HIV Diagnosis and Screening Guidelines

Screening Recommendations

The American Academy of Family Physicians recommends universal screening for all adolescents and adults aged 15-65 years regardless of perceived risk, using routine opt-out testing in primary care, emergency departments, and for all pregnant women 2
The American Academy of Family Physicians suggests that younger adolescents and adults over 65 should be screened if they have ongoing risk factors such as new sexual partners 3, 4
Men who have sex with men and active injection drug users are at very high risk and should be rescreened at least annually, according to the American Academy of Family Physicians 3, 4
Persons with unprotected vaginal or anal intercourse, sex partners who are HIV-infected or injection drug users, those exchanging sex for drugs or money, and anyone requesting testing for sexually transmitted infections should be screened annually, as recommended by the American Academy of Family Physicians 4
Patients in high-prevalence settings, including STD clinics, correctional facilities, homeless shelters, tuberculosis clinics, and adolescent health clinics with high STI prevalence, require more frequent screening, according to the American Academy of Family Physicians 3, 5

The Centers for Disease Control and Prevention (CDC) recommends a diagnostic testing algorithm that begins with a fourth-generation HIV antigen/antibody combination assay, allowing detection of acute infection approximately 2 weeks earlier than antibody-only tests 1, 2, 6
The CDC-recommended algorithm includes confirmatory testing with HIV-1/HIV-2 antibody differentiation immunoassay, and nucleic acid amplification test (NAAT/HIV RNA qualitative or quantitative) if necessary 1

The Infectious Diseases