{"id":3427,"date":"2012-11-22T09:52:02","date_gmt":"2012-11-22T14:52:02","guid":{"rendered":"http:\/\/blogs.nejm.org\/?p=3427"},"modified":"2015-06-04T15:13:38","modified_gmt":"2015-06-04T19:13:38","slug":"the-u-s-preventive-services-task-force-recommends-hiv-screening-and-why-is-this-news","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/the-u-s-preventive-services-task-force-recommends-hiv-screening-and-why-is-this-news\/2012\/11\/22\/","title":{"rendered":"The U.S. Preventive Services Task Force Recommends HIV Screening &#8212; And Why is This News?"},"content":{"rendered":"<p><a href=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2012\/11\/15533114_blog1.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignright  wp-image-3432\" title=\"Happy Thanksgiving!\" src=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2012\/11\/15533114_blog-300x2001.jpg\" alt=\"\" width=\"240\" height=\"160\" \/><\/a>A <a href=\"https:\/\/www.google.com\/news?ncl=drWMzJO9LfbYMOMeo-HjLZ48n65hM&amp;q=hiv+testing&amp;lr=English&amp;hl=en\" target=\"_blank\">flurry of coverage<\/a> recently appeared about the\u00a0U.S. Preventive Services Task Force&#8217;s recommendation for one-time HIV screening for all Americans, ages 15-64.<\/p>\n<p>Some might wonder why this is news &#8212; um, hasn&#8217;t this been recommended now for years? &#8212; and I <em>think<\/em> I&#8217;ve figured it out.<\/p>\n<p>Let me start by relaying that every ID\/HIV specialists can tell some version of the following sad story, which is still repeated on a regular basis (including just the other day, in our very own hospital):<\/p>\n<ul>\n<li>Person sees several clinicians over months-years for various medical issues (some combination of fatigue, swollen glands, anemia, thrombocytopenia, skin rashes &#8212; especially zoster).<\/li>\n<li>Many tests (blood tests, X-rays, sometimes even biopsies) are done, but because the person is not identified as being &#8220;at risk&#8221;, no HIV test is sent; or, ironically, he\/she is &#8220;known&#8221; to be HIV negative based on a test done several years ago.<\/li>\n<li>Person eventually shows up in the hospital with some serious complication that all but screams &#8220;AIDS&#8221; &#8212; PCP, toxoplasmosis, cryptococcal meningitis, or even worse, PML or lymphoma &#8212; and the HIV test is finally done, of course returning positive.<\/li>\n<\/ul>\n<p>Because the above sequence of events is all but 100% preventable with early identification of HIV &#8212; and because people who are unaware they are infected continue to spread the virus &#8212; \u00a0<a href=\"http:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/rr5514a1.htm\" target=\"_blank\">in 2006<\/a> (yes, it was that long ago) the CDC made a big splash by recommending one-time HIV screening for adolescent and adult patients in all health care settings.<\/p>\n<p>(They also said that high risk patients should be screened annually &#8212; unfortunately this is all too rarely done, but that&#8217;s an issue for a different day.)<\/p>\n<p>To say that the ID\/HIV provider community (docs, nurses, PAs, social workers) supported the CDC recommendations is like saying dermatologists support wearing sunscreen and a hat in the tropical sun.<\/p>\n<p>&#8220;Support&#8221; just isn&#8217;t strong enough &#8212; we were strongly, unanimously, and vociferously behind them, so much so that virtually every lecture on HIV for the next several years mentioned the guidelines. To us, this was a total no-brainer &#8212; how could anyone oppose screening?<\/p>\n<p>Indeed, the American College of Physicians, the\u00a0American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics all came out with guidelines that said pretty much the same thing.<\/p>\n<p>But not everyone did agree &#8212; namely, on the books already were guidelines from the U.S. Preventive Services Task Force, who had come out with their recommendation in 2005 for risk-based testing only.<\/p>\n<p>For the unaware, the <a href=\"http:\/\/www.ahrq.gov\/clinic\/uspstfix.htm\" target=\"_blank\">USPSTF<\/a> is &#8220;an independent group of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, or preventive medications.&#8221;<\/p>\n<p>I picture these USPSTF folks with hats, T-shirts, and coffee mugs\u00a0emblazoned\u00a0with &#8220;Evidenced-Based Only, Please.&#8221;\u00a0Nothing speaks more clearly about their mission than these slide presentations\u00a0entitled &#8220;<a href=\"http:\/\/www.ahrq.gov\/about\/annualconf09\/brownlee.htm\" target=\"_blank\">Too Much Prevention<\/a>&#8221; and &#8220;<a href=\"http:\/\/www.ahrq.gov\/about\/annualconf09\/lefevre.htm\" target=\"_blank\">What Not to Do in Primary Care<\/a>&#8220;. In plain English, the presenters make the excellent case that many well-intentioned screening strategies don&#8217;t\u00a0help patients &#8212; and actually hurt them by uncovering clinically silent conditions that lead inexorably to procedures and medical treatments that are harmful and expensive.<\/p>\n<p>Most cancer screening (infamously PSA) falls into this category. Cardiac CT. EKGs. Regular physical exams. Spirometry as a screen for COPD. Routine urinalysis. RPR.\u00a0Hepatitis C testing (<a href=\"http:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/rr6104a1.htm\" target=\"_blank\">ahem<\/a>).<\/p>\n<p>And I generally agree with them. But HIV testing? That cheap, accurate test that identifies a clinically silent, eventually deadly infection that is both treatable and can be spread to others? Don&#8217;t they realize that the &#8220;risk based&#8221; testing they favored has been a failure?<\/p>\n<p>Well now they do. In the plain language so characteristic of this committee, <a href=\"http:\/\/annals.org\/article.aspx?articleid=1392192&amp;atab=7\" target=\"_blank\">they write<\/a>:<\/p>\n<blockquote><p>Previous studies have shown that HIV screening is accurate, targeted screening misses a substantial proportion of cases, and treatments are effective in patients with advanced immunodeficiency.\u00a0New [well, &#8220;new&#8221; since 2005!] evidence indicates that ART reduces risk for AIDS-defining events and death in persons with less advanced immunodeficiency and reduces sexual transmission of HIV.<\/p><\/blockquote>\n<div>\n<p>The bottom line is if this group recommends screening, it <em>must<\/em> be the right thing to do. Because these guys are tough.<\/p>\n<div>Welcome to the club, USPSTF.<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>A flurry of coverage recently appeared about the\u00a0U.S. Preventive Services Task Force&#8217;s recommendation for one-time HIV screening for all Americans, ages 15-64. Some might wonder why this is news &#8212; um, hasn&#8217;t this been recommended now for years? &#8212; and I think I&#8217;ve figured it out. Let me start by relaying that every ID\/HIV specialists [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,8,9],"tags":[423,447,960],"class_list":["post-3427","post","type-post","status-publish","format-standard","hentry","category-health-care","category-patient-care","category-policy","tag-hiv","tag-hiv-testing","tag-uspstf"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/3427","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=3427"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/3427\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=3427"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=3427"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=3427"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}