Skip Navigation
American College of Physicians Logo
  • Subscribe
  • Submit a Manuscript
  • Sign In
    Sign in below to access your subscription for full content
    INDIVIDUAL SIGN IN
    Sign In|Set Up Account
    You will be directed to acponline.org to register and create your Annals account
    INSTITUTIONAL SIGN IN
    Open Athens|Shibboleth|Log In
    Annals of Internal Medicine
    SUBSCRIBE
    Subscribe to Annals of Internal Medicine.
    You will be directed to acponline.org to complete your purchase.
Annals of Internal Medicine Logo Menu
  • Latest
  • Issues
  • Channels
  • CME/MOC
  • In the Clinic
  • Journal Club
  • Web Exclusives
  • Author Info
Advanced Search
  • ‹ PREV ARTICLE
  • This Issue
  • NEXT ARTICLE ›
Editorials |5 December 2006

To Screen or Not to Screen: Is That Really the Question? Free

Bernard M. Branson, MD

Bernard M. Branson, MD
From the Centers for Disease Control and Prevention–Division of HIV/AIDS Prevention, Atlanta, Georgia.

Article, Author, and Disclosure Information
Author, Article, and Disclosure Information
  • From the Centers for Disease Control and Prevention–Division of HIV/AIDS Prevention, Atlanta, Georgia.

    Disclaimer: The findings and conclusions in this report are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.

    Potential Financial Conflicts of Interest: None disclosed.

    Requests for Single Reprints: Bernard M. Branson, MD, CDC–Division of HIV/AIDS Prevention, 1600 Clifton Road, MS D-21, Atlanta, GA 30333; e-mail, bmb2@cdc.gov.

