Clinical Context

There are more than 1 million US adolescents and adults currently living with HIV infection, and the National HIV Strategic Plan and Ending the HIV Epidemic in the US initiative share a goal of reducing the rate of new HIV infections by 90% by 2030. Part of the tactics for achieving this goal include at least 1-time screening for HIV among all US residents between 13 and 64 years of age.

Implementation of HIV screening is particularly important for adolescents, who represent 20% of incident diagnoses of HIV, yet have traditionally had lower rates of HIV screening and use of preexposure prophylaxis (PrEP). The application of clinical decision support tools could improve rates of HIV screening and appropriate use of PrEP, and a recent study by Pickel and colleagues assessed pediatricians’ perspectives on the use of clinical decision support to improve HIV prevention. Their results were published in the February 21, 2023, issue of Implementation Science Communications.^[1]

Respondents rated clinical decision support as highly acceptable and appropriate, with a strong rating for feasibility as well. However, there were concerns regarding patient confidentiality with use of clinical decision support, and clinicians wanted a system that allowed support based on the patient’s risk factors for HIV infection.

The current study provides a broader snapshot of routine HIV screening in the US.

Study Synopsis and Perspective

Almost three quarters of adults living in the US report having never tested for HIV according to a newly published study from the Centers for Disease Control and Prevention (CDC).^[2] The reasons are complex and could jeopardize goals of ending the AIDS epidemic by 2030.

Patients and clinicians alike face system challenges, including stigma, confidentiality concerns, racism, and inequitable access. Yet clinicians, public health authorities, and even some patients agree that testing does work: In 2022, 81% of people diagnosed with HIV were linked to care within 30 days. Moreover, many patients are aware of where and how they wish to be tested. So, what would it take to achieve what ostensibly should be the lowest hanging fruit in the HIV care continuum?

The “never tested” populations (4334 of 6072) in Pitasi’s study were predominantly ages 18 to 29 years (79.7% vs 20.3% tested) and 50 years plus (78.1% vs 21.9% tested). A total of 48.0% of never-tested adults also indicated that they had engaged in past-year risky behaviors (ie, injection drug use, being treated for a sexually transmitted disease, exchanging sex/drugs for money, engaging in condomless anal sex, or having more than 4 sex partners). However, the difference between never-tested adults who live in Ending the HIV Epidemic in the US (EHE)-designated jurisdictions (comprising 50 areas and 7 US states responsible for more than 50% of new HIV infections) and those residing in non-EHE areas was only about 5 percentage points (69.1% vs 74.5%, respectively), underscoring the need for broader engagement.

“There’s definitely a lack of testing across the board,” explained Lina Rosengren-Hovee, MD, MPH, an infectious disease epidemiologist at the University of North Carolina School of Medicine in Chapel Hill. “There are all sorts of biases on how we make decisions and how we stratify...and these heuristics that we have in our minds to identify who is at risk and who needs testing,” she said.

“If we just look at the need for HIV testing based on who is at risk, I think that we are always going to fall short.”

Conflicting Priorities

Seventeen years have passed since the CDC recommended that HIV testing and screening be offered at least once to all people aged 13 to 64 years in a routine clinical setting, with an opt-out option and without a separate written consent. People at higher risk (sexually active gay, bisexual, and other men who have sex with men) should be rescreened at least annually.

These recommendations were subsequently reinforced by numerous organizations, including the US Preventive Services Task Force (USPSTF) in 2013 and again in 2019, and the American Academy of Pediatrics (AAP) in 2021.

However, Dr Rosengren-Hovee said that some clinicians remain unaware of the guidelines; for others, they are usually not top-of-mind because of conflicting priorities.

This is especially true of pediatricians, who, despite data demonstrating that adolescents account for roughly 21% of new HIV diagnoses, rarely recognize or take advantage of HIV testing opportunities during routine clinical visits.^[3]

“Pediatricians want to do the right thing for their patients, but at the same time, they want to do the right thing on so many different fronts,” said Sarah Wood, MD, assistant professor at the University of Pennsylvania School of Medicine and attending physician of adolescent medicine at Children’s Hospital of Philadelphia.

Dr Wood is coauthor of a study published this past February in Implementation Science Communications examining pediatrician perspectives on implementing HIV testing and prevention.^[1] Participants identified confidentiality and time constraints as the most important challenges across every step of their workflow, which in turn influenced perceptions about patients’ perceived risks for acquiring HIV--perceptions that Dr Wood believes can be overcome.

“We need to really push pediatricians (through guideline-making societies like AAP and USPSTF) that screening should be universal and not linked to sexual activity or pinned to behavior, so the offer of testing is a universal opt-out,” she said. In addition, “we need to make it easier for pediatricians to order the test,” for example, “through an office rapid test...and a redesigned workflow that moves the conversation away from physicians and nurse practitioners to medical assistants.”

Dr Wood also pointed out that any effort would require clinicians to overcome discomfort around sexual health conversations, noting that although pediatricians are ideally positioned to work with parents to do education around sexual health, training and impetus are needed.

A Fractured System

A fractured, often ill-funded US healthcare system might also be at play, according to Scott Harris, MD, MPH, state health officer of the Alabama Department of Public Health and Association of State and Territorial Health Officials’ Infectious Disease Policy Committee chair.

“There’s a general consensus among everyone in public health that [HIV testing] is an important issue that we’re not addressing as well as we’d like to,” he said.

Dr Harris acknowledged that although COVID-19 diverted attention away from HIV, some states have prioritized HIV more than others.

“We don’t have a national public health program; we have a nationwide public health program,” he said. “Everyone’s different and has different responsibilities and authorities...depending on where their funding streams come from.”

In mid-March the White House announced that it proposed a measure in its Fiscal Year 2023 budget to increase funding for HIV a further $313 million to accelerate efforts to end HIV by 2030, also adding a mandatory program to increase PrEP access. Without congressional approval, the measures are doomed to fail, leaving many states without the proper tools to enhance existing programs, and further painting overworked clinicians into a corner.

For patients, the ramifications are even greater.

“The majority of folks [in the CDC study] that were not tested said that if they were to get tested, they’d prefer to do that within the context of their primary care setting,” said Justin C. Smith, MPH, director of the Campaign to End AIDS, Positive Impact Health Centers, and a member of the Presidential Advisory Council on HIV/AIDS.

“When you create a more responsive system that really speaks to the needs that people are expressing, that can provide better outcomes,” Smith said.

“It’s vital that we create healthcare and public health interventions that change the dynamics...and make sure that we’re designing systems with the people that we’re trying to serve at the center.”

Pitasi, Rosengren-Hovee, Wood, Harris, and Smith have disclosed no relevant financial relationships.

Implications for the healthcare team

• In a recent study, clinicians rated clinical decision support for HIV preventions as highly acceptable and appropriate, with a strong rating for feasibility as well. However, there were concerns regarding patient confidentiality with the use of clinical decision support.
• In the current study of US adults, 72.5% had not been tested for HIV, and 43.9% of adults who had not been tested reported that they never wanted to be tested for HIV. Rates of never being tested were higher among White adults (76.0%) compared with Black (53.5%) and Hispanic (69.3%) adults. The Midwest was the area of the country with the highest rate of no testing (77.3%).
• Given the fact that adolescents account for roughly 21% of new HIV diagnoses, members of the healthcare team caring for this patient population should take advantage of HIV testing opportunities during routine clinical visits.

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