test to use for HIV screening? The optimal test for screening is a 4th-generation HIV 1/2 antigen/antibody (Ag/Ab) immunoassay, which is a laboratory-based test that uses serum or plasma.

Can a rapid point-of-care test be used for HIV screening? Yes, although it will detect antibodies later in the course of HIV infection and may miss early infection in many cases. There are also newer point-of-care tests that detect antigen and, therefore, earlier infection. It is worth clarifying with your facility which rapid test is used.

Which HIV test should be performed in an individual who has been diagnosed with an STI? The optimal HIV test is always a 4th-generation HIV Ag/Ab blood test.

Should a 4th-generation Ag/Ab HIV test be used to screen for HIV in individuals who are taking PrEP? Yes, that is the optimal test. A rapid point-of-care test can be performed at the same time so patients have an immediate answer, but the rapid test should not replace the 4th-generation Ag/Ab test. If exposure is recent (within past 10 days) or patient has signs or symptoms of acute HIV, an HIV RNA test should be ordered.

HIV Testing Follow-Up

What follow-up is recommended if the 4th-generation HIV Ag/Ab test is reactive but the confirmatory HIV-1/2 differentiation assay is indeterminate or negative? An HIV-1 viral load test will differentiate acute HIV infection from a false positive screening result.

What follow-up is recommended if an individual has a reactive point-of-care rapid test (such as OraQuick)? As follow-up, the healthcare provider should:

  • Perform a 4th-generation HIV Ag/Ab test and counsel the patient that the result of the rapid test is preliminary pending the result of the confirmatory HIV test and follow-up differentiation assay.
  • Discuss the patient’s option of starting antiretroviral therapy (ART) while awaiting confirmatory test results.
  • Screen for suicidality and domestic violence and make sure the patient is safe.
  • Make sure a return appointment is scheduled so test results can be delivered in person.

What follow-up is recommended when a patient’s 4th-generation HIV Ag/Ab test is reactive? In this scenario, the healthcare provider should:

  • Have the patient’s specimens tested for HIV-1 and HIV-2 antibodies. Order HIV 1/ 2 Ag/Ab assay with reflex. Always include “with reflex” so if indicated, additional recommended tests are conducted on the same specimen.
  • If the results are negative or indeterminate, then perform an HIV-1 RNA test.
  • Interpret the final result based on a combination of test results. The NYSDOH Testing Toolkit provides more information about HIV diagnostic tests and the CDC’s Recommended Laboratory HIV Testing Algorithm for Serum or Plasma Specimens. The NYSDOH AIDS Institute guideline HIV Testing may be consulted as well.
  • Discuss ART initiation at the time of a positive result with the first rapid test. Initiation of ART during acute infection may have a number of beneficial clinical outcomes.
  • When a diagnosis of acute HIV infection is made, discuss the importance of notifying all recent contacts and refer patients to partner notification services, as mandated by New York State Law. The Department of Health can provide assistance if necessary.

What follow-up is recommended if an individual’s HIV test is negative but they remain at high risk of acquiring HIV? In this scenario, the healthcare provider should discuss and/or recommend PrEP and ensure that the patient has access to PrEP services. The healthcare provider should also provide risk-reduction counseling (e.g., safer sex practices, needle exchange, post-exposure prophylaxis [PEP]) and advise retesting for HIV every 3 months for as long as the individual is at risk.

Detection of HIV

How soon after infection can HIV be detected with existing HIV tests? The length of time depends on which HIV test is used. The “window period” is the time between acquiring HIV infection and the time when a specific diagnostic test can detect HIV. For example, as early as approximately 10 days after infection, a 4th-generation Ag/Ab test may be positive for HIV, reliably up to 28 days afterwards (window period). It takes approximately 7 days after infection for HIV viral load to be detectable on an HIV RNA test. For an HIV antibody test with reflex to Western blot, there is a window period of up to 3 months (updated May 28, 2019).

Can a person who has HIV transmit the virus to another person during the window period? Yes.

Acute HIV Infection

What is acute HIV infection and when should it be considered? Acute HIV infection is the very early initial stage of HIV infection when the virus is multiplying rapidly and the body has not yet developed antibodies to fight it. Clinicians should consider acute HIV infection if a patient presents with a clinical syndrome consistent with acute HIV. 

What are the symptoms of acute HIV infection? Symptoms of acute HIV infection are similar to those of influenza and may include fever, fatigue, malaise, joint pains, headache, loss of appetite, rash, night sweats, myalgia, nausea, diarrhea, and pharyngitis.

Which laboratory tests should be ordered for an individual who is suspected to have acute HIV? The healthcare provider should order an HIV-1 RNA test (viral load) and a 4th-generation HIV Ag/Ab HIV test.

