Roger Chou, MD; Laurie Hoyt Huffman, MS; Rongwei Fu, PhD; Ariel K. Smits, MD, MPH; P. Todd Korthuis, MD, MPH
Chou R, Huffman LH, Fu R, Smits AK, Korthuis PT. Screening for HIV: A Review of the Evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2005;143:55-73. doi: 10.7326/0003-4819-143-1-200507050-00010
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Published: Ann Intern Med. 2005;143(1):55-73.
HIV infection affects 850â€‰000 to 950â€‰000 persons in the United States. The management and outcomes of HIV infection have changed substantially since the U.S. Preventive Services Task Force issued recommendations in 1996.
To synthesize the evidence on risks and benefits of screening for HIV infection.
MEDLINE, the Cochrane Library, reference lists, and experts.
Studies of screening, risk factor assessment, accuracy of testing, follow-up testing, and efficacy of interventions.
Data on settings, patients, interventions, and outcomes were abstracted for included studies; quality was graded according to criteria developed by the Task Force.
No trials directly link screening for HIV with clinical outcomes. Many HIV-infected persons in the United States currently receive diagnosis at advanced stages of disease, and almost all will progress to AIDS if untreated. Screening based on risk factors could identify persons at substantially higher risk but would miss a substantial proportion of those infected. Screening tests for HIV are extremely (>99%) accurate. Acceptance rates for screening and use of recommended interventions vary widely. Highly active antiretroviral therapy (HAART) substantially reduces the risk for clinical progression or death in patients with immunologically advanced disease. Along with other adverse events, HAART is associated with an increased risk for cardiovascular complications, although absolute rates are low after 3 to 4 years.
Data are insufficient to estimate the effects of screening and interventions on transmission rates or in patients with less immunologically advanced disease. Long-term data on adverse events associated with HAART are not yet available.
Benefits of HIV screening appear to outweigh harms. The yield from screening higher-prevalence populations would be substantially higher than that from screening the general population.
Key Question (KQ) 1: Does screening for HIV infection in asymptomatic adolescents and adults reduce premature death and disability or spread of disease? KQ 2: Can clinical or demographic characteristics (including specific settings) identify subgroups of asymptomatic adolescents and adults at increased risk for HIV compared to the general population? KQ 3: What are the test characteristics of HIV antibody test strategies? KQ 4: What are the harms (including labeling and anxiety) associated with screening? Is screening acceptable to patients? KQ 5: How many newly diagnosed HIV-positive patients meet criteria for antiretroviral treatment or prophylaxis against opportunistic infections? How many patients who meet criteria for interventions receive them? KQ 6: What are the harms associated with the work-up for HIV infection? KQ 7: a) How effective are interventions (antiretroviral treatment, counseling on risky behaviors, immunizations, routine monitoring and follow-up, more frequent Papanicolaou testing, or prophylaxis against opportunistic infections) in improving clinical outcomes (mortality, functional status, quality of life, symptoms, opportunistic infections, or transmission rates)? b) In asymptomatic patients with HIV infection, does immediate antiretroviral treatment result in improvements in clinical outcomes compared to delayed treatment until the patient is symptomatic? c) How well do interventions reduce the rate of viremia, improve CD4 counts, or reduce risky behaviors? KQ 8: What are the harms associated with antiretroviral therapy? KQ 9: Have improvements in intermediate outcomes (CD4 counts, viremia, risky behaviors) been shown to reduce premature death and disability or spread of disease? KQ 10: What is the cost-effectiveness of screening for HIV infection? *Excluding pregnant women, patients undergoing dialysis, and patients receiving transplants. A separate report reviews KQs 6, 7c, 9, and portions of 7a (immunizations, routine monitoring and follow-up, and more frequent Papanicolaou testing).