×
  • ‹ PREV ARTICLE
  • This Issue
  • NEXT ARTICLE ›
Jump To
  • Full Article
  • FULL ARTICLE
  • FULL ARTICLE
      1. References
  • Figures
  • Tables
  • Supplements
  • Audio/Video
  • Summary for Patients
  • Clinical Slide Sets
  • CME / MOC
  • Comments
  • Twitter Link
  • Facebook Link
  • Email Link
More
  • LinkedIn Link
  • CiteULike Link
Few diagnostic tests or screening procedures have engendered as much controversy as the HIV test. From the inception of HIV testing, unique social issues have complicated deliberations about HIV testing. In 1985, when the HIV antibody test was first introduced, evidence suggested that approximately half of persons who were antibody-positive would become persistently infected carriers, and only 10% would develop AIDS (1).
No effective treatment existed, and specific pretest counseling evolved (based on models used with genetic testing for untreatable conditions) to ensure that persons who sought HIV testing were aware of the uncertain meaning of a positive test result. In the context of widespread fear, stigma, and concern about discrimination, many states adopted requirements for separate written consent for HIV testing and established dedicated HIV testing sites, often outside of health care facilities, to allow anonymous testing. Routine HIV screening was unheard of except for blood donors.
Once studies showed that HIV was highly fatal, the Centers for Disease Control and Prevention (CDC) recommended HIV counseling and testing for persons at high risk and patients at hospitals with HIV prevalence rates greater than 1%. The discovery that zidovudine prophylaxis reduced perinatal transmission by two thirds led directly to a recommendation to screen all pregnant women. As of 2002, 38% of adults aged 18 to 64 years (68 million people) reported that they had been tested for HIV at least once; an estimated 16 to 18 million adults are tested annually (2). However, an estimated one quarter of the approximately 1 million to 1.2 million HIV-infected persons in the United States are unaware that they are infected (3). Infection often remains undiagnosed until late in the course of disease despite multiple encounters with the health care system (4, 5). With the advent of effective treatment, clinicians and public health officials have increasingly called for expanded routine screening (6, 7), and the CDC recently recommended HIV screening in health care settings for all patients aged 13 to 64 years (8).
In this issue, Paltiel and colleagues (9) examine the cost-effectiveness of HIV screening with rapid tests, using a sophisticated cost–utility analysis that expresses benefits as gains in quality-adjusted life-years (QALYs). The authors consider the medical benefits to individual patients and investigate several assumptions—both favorable and unfavorable—about the effects of earlier HIV diagnosis and treatment on subsequent transmission. Their conclusion: Routine, one-time rapid HIV testing for all adult patients is cost-effective even when the prevalence of undiagnosed HIV infection is as low as 0.2% (assuming that earlier diagnosis and antiretroviral treatment reduces HIV transmission). Screening is still cost-effective under unfavorable assumptions about the effects on subsequent transmission, but only at a somewhat higher prevalence (0.4%). The unfavorable transmission scenario assumes that HIV screening and treatment increase HIV transmission by prolonging life (and therefore the duration of infectiousness) and that infected persons might increase sexual risk-taking because they mistakenly think that having an undetectable viral load means that they are not infectious. The conclusion about the cost-effectiveness of screening is based on the conventional premise that interventions that produce a QALY for $50 000 or less are a bargain (10). Paltiel and colleagues also show that HIV screening remains cost-effective at an even lower prevalence of undiagnosed HIV infection if early detection leads to a more pronounced reduction in subsequent transmission or if society is willing to pay more than $50 000 per QALY.
How does the cost-effectiveness of HIV screening in Paltiel and colleagues' study compare with the cost-effectiveness of other HIV screening programs? Since 1995, when the CDC recommended HIV testing for all pregnant women, the number of infants born annually in the United States with HIV infection has decreased more than 90%. In 2002, nearly 70% of the 4 million women who became pregnant reported that they had been tested for HIV during prenatal care (11). Prenatal screening averts as many as 1500 neonatal HIV infections per year. It is cost-saving wherever the HIV prevalence among pregnant women is more than 0.2% and costs less than $50 000 per QALY until HIV prevalence falls below 0.0075% (12). Current policies for testing donated blood are at the other extreme of cost-effectiveness. HIV antibody screening of the 15 million units of blood collected annually averts 1568 infections per year and costs $3600 per QALY (13). Pooled nucleic acid testing for HIV and hepatitis C virus (HCV) was added to the battery of screening tests for donated blood in 1999. According to current estimates, this additional screening averts an additional 4 HIV and 56 HCV infections annually, at a cost of $4.3 million per QALY (14).