  • If HIV RNA is not detected, then no further testing is needed.
  • Detection of ≥5,000 copies/mL of HIV RNA indicates a preliminary diagnosis of HIV infection.
  • Detection of HIV RNA with <5,000 copies/mL requires repeat HIV RNA testing.
  • If a diagnosis of HIV infection is made on the basis of HIV RNA testing alone, then the clinician should collect a new specimen 3 weeks after the first and repeat HIV diagnostic testing.
KEY POINT
  • When acute infection is suspected, an HIV RNA assay should always be requested in conjunction with an HIV screening test.

Is a person with acute HIV able to transmit the virus to others? Yes. A person’s HIV viral load rises quickly during the acute phase, which makes the virus highly transmissible.

When treating a pregnant individual who has acute HIV, should the healthcare provider consult with a specialist? If acute HIV infection is suspected in a pregnant individual, the care provider should first order HIV RNA testing and a 4th-generation (recommended) or 3rd-generation (alternative) HIV test. If the HIV RNA test is positive or the HIV test is reactive, then, as soon as possible, the care provider should consult with or refer the patient to a clinician who is experienced in diagnosing and evaluating acute HIV infection.

KEY POINT

PrEP and PEP

Should all patients who are tested for HIV be offered PrEP? PrEP should be offered to all individuals whose behavior may expose them to HIV. PrEP should be prescribed as part of a comprehensive prevention strategy that includes risk-reduction counseling about safer sex practices, condom use, and safer injection practices, as well as referral to syringe exchange programs and drug treatment services when appropriate.

KEY POINT

What is the recommended response to an individual who reports a possible exposure to HIV? Exposure to HIV is a medical emergency that requires prompt response.

  • A person who reports a potential exposure to HIV should be given a first dose of antiretroviral medications for PEP immediately (ideally within 2 hours of the exposure). The effectiveness of PEP diminishes over time, and PEP is not effective if initiated more than 72 hours after a potential exposure.
  • Once the first dose of PEP has been administered, then the evaluation of the exposure and recommended testing of the exposed individual and the source (if available) can be performed.
  • Refer to the NYSDOH AI guidelines on PEP for more information, including recommendations for PEP regimens and follow-up HIV testing. Guidelines are available for PEP following occupational and non-occupational exposure to HIV and following sexual assault.

Should an individual who has been exposed to HIV be tested more than once? The NYSDOH AI guideline recommends serial HIV testing, with the first test at baseline (at the time the person presents for PEP) and then at 4 and 12 weeks after the exposure.

Where can I learn more about PEP (including the antiretroviral medications used for PEP) and PrEP? See the NYSDOH AI guidelines PEP for HIV Prevention and PrEP to Prevent HIV and Promote Sexual Health.

How to Find an Expert in HIV Care

How do I locate a healthcare provider with experience in treating patients with HIV, for consultation or referral? The NYSDOH Clinical Education Initiative (CEI) provides access to HIV specialists through their toll-free CEI Line: 1-866-637-2342.

How to Learn More

References

Dailey AF, Hoots BE, Hall HI, et al. Vital Signs: Human Immunodeficiency Virus Testing and Diagnosis Delays – United States. MMWR Morb Mortal Wkly Rep 2017;66(47):1300-1306. [PMID: 29190267]

U.S. Preventive Services Task Force. Final Recommendation Statement Human Immunodeficiency Virus (HIV) Infection: Screening. 2016 Dec. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/human-immunodeficiency-virus-hiv-infection-screening#consider [accessed 2019 Mar 19] 

HIV Care Provider Definitions

New York State Department of Health AIDS Institute, April 2017

Experienced HIV care provider: Practitioners who have been accorded HIV-Experienced Provider status by the American Academy of HIV Medicine (AAHIVM) or have met the HIV Medicine Association’s (HIVMA) definition of and experienced provider are eligible for designation as an HIV Experienced Provider in New York State.

Nurse practitioners and licensed midwives who provide clinical care to HIV-Infected individuals in collaboration with a physician may be considered HIV Experienced Providers provided that all other practice agreements are met (8 NYCRR 79-5:1; 10 NYCRR 85.36; 8 NYCRR 139-6900)

Physician assistants who provide clinical care to HIV-infected individuals under the supervision of an HIV Specialist physician may also be considered HIV Experienced Providers (10 NYCRR 94.2)

Expert HIV care provider: A provider with extensive experience in the management of complex patients with HIV.