exp hiv infections/ or exp hiv/
exp Viral Hepatitis Vaccines/
exp Influenza Vaccine/
exp Bacterial Vaccines/
2 or 3 or 4
1 and 5
exp Immunization Programs/
7 or 8
10 or 11 or 12
1 and 9 and 13
6 or 14
exp Evaluation Studies/
exp Epidemiologic Studies/
16 or 17 or 18
15 and 19
limit 15 to (clinical trial or guideline or meta analysis or multicenter study or practice guideline)
20 or 21
limit 22 to (human and english language)
from 23 keep 1-206
exp AIDS-Related Opportunistic Infections/pc [Prevention & Control]
exp HIV Infections/co [Complications]
exp AIDS-Related Opportunistic Infections/
2 and (3 or 4)
1 or 5
limit 6 to (human and english language and (clinical trial or guideline or meta analysis or multicenter study or practice guideline))
from 7 keep 1-396
exp HIV Infections/ or exp HIV/
1 and 2
exp impulsive behavior/ or risk reduction behavior/ or risk-taking/
1 and 4
3 or 5
7 or 8 or 9
6 and 10
limit 6 to (clinical trial or guideline or meta analysis or multicenter study or practice guideline)
11 or 12
limit 13 to (human and english language)
from 14 keep 1-1272
exp HIV Infections/mo, ep, eh, et, tm, pc [Mortality, Epidemiology, Ethnology, Etiology, Transmission, Prevention & Control]
limit 3 to (human and english language and (clinical trial or guideline or meta analysis or multicenter study or practice guideline))
4 or 7
9 or 10 or 11
(3 or 6) and 12
from 8 keep 1-573
exp AIDS Serodiagnosis/
exp HIV SERONEGATIVITY/ or exp HIV ANTIGENS/ or exp HIV/ or exp HIV SEROPREVALENCE/ or exp HIV SEROPOSITIVITY/ or exp HIV ANTIBODIES/
exp Mass Screening/
2 and 3
1 or 4
exp “Sensitivity and Specificity”/
5 and 6
exp stress, psychological/
Life Change Events/
exp prejudice/ or prejudic$.mp.
8 or 9 or 10 or 11
5 and 12
exp diagnostic errors/
5 and 14
7 or 13 or 15
exp longitudinal studies/
17 or 18 or 19
16 and 20
limit 16 to (clinical trial or guideline or meta analysis or multicenter study or practice guideline or review)
22 or 21
limit 23 to (human and english language)
limit 23 to (human and abstracts)
24 or 25
from 26 keep 1-247
exp HIV Infections/dt [Drug Therapy]
exp HIV/de [Drug Effects]
1 or 2
exp Reverse Transcriptase Inhibitors/ad, tu
exp HIV Protease Inhibitors/ad, tu
exp anti-hiv agents/ad, tu
4 or 5 or 6
3 and 7
limit 8 to (human and english language and (clinical trial or guideline or meta analysis or multicenter study or practice guideline))
exp Reverse Transcriptase Inhibitors/ae, ct, to, po
exp HIV Protease Inhibitors/ae, ct, to, po
exp anti-hiv agents/ae, ct, to, to
3 and 13
limit 14 to (human and english language and (clinical trial or guideline or meta analysis or multicenter study or practice guideline))
14 and exp epidemiologic studies/
14 and (exp evaluation studies/ or exp comparative study/)
16 or 17
limit 18 to (human and english language)
15 or 19
limit 9 to yr = 1998-2003
from 21 keep 1-1157
limit 20 to yr = 1998-2003
from 23 keep 1-732
from 24 keep 1-732
viral load.mp. or Viral Load/
exp HIV Infections/
2 or 3
(exp leukocyte count/ and cd4.mp.) or exp cd4 lymphocyte count/
exp “pathological conditions, signs and symptoms”/ or disease progression/
7 and 8 and 9
exp “sensitivity and specificity”/
10 and 11
exp epidemiologic studies/
10 and 13
limit 10 to (human and english language and (clinical trial or guideline or meta analysis or multicenter study or practice guideline))
limit 14 to (human and english language)
15 or 16
from 17 keep 1-232
exp HIV/ or exp HIV INFECTIONS/
exp Anti-HIV Agents/ad, ae, po, ct, tu, to [Administration & Dosage, Adverse Effects, Poisoning, Contraindications, Therapeutic Use, Toxicity]