The CDC now recommends HIV screening for all adults, which means that HIV screening should become routine practice in primary care offices. Routine HIV screening is likely to be more cost-effective than Paltiel and colleagues suggest. Their model, like other recent analyses (15–17), includes pretest counseling, which costs 3 times more than the rapid HIV test. In addition to increasing the cost, requirements for pretest counseling might also diminish physicians' willingness to perform HIV screening. Because of competing demands, many clinicians already have difficulty providing all the preventive services recommended for their patients. A recent study in a primary care practice suggests that physicians are more likely to conduct screening than counseling: Patients were up to date on 55% of recommended screening services but on only 9% of health habit counseling (18). These considerations, and equivocal evidence for the effectiveness of counseling for persons who have negative test results, led the CDC to recommend HIV screening on the same voluntary basis as other screening or diagnostic tests—without pretest counseling or separate, written consent. Counseling efforts should focus on patients most likely to benefit: those with positive HIV test results and patients who have negative test results but engage in high-risk behaviors (8).
Cost-effectiveness models for infectious diseases like HIV often underestimate the ultimate benefits to society. HIV is a communicable, fatal disease for which there is effective treatment but no cure. Paltiel and colleagues conclude that HIV screening is cost-effective when only the medical benefits to infected patients are considered, which is the usual basis for decisions about practice guidelines. However, they modeled the effects on subsequent transmission primarily on the basis of the potential for antiretroviral therapy to reduce infectiousness. They also restricted their benefit calculations to “first-generation” secondary transmissions—that is, new infections attributable to patients who are already infected, but not subsequent transmissions from the persons they might infect. It is crucial to more accurately quantify the many ramifications of early detection and treatment of HIV on overall transmission dynamics. Most patients, after learning that they are infected, take steps to protect their partners; these steps substantially reduce HIV transmission. The aggregate annual transmission rate for persons unaware of their HIV infection is estimated to be 6.9% compared with 2.0% for persons who are aware (19). This reduction in transmission is similar to that achieved with zidovudine prophylaxis to reduce the risk for perinatal transmission, and could have substantial implications for curbing the HIV epidemic. Many of the essential parameters needed to guide decisions about screening—including the prevalence of undiagnosed HIV infection in specific settings, the optimal frequency for retesting, and the ultimate effects on the course of the epidemic—will be known with certainty only after we implement screening and examine the results.
No other industrialized country has instituted HIV screening for all patients. Nonetheless, the new U.S. policy seems proportionate to the problem, because few industrialized countries have an HIV/AIDS epidemic as severe as that of the United States. Current testing practices have successfully identified HIV in approximately 75% of infected patients. However, progress has stalled. An estimated 40 000 new HIV infections continue to occur each year. Nearly 40% of infected patients are not tested for HIV until they develop symptoms, after they have been infected—and infectious—for a decade. The prevalence of undiagnosed HIV infection is likely to fall within Paltiel and colleagues' range for cost-effective screening in most practice settings. The 1999–2002 National Health and Nutrition Examination Survey estimates that HIV prevalence is 0.43% in the U.S. adult population and is considerably higher among African Americans: 1.42% among non-Hispanic blacks 18 to 39 years of age and 3.58% among those aged 40 to 49 (20). Consistent with CDC estimates, 25% of persons infected with HIV did not know they were infected.
The CDC's recommendation for opt-out screening is designed to make HIV screening more practical for both physicians and their patients. Patients are free to decline the test without recrimination, and they do not need to admit to some past indiscretion to qualify for testing. Physicians can provide information about HIV testing easily and effectively, with such aids as the prescription-like tear-off sheet developed by the American College of Obstetricians and Gynecologists. HIV screening can bring lifesaving information to infected patients earlier, when it is most beneficial, helping them to protect themselves and their partners. Eventually, reminiscent of successful screening programs for syphilis and tuberculosis, the cost-effectiveness question for HIV will change from whether we should screen for HIV to when we should stop.

