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Screening for HIV: Systematic Review to Update the 2005 U.S. Preventive Services Task Force Recommendation

Roger Chou, MD; Shelley Selph, MD, MPH; Tracy Dana, MLS; Christina Bougatsos, MPH; Bernadette Zakher, MBBS; Ian Blazina, MPH; and P. Todd Korthuis, MD, MPH
[+] Article and Author Information

From Oregon Evidence-based Practice Center and Oregon Health & Science University, Portland, Oregon.

Acknowledgment: The authors thank Laurie Hoyt Huffman, MS, and Jennifer Croswell, MD, MPH, as well as U.S. Preventive Services Task Force leads Susan Curry, PhD; Virginia Moyer, MD, MPH; Wanda Nicholson, MD, MPH, MBA; Timothy Wilt, MD, MPH; and Douglas Owens, MD, MS.

Grant Support: By contract HHSA 290-2007-10057-I, task order 8, from the Agency for Healthcare Research and Quality.

Potential Conflicts of Interest: Dr. Chou: Grant: Agency for Healthcare Research and Quality. Dr. Selph: Payment for writing or reviewing the manuscript: Agency for Healthcare Research and Quality. Dr. Dana: Grant (money to institution): Agency for Healthcare Research and Quality; Grants/grants pending: Agency for Healthcare Research and Quality. Dr. Bougatsos: Other: This manuscript was based on a report funded by the Agency for Healthcare Research and Quality. Dr. Zakher: Grant (money to institution): Agency for Healthcare Research and Quality; Support for travel to meetings for the study or other purposes (money to institution): Agency for Healthcare Research and Quality. Dr. Blazina: Grant (money to institution): Agency for Healthcare Research and Quality; Support for travel to meetings for the study or other purposes (money to institution): Agency for Healthcare Research and Quality. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1193.

Requests for Single Reprints: Roger Chou, MD, Oregon Health & Science University; 3181 Southwest Sam Jackson Park Road, Mail Code BICC, Portland, OR 97239; e-mail, chour@ohsu.edu.

Current Author Addresses: Drs. Chou, Selph, and Korthuis; Ms. Dana; Ms. Bougatsos; Ms. Zakher, and Mr. Blazina: 3181 Southwest Sam Jackson Park Road, Mail Code BICC, Portland, OR 97239.

Author Contributions: Conception and design: R. Chou, P.T. Korthuis.

Analysis and interpretation of the data: R. Chou, S. Selph, T. Dana, C. Bougatsos, B. Zakher, P.T. Korthuis.

Drafting of the article: R. Chou, S. Selph, T. Dana, C. Bougatsos, B. Zakher, I. Blazina.

Critical revision of the article for important intellectual content: R. Chou, T. Dana, B. Zakher, I. Blazina, P.T. Korthuis.

Final approval of the article: R. Chou, B. Zakher, I. Blazina, P.T. Korthuis.

Statistical expertise: R. Chou.

Obtaining of funding: R. Chou.

Administrative, technical, or logistic support: R. Chou, T. Dana, C. Bougatsos, I. Blazina.

Collection and assembly of data: R. Chou, S. Selph, T. Dana, C. Bougatsos, B. Zakher, I. Blazina, P.T. Korthuis.


Ann Intern Med. 2012;157(10):706-718. doi:10.7326/0003-4819-157-10-201211200-00007
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Background: A 2005 U.S. Preventive Services Task Force (USPSTF) review found good evidence that HIV screening is accurate and that antiretroviral therapy (ART) for immunologically advanced disease is associated with substantial clinical benefits, but insufficient evidence to determine the effects on transmission or in less immunologically advanced disease.

Purpose: To update the 2005 USPSTF review on benefits and harms of HIV screening in adolescents and adults, focusing on research gaps identified in the prior review.

Data Sources: MEDLINE (2004 to June 2012) and the Cochrane Library (through the second quarter of 2012).

Study Selection: Randomized trials and observational studies that compared HIV screening strategies and reported clinical outcomes, evaluated the effects of starting ART at different CD4 cell count thresholds and long-term harms, or reported the effects of interventions on transmission risk.

Data Extraction: 2 authors abstracted and checked study details and quality using predefined criteria.

Data Synthesis: No study directly evaluated the effects on clinical outcomes of screening versus no screening for HIV infection. A randomized trial and a subgroup analysis from a randomized trial found that ART initiation at CD4 counts less than 0.250 × 109 cells/L was associated with a higher risk for death or AIDS-defining events than initiation at CD4 counts greater than 0.350 × 109 cells/L (hazard ratios, 1.7 [95% CI, 1.1 to 2.5] and 5.3 [CI, 1.3 to 9.6]). Large, fair-quality cohort studies also consistently found that ART initiation at CD4 counts of 0.350 to 0.500 × 109 cells/L was associated with lower risk for death or AIDS-defining events than delayed initiation. New evidence from good-quality cohorts with longer-term follow-up confirms a previously observed small increased risk for cardiovascular events associated with certain antiretrovirals. Strong evidence from 1 good-quality randomized trial and 7 observational studies found that ART was associated with a 10- to 20-fold reduction in risk for sexual transmission of HIV.

Limitations: Only English-language articles were included. Observational studies were included. Studies done in resource-poor or high-prevalence settings were included but might have limited applicability to general screening in the United States.

Conclusion: 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. New evidence indicates that ART reduces risk for AIDS-defining events and death in persons with less advanced immunodeficiency and reduces sexual transmission of HIV.

Primary Funding Source: Agency for Healthcare Research and Quality.

Figures

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Figure.

Analytic framework and key questions for screening for HIV in nonpregnant adolescents and adults.

HIV Ab = HIV antibody.

* Selected key questions have been omitted from this article. Details on these key questions are available in the full report (13).

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Appendix Figure.

Summary of evidence search and selection.

ART = antiretroviral therapy; RCT = randomized, controlled trial.

* Includes the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews.

† Includes reference lists and sources suggested by peer reviewers.

‡ Some articles are included for more than 1 key question.

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