exp Reverse Transcriptase Inhibitors/ad, ae, po, ct, tu, to [Administration & Dosage, Adverse Effects, Poisoning, Contraindications, Therapeutic Use, Toxicity]
exp HIV Protease Inhibitors/ad, ae, po, tu, ct, to [Administration & Dosage, Adverse Effects, Poisoning, Therapeutic Use, Contraindications, Toxicity]
1 and (2 or 3 or 4)
exp Disease Transmission, Vertical/
exp HIV Infections/tm
pregnancy complications/ or exp pregnancy complications, infectious/
6 or 7
8 or 9
limit 13 to (human and english language and (clinical trial or guideline or meta analysis or multicenter study or practice guideline))
15 or 16 or 17
13 and 18
limit 19 to (human and english language)
14 or 20
from 21 keep 1-373
exp cesarean section/
1 and (2 or 3 or 4 or 5)
9 or 10
11 and 12
6 and 13
14 and 19
limit 20 to (human and english language)
15 or 21
exp “Costs and Cost Analysis”/
3 and 4
exp epidemiologic study characteristics/
5 and (6 or 7 or 8)
limit 9 to (human and english language)
9 and 11
5 and 11
3 and 15
16 and 11
limit 17 to (human and english language)
14 or 18
from 19 keep 1-179
hiv/de [mh] OR hiv infections/dt [mh]
anti hiv agents[pa] OR reverse transcriptase inhibitors[pa] OR hiv protease inhibitors [pa]
#1 OR #2
evaluation studies[mh] OR epidemiologic studies[mh] OR comparative study [mh]
#3 AND #4
tu[sh] OR ad[sh] OR ae[sh] OR to[sh] OR po[sh] OR ct[sh]
#5 AND #6
#7 AND systematic [sb]
#8 AND Limits: Publication Date from 1989 to 1997, English, Human
Screening test relevant, available for primary care, adequately described.
Credible reference standard, performed regardless of test results.
Reference standard interpreted independently of screening test.
Indeterminate results handled in a reasonable manner.
Spectrum of patients included in study.
Administration of reliable screening test.
Initial assembly of comparable groups: randomized, controlled trials—adequate randomization, including concealment and statement of whether potential confounders were distributed equally among groups; cohort studies—consideration of potential confounders with either restriction or measurement for adjustment in the analysis; consideration of inception cohorts.
Maintenance of comparable groups (includes attrition, crossovers, adherence, and contamination).
Important differential loss to follow-up or overall high loss to follow-up.
Measurements: equal, reliable, and valid (includes masking of outcome assessment).
Clear definition of interventions.
Important outcomes considered.
Analysis: adjustment for potential confounders for cohort studies, or intention-to-treat analysis for randomized, controlled trials.
Accurate ascertainment of cases.
Nonbiased selection of case-patients and controls, with exclusion criteria applied equally to both.
Diagnostic testing procedures applied equally to each group.
Measurement of exposure accurate and applied equally to each group.
Appropriate attention to potential confounding variable.
Are interventions and populations compared appropriate?
Is the study conducted from the societal perspective?
Is the time horizon clinically appropriate and relevant to the study question?
Are all important drivers of effectiveness included?
Are key harms included?
Is the best available evidence used to estimate effectiveness?
Are long-term outcomes used?
Do effect measures capture preferences or utilities?
Are all appropriate downstream costs included?
Are charges converted to costs appropriately?
Are the best available data used to estimate costs?
Are incremental cost-effectiveness ratios presented?
Are appropriate sensitivity analyses performed?
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