References

  1. Francis
    DP
    ,  
    Jaffe
    HW
    ,  
    Fultz
    PN
    ,  
    Getchell
    JP
    ,  
    McDougal
    JS
    ,  
    Feorino
    PM
    .  
    The natural history of infection with the lymphadenopathy-associated virus/human T-lymphotropic virus type III.
    Ann Intern Med
    1985
    103
    719
    22
    CrossRef
    PubMed
  2. Number of persons tested for HIV—United States, 2002.
    MMWR Morb Mortal Wkly Rep
    2004
    53
    1110
    3
    PubMed
    PubMed
  3. Glynn M, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003 [Abstract]. Presented at the National HIV Prevention Conference, Atlanta, Georgia; 12-15 June 2005.
  4. Klein
    D
    ,  
    Hurley
    LB
    ,  
    Merrill
    D
    ,  
    Quesenberry
    CP
    Jr
    .  
    Consortium for HIV/AIDS Interregional Research
    Review of medical encounters in the 5 years before a diagnosis of HIV-1 infection: implications for early detection.
    J Acquir Immune Defic Syndr
    2003
    32
    143
    52
    PubMed
    CrossRef
    PubMed
  5. Liddicoat
    RV
    ,  
    Horton
    NJ
    ,  
    Urban
    R
    ,  
    Maier
    E
    ,  
    Christiansen
    D
    ,  
    Samet
    JH
    .  
    Assessing missed opportunities for HIV testing in medical settings.
    J Gen Intern Med
    2004
    19
    349
    56
    PubMed
    CrossRef
    PubMed
  6. Beckwith
    CG
    ,  
    Flanigan
    TP
    ,  
    del Rio
    C
    ,  
    Simmons
    E
    ,  
    Wing
    EJ
    ,  
    Carpenter
    CC
    .  
    et al
    It is time to implement routine, not risk-based, HIV testing.
    Clin Infect Dis
    2005
    40
    1037
    40
    PubMed
    CrossRef
    PubMed
  7. Frieden
    TR
    ,  
    Das-Douglas
    M
    ,  
    Kellerman
    SE
    ,  
    Henning
    KJ
    .  
    Applying public health principles to the HIV epidemic.
    N Engl J Med
    2005
    353
    2397
    402
    PubMed
    CrossRef
    PubMed
  8. Branson
    BM
    ,  
    Handsfield
    HH
    ,  
    Lampe
    MA
    ,  
    Janssen
    RS
    ,  
    Taylor
    AW
    ,  
    Lyss
    SB
    .  
    et al
    Centers for Disease Control and Prevention (CDC)
    Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.
    MMWR Morb Mortal Wkly Rep
    2006
    55
    RR-14
    1
    17
    PubMed
    PubMed
  9. Paltiel
    AD
    ,  
    Walensky
    RP
    ,  
    Schackman
    BR
    ,  
    Seage
    GR
    III
    ,  
    Mercincavage
    LM
    ,  
    Weinstein
    MC
    .  
    et al
    Expanded HIV screening in the United States: effect on clinical outcomes, HIV transmission, and costs.
    Ann Intern Med
    2006
    145
    797
    806
    CrossRef
    PubMed
  10. Ubel
    PA
    ,  
    Hirth
    RA
    ,  
    Chernew
    ME
    ,  
    Fendrick
    AM
    .  
    What is the price of life and why doesn't it increase at the rate of inflation?
    Arch Intern Med
    2003
    163
    1637
    41
    PubMed
    CrossRef
    PubMed
  11. Anderson
    JE
    ,  
    Sansom
    S
    .  
    HIV testing among U.S. women during prenatal care: findings from the 2002 National Survey of Family Growth.
    Matern Child Health J
    2006
    10
    413
    7
    PubMed
    CrossRef
    PubMed
  12. Immergluck
    LC
    ,  
    Cull
    WL
    ,  
    Schwartz
    A
    ,  
    Elstein
    AS
    .  
    Cost-effectiveness of universal compared with voluntary screening for human immunodeficiency virus among pregnant women in Chicago.
    Pediatrics
    2000
    105
    54
    63
    PubMed
    CrossRef
  13. AuBuchon
    JP
    ,  
    Birkmeyer
    JD
    ,  
    Busch
    MP
    .  
    Cost-effectiveness of expanded human immunodeficiency virus-testing protocols for donated blood.
    Transfusion
    1997
    37
    45
    51
    PubMed
    CrossRef
    PubMed
  14. Jackson
    BR
    ,  
    Busch
    MP
    ,  
    Stramer
    SL
    ,  
    AuBuchon
    JP
    .  
    The cost-effectiveness of NAT for HIV, HCV, and HBV in whole-blood donations.
    Transfusion
    2003
    43
    721
    9
    PubMed
    CrossRef
    PubMed
  15. Sanders
    GD
    ,  
    Bayoumi
    AM
    ,  
    Sundaram
    V
    ,  
    Bilir
    SP
    ,  
    Neukermans
    CP
    ,  
    Rydzak
    CE
    .  
    et al
    Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy.
    N Engl J Med
    2005
    352
    570
    85
    PubMed
    CrossRef
    PubMed
  16. Walensky
    RP
    ,  
    Weinstein
    MC
    ,  
    Kimmel
    AD
    ,  
    Seage
    GR
    3rd
    ,  
    Losina
    E
    ,  
    Sax
    PE
    .  
    et al
    Routine human immunodeficiency virus testing: an economic evaluation of current guidelines.
    Am J Med
    2005
    118
    292
    300
    PubMed
    CrossRef
    PubMed
  17. Paltiel
    AD
    ,  
    Weinstein
    MC
    ,  
    Kimmel
    AD
    ,  
    Seage
    GR
    3rd
    ,  
    Losina
    E
    ,  
    Zhang
    H
    .  
    et al
    Expanded screening for HIV in the United States—an analysis of cost-effectiveness.
    N Engl J Med
    2005
    352
    586
    95
    PubMed
    CrossRef
    PubMed
  18. Stange
    KC
    ,  
    Flocke
    SA
    ,  
    Goodwin
    MA
    ,  
    Kelly
    RB
    ,  
    Zyzanski
    SJ
    .  
    Direct observation of rates of preventive service delivery in community family practice.
    Prev Med
    2000
    31
    167
    76
    PubMed
    CrossRef
    PubMed
  19. Marks
    G
    ,  
    Crepaz
    N
    ,  
    Janssen
    RS
    .  
    Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA.
    AIDS
    2006
    20
    1447
    50
    PubMed
    CrossRef
    PubMed
  20. McQuillan
    GM
    ,  
    Kruszon-Moran
    D
    ,  
    Kottiri
    BJ
    ,  
    Kamimoto
    LA
    ,  
    Lam
    L
    ,  
    Cowart
    MF
    .  
    et al
    Prevalence of HIV in the US household population: the National Health and Nutrition Examination Surveys, 1988 to 2002.
    J Acquir Immune Defic Syndr
    2006
    41
    651
    6
    PubMed
    CrossRef
    PubMed

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

This feature is available only to Registered Users

Subscribe/Learn More
Submit a Comment

2 Comments

Bernard Hirschel

Geneva University Hospital

December 13, 2006

Risk of HIV transmission with undetectable viral load

To quote the author:

"The unfavorable transmission scenario assumes that HIV screening and treatment increase HIV transmission by prolonging life (and therefore the duration of infectiousness) and that infected persons might increase sexual risk-taking because they mistakenly think that having an undetectable viral load means that they are not infectious."