Online Resources for Education, Information, and Services

May 2019

EDUCATION

GUIDELINES

LAW

SERVICES

GOALS Framework for Sexual History Taking in Primary Care

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Developed by Sarit A. Golub, PhD, MPH, Hunter College and Graduate Center, City University of New York, in collaboration with the NYC Department of Health and Mental Hygiene, Bureau of HIV, July 2019

Background: Sexual history taking can be an onerous and awkward task that does not always provide accurate or useful information for patient care. Standard risk assessment questions (e.g., How many partners have you had sex with in the last 6 months?; How many times did you have receptive anal sex with a man when he did not use a condom?) may be alienating to patients, discourage honest disclosure, and communicate that the number of partners or acts is the only component of sexual risk and health.

In contrast, the GOALS framework is designed to streamline sexual history conversations and elicit information most useful for identifying an appropriate clinical course of action.

The GOALS framework was developed in response to 4 key findings from the sexual health research literature:

  1. Universal HIV/STI screening and biomedical prevention education is more beneficial and cost-effective than risk-based screening [Wimberly, et al. 2006; Hoots, et al. 2016; Owusu-Edusei, et al. 2016; Hull, et al. 2017; Lancki, et al. 2018].
  2. Emphasizing benefits—rather than risks—is more successful in motivating patients toward prevention and care behavior [Weinstein and Klein 1995; Schuz, et al. 2013; Sheeran, et al. 2014].
  3. Positive interactions with healthcare providers promote engagement in prevention and care [Bakken, et al. 2000; Alexander, et al. 2012; Flickinger, et al. 2013].
  4. Patients want their healthcare providers to talk with them about sexual health [Marwick 1999; Ryan, et al. 2018].

Rather than seeing sexual history taking as a means to an end, the GOALS framework considers the sexual history taking process as an intervention that will:

  • Increase rates of routine HIV/STI screening;
  • Increase rates of universal biomedical prevention and contraceptive education;
  • Increase patients’ motivation for and commitment to sexual health behavior; and
  • Enhance the patient-care provider relationship, making it a lever for sexual health specifically and overall health and wellness in general.

The GOALS framework includes 5 steps:

  1. Give a preamble that emphasizes sexual health. The healthcare provider briefly introduces the sexual history in a way that de-emphasizes a focus on risk, normalizes sexuality as part of routine healthcare, and opens the door for the patient’s questions.
  2. Offer opt-out HIV/STI testing and information. The healthcare provider tells the patient that they test everyone for HIV and STIs, normalizing both testing and HIV and STI concerns.
  3. Ask an open-ended question. The healthcare provider starts the sexual history taking with an open-ended question that allows them to identify the aspects of sexual health that are most important to the patient, while allowing them to hear (and then mirror) the language that the patient uses to describe their body, partner(s), and sexual behaviors.
  4. Listen for relevant information and fill in the blanks. The healthcare provider asks more pointed questions to elicit information that might be needed for clinical decision-making (e.g., 3-site versus genital-only testing), but these questions are restricted to specific, necessary information. For instance, if a patient has already disclosed that he is a gay man with more than 1 partner, there is no need to ask about the total number of partners or their HIV status in order to recommend STI/HIV testing and PrEP education.
  5. Suggest a course of action. Consistent with opt-out testing, the healthcare provider offers all patients HIV testing, 3-site STI testing, PrEP education, and contraceptive counseling, unless any of this testing is specifically contraindicated by the sexual history. Rather than focusing on any risk behaviors the patient may be engaging in, this step focuses specifically on the benefits of engaging in prevention behaviors, such as exerting greater control over one’s sex life and sexual health and decreasing anxiety about potential transmission.

Resources for implementation:

  • Script, rationale, and goals: Box 1, below, provides a suggested script for each step in the GOALS framework, along with the specific rationale for that step and the goal it is designed to accomplish.
  • The 5Ps model for sexual history-taking (CDC): Note that the GOALS framework is not designed to completely replace the 5Ps model (partners, practices, protection from STI, past history of STI, prevention of pregnancy); instead, it provides a framework for identifying information related to the 5Ps that improves patient-care provider communication, reduces the likelihood of bias or missed opportunities, and enhances patients’ motivation for prevention and sexual health behavior.
Box 1: GOALS Framework for the Sexual History [download chart PDF]
Component Suggested Script Rationale and Goal Accomplished
Give a preamble that emphasizes sexual health. I’d like to talk with you for a couple of minutes about your sexuality and sexual health. I talk to all of my patients about sexual health, because it’s such an important part of overall health. Some of my patients have questions or concerns about their sexual health, so I want to make sure I understand what your questions or concerns might be and provide whatever information or other help you might need.
  • Focuses on sexual health, not risk.
  • Normalizes sexuality as part of health and healthcare.
  • Opens the door for the patient’s questions.
  • Clearly states a desire to understand and help.
Offer opt-out HIV/STI testing and information. First, I like to test all my patients for HIV and other sexually transmitted infections. Do you have any concerns about that?
  • Doesn’t commit to specific tests, but does normalize testing.
  • Sets up the idea that you will recommend some testing regardless of what the patient tells you.
  • Opens the door for the patient to talk about HIV or STIs as a concern.
Ask an open-ended question.

