Selected Resources

Download Q&A PDF

Lead authors: Aisha Khan, DO, and Christine Kerr, MD, updated March 2019

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 old 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 old receiving care in a primary care setting, an emergency room, or a hospital be offered an HIV test at least once. The law also 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?
Patients who engage in high-risk behavior should be screened every 3 months. Healthcare providers 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 do not fall into a high-risk behavior category? 
According to data from the Centers for Disease Control and Prevention (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. Preventive Services Task Force notes that for individuals not engaged in the high-risk behavior outlined above but still at increased risk, a somewhat longer interval (for example, 3 to 5 years) may be adopted [U.S. Preventive Services Task Force 2019]. A change in sex 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.

Consent

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.

Recommended HIV Test

What is the best test to use for HIV screening? 
The optimal test for screening is an HIV antigen/antibody (Ag/Ab) combination 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 antigens 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 an HIV Ag/Ab combination immunoassay.

Should an Ag/Ab HIV combination immunoassay 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  Ag/Ab combination immunoassay. If exposure is recent (within the past 10 days) or the 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 HIV Ag/Ab combination immunoassay is reactive but the confirmatory HIV-1/2 Ab differentiation immunoassay 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 an HIV Ag/Ab combination immunoassay and counsel the patient that the result of the rapid test is preliminary pending the result of the confirmatory HIV test and follow-up Ab differentiation immunoassay.
• 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 HIV Ag/Ab combination immunoassay is reactive? 
In this scenario, the healthcare provider should:

• Have the patient’s specimens tested for HIV-1 and HIV-2 antibodies using an Ab differentiation immunoassay 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/Association of Public Health Laboratories (APHL) Laboratory Testing Algorithm in Serum/Plasma. 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 18 days after infection, an Ag/Ab combination immunoassay may be positive for HIV, reliably up to 45 days (window period for laboratory test) or 90 days (window period for rapid test) afterward. It takes approximately 10 days after infection for HIV viral load to be detectable on an HIV RNA test.

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 of having acute HIV? 
The healthcare provider should order an HIV-1 RNA test (viral load) and an HIV Ag/Ab combination immunoassay.

• 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.

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 an Ag/Ab combination immunoassay (recommended) or Ab differentiation immunoassay (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.

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.

What is the recommended response to an individual who reports a possible exposure to HIV? 
Exposure to HIV is a medical emergency that requires a 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 evaluation of the exposure and recommended testing of the exposed individual and the source (if available) can be performed.
• Refer to the NYSDOH AI guideline 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 PEP to Prevent HIV Infection 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 exposure.

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

• NYSDOH AI Provider Directory
• NYSDOH AI Designated AIDS Centers

How to Learn More

• Related NYSDOH AI Clinical Guidelines:
  • HIV Testing
  • Diagnosis and Management of Acute HIV
  • Rapid ART Initiation
  • Selecting an Initial ART Regimen
  • NYS Good Practices to Prevent Perinatal HIV Transmission
  • PEP to Prevent HIV Infection
  • PrEP to Prevent HIV and Promote Sexual Health
  • STI Care
• NYSDOH: HIV Testing, Reporting and Confidentiality in New York State 2017-18 Update: Fact Sheet and Frequently Asked Questions
• NYSDOH: 2018 Guidelines for use of the HIV Diagnostic Testing Algorithm for Laboratories

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. Human Immunodeficiency Virus (HIV) Infection: Screening. 2019 Jun 11. https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/human-immunodeficiency-virus-hiv-infection-screening#consider [accessed 2019 Mar 19]

Download Printable PDF of GOALS Framework

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

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.

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. PRiMER 2018;2:23. [PMID: 32818195] 

Schüz N, Schüz 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]