Why "mistakenly"? HIV viral load is by far the most important determinant of infectiousness (1). Where is the evidence that transmission from persons with a undetectable viral load play a role in the HIV epidemic? Even isolated case reports are difficult to find.

(1) Quinn,T.C.; Wawer,M.J.; Sewankambo,N.; Serwadda,D.; Li,C.; Wabwire-Mangen,F.; Meehan,M.O.; Lutalo,T.; Gray,R.H. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Engl J Med 2000;342:921-29.

Conflict of Interest:

None declared

Curt G Beckwith

Brown Medical School

January 5, 2007

Routine HIV Testing in Jails

We applaud Drs. Paltiel and co-authors and Dr. Branson for their recent articles [1-2] that support routine HIV testing. However, their recommendation for routine, voluntary HIV testing as part of primary medical care may miss most of the 750,000 individuals who are incarcerated in U.S. jails on any given day [3]. Most of these individuals do not have primary care providers and are not clients of our nations' mainstream healthcare system. The prevalence of known HIV infection in U.S. jails is estimated to be 1.3 % [4] which is over 3 times greater than the prevalence rate for the general U.S. population however the true HIV prevalence in jails may be significantly higher. An estimated one-fourth of all people living with HIV in the U.S. each year are released from a correctional facility that same year [5]. In particular, African-American men (the demographic group with the highest rate of HIV infection) are incarcerated in jail five times more frequently than White men [3]. The Centers for Disease Control and Prevention recommend routine opt-out HIV testing in incarcerated settings but most jails have not yet implemented it. Focused advocacy is needed now by AIDS activists and the public health community to initiate routine HIV testing in jails with real possibility for opt-out voluntary testing, appropriate protection for confidentiality of results, and linkage to HIV care both within correctional facilities and in the community post-release.

1. Paltiel DA, Walensky RP, Schackman BR, Seage GR, Mercincavage LM, Weinstein MC, et al. Expanded HIV screening in the United States: Effect on clinical outcomes, HIV transmission, and costs. Ann Int Med. 2006; 145: 797-806.

2. Branson BM. To screen or not to screen: Is that really the question? Ann Intern Med. 2006; 145: 857-859.

3. Harrison PM, Beck AJ. Prison and jail inmates at midyear 2005. NCJ publication no. 213133. Bureau of Justice Statistics, US Department of Justice, Office of Justice Programs. Washington, DC, 2006.

4. Maruschak LM. HIV in prisons and jails, 2002. NCJ publication no. 205333. Bureau of Justice Statistics, US Department of Justice, Office of Justice Programs. Washington, DC, 2004.

5. Hammett TM, Harmon MP, Rhodes W. The burden of infectious disease among inmates of and releasees from U.S. correctional facilities, 1997. Am J Public Health. 2002; 92: 189-94.

Conflict of Interest:

None declared

PDF
Not Available
Citations
Citation

Branson BM. To Screen or Not to Screen: Is That Really the Question?. Ann Intern Med. ;145:857–859. doi: 10.7326/0003-4819-145-11-200612050-00011

Download citation file:

  • Ris (Zotero)
  • EndNote
  • BibTex
  • Medlars
  • ProCite
  • RefWorks
  • Reference Manager

© 2019

×
Permissions

Published: Ann Intern Med. 2006;145(11):857-859.

DOI: 10.7326/0003-4819-145-11-200612050-00011

9 Citations

See Also

Expanded HIV Screening in the United States: Effect on Clinical Outcomes, HIV Transmission, and Costs
View MoreView Less

Related Articles

Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement
Annals of Internal Medicine; 159 (1): 51-60
Screening for HIV: A Review of the Evidence for the U.S. Preventive Services Task Force
Annals of Internal Medicine; 143 (1): 55-73
Name-Based Surveillance and Public Health Interventions for Persons with HIV Infection
Annals of Internal Medicine; 131 (10): 775-779
Prenatal Screening for HIV: A Review of the Evidence for the U.S. Preventive Services Task Force
Annals of Internal Medicine; 143 (1): 38-54
View MoreView Less