Pick one (or use an open-ended question that you prefer):

  • Tell me about your sex life.
  • What would you say are your biggest sexual health questions or concerns?
  • How is your current sex life similar or different from what you think of as your ideal sex life?
  • Puts the focus on the patient.
  • Lets you hear what the patient thinks is most important first.
  • Lets you hear the language the patient uses to talk about their body, partners, and sex.
Listen for relevant information and probe to fill in the blanks.
  • Besides [partner(s) already disclosed], tell me about any other sexual partners.
  • How do you protect yourself against HIV and STIs?
  • How do you prevent pregnancy (unless you are trying to have a child)?
  • What would help you take (even) better care of your sexual health?
  • Makes no assumption about monogamy or about gender of partners.
  • Avoids setting up a script for over-reporting condom use.
  • Can be asked of patients regardless of gender.
  • Increases motivation by asking the patient to identify strategies/ interventions.
Suggest a course of action.
  • So, as I said before, I’d like to test you for [describe tests indicated by sexual history conversation].
  • I’d also like to give you information about PrEP/contraception/other referrals. I think it might be able to help you [focus on benefit].
  • Allows you to tailor STI testing to the patient so they don’t feel targeted.
  • Shows that you keep your word.
  • Allows you to couch education or referral in terms of relevant benefits, tailored to the specific patient.
References

Alexander JA, Hearld LR, Mittler JN, et al. Patient-physician role relationships and patient activation among individuals with chronic illness. Health Serv Res 2012;47(3 Pt 1):1201-1223. [PMID: 22098418]

Bakken S, Holzemer WL, Brown MA, et al. Relationships between perception of engagement with health care provider and demographic characteristics, health status, and adherence to therapeutic regimen in persons with HIV/AIDS. AIDS Patient Care STDS 2000;14(4):189-197. [PMID: 10806637]

Flickinger TE, Saha S, Moore RD, et al. Higher quality communication and relationships are associated with improved patient engagement in HIV care. J Acquir Immune Defic Syndr 2013;63(3):362-366. [PMID: 23591637]

Hoots BE, Finlayson T, Nerlander L, et al. Willingness to take, use of, and indications for pre-exposure prophylaxis among men who have sex with men-20 US cities, 2014. Clin Infect Dis 2016;63(5):672-677. [PMID: 27282710]

Hull S, Kelley S, Clarke JL. Sexually transmitted infections: Compelling case for an improved screening strategy. Popul Health Manag 2017;20(S1):S1-S11. [PMID: 28920768]

Lancki N, Almirol E, Alon L, et al. Preexposure prophylaxis guidelines have low sensitivity for identifying seroconverters in a sample of young Black MSM in Chicago. AIDS 2018;32(3):383-392. [PMID: 29194116]

Marwick C. Survey says patients expect little physician help on sex. JAMA 1999;281(23):2173-2174. [PMID: 10376552]

Owusu-Edusei K, Jr., Hoover KW, Gift TL. Cost-effectiveness of opt-out chlamydia testing for high-risk young women in the U.S. Am J Prev Med 2016;51(2):216-224. [PMID: 26952078]

Ryan KL, Arbuckle-Bernstein V, Smith G, et al. Let’s talk about sex: A survey of patients’ preferences when addressing sexual health concerns in a family medicine residency program office. 2018;2. https://journals.stfm.org/primer/2018/ryan-2018-0004

Schuz N, Schuz B, Eid M. When risk communication backfires: randomized controlled trial on self-affirmation and reactance to personalized risk feedback in high-risk individuals. Health Psychol 2013;32(5):561-570. [PMID: 23646839]

Sheeran P, Harris PR, Epton T. Does heightening risk appraisals change people’s intentions and behavior? A meta-analysis of experimental studies. Psychol Bull 2014;140(2):511-543. [PMID: 23731175]

Weinstein ND, Klein WM. Resistance of personal risk perceptions to debiasing interventions. Health Psychol 1995;14(2):132-140. [PMID: 7789348]

Wimberly YH, Hogben M, Moore-Ruffin J, et al. Sexual history-taking among primary care physicians. J Natl Med Assoc 2006;98(12):1924-1929. [PMID: 17225835]