Journal Club

Prophylactic tenofovir reduced HIV infection in injectable drug users
Annals of Internal Medicine; 159 (6): JC8
Review: Newer second-line drugs for diabetes are not more cost-effective than sulfonylureas
Annals of Internal Medicine; 168 (2): JC8
Review: In patients with a first VTE, extended testing for undiagnosed cancer does not reduce mortality
Annals of Internal Medicine; 167 (12): JC64
Isoniazid prevented active tuberculosis in patients with HIV treated with antiretroviral therapy
Annals of Internal Medicine; 161 (6): JC12
View MoreView Less

Related Point of Care

Management of Newly Diagnosed HIV Infection
Annals of Internal Medicine; 167 (1): ITC1-ITC16
Management of Newly Diagnosed HIV Infection
Annals of Internal Medicine; 155 (7): ITC4-1
View MoreView Less

Related Topics

HIV
Infectious Disease

HIV, Infectious Disease.

PubMed Articles

Impact of antiretroviral therapy containing tenofovir disoproxil fumarate on the survival of patients with HBV and HIV coinfection.
Liver Int 2019.
Role of Social and Sexual Network Factors in PrEP Utilization Among YMSM and Transgender Women in Chicago.
Prev Sci 2019.
View More

Results provided by: PubMed

CME/MOC Activity Requires Users to be Registered and Logged In.
Sign in below to access your subscription for full content
INDIVIDUAL SIGN IN
Sign In|Set Up Account
You will be directed to acponline.org to register and create your Annals account
Annals of Internal Medicine
CREATE YOUR FREE ACCOUNT
Create Your Free Account|Why?
To receive access to the full text of freely available articles, alerts, and more. You will be directed to acponline.org to complete your registration.
×
The Comments Feature Requires Users to be Registered and Logged In.
Sign in below to access your subscription for full content
INDIVIDUAL SIGN IN
Sign In|Set Up Account
You will be directed to acponline.org to register and create your Annals account
Annals of Internal Medicine
CREATE YOUR FREE ACCOUNT
Create Your Free Account|Why?
To receive access to the full text of freely available articles, alerts, and more. You will be directed to acponline.org to complete your registration.
×
link to top

Content

  • Home
  • Latest
  • Issues
  • Channels
  • CME/MOC
  • In the Clinic
  • Journal Club
  • Web Exclusives

Information For

  • Author Info
  • Reviewers
  • Press
  • Readers
  • Institutions / Libraries / Agencies
  • Advertisers

Services

  • Subscribe
  • Renew
  • Alerts
  • Current Issue RSS
  • Latest RSS
  • In the Clinic RSS
  • Reprints & Permissions
  • Contact Us
  • Help
  • About Annals
  • About Mobile
  • Patient Information
  • Teaching Tools
  • Annals in the News
  • Share Your Feedback

Awards and Cover

  • Personae (Cover Photo)
  • Junior Investigator Awards
  • Poetry Prize

Other Resources

  • ACP Online
  • Career Connection
  • ACP Advocate Blog
  • ACP Journal Wise

Follow Annals On

  • Twitter Link
  • Facebook Link
acp link acp
silverchair link silverchair

Copyright © 2019 American College of Physicians. All Rights Reserved.

Print ISSN: 0003-4819 | Online ISSN: 1539-3704

Privacy Policy

|

Conditions of Use

This site uses cookies. By continuing to use our website, you are agreeing to our privacy policy. | Accept
×

You need a subscription to this content to use this feature.

×
PDF Downloads Require Access to the Full Article.
Sign in below to access your subscription for full content
INDIVIDUAL SIGN IN
Sign In|Set Up Account
You will be directed to acponline.org to register and create your Annals account
INSTITUTIONAL SIGN IN
Open Athens|Shibboleth|Log In
Annals of Internal Medicine
PURCHASE OPTIONS
Buy This Article|Subscribe
You will be redirected to acponline.org to sign-in to Annals to complete your purchase.
CREATE YOUR FREE ACCOUNT
Create Your Free Account|Why?
To receive access to the full text of freely available articles, alerts, and more. You will be directed to acponline.org to complete your registration.
×
Access to this Free Content Requires Users to be Registered and Logged In. Please Choose One of the Following Options
Sign in below to access your subscription for full content
INDIVIDUAL SIGN IN
Sign In|Set Up Account
You will be directed to acponline.org to register and create your Annals account
Annals of Internal Medicine
CREATE YOUR FREE ACCOUNT
Create Your Free Account|Why?
To receive access to the full text of freely available articles, alerts, and more. You will be directed to acponline.org to complete your registration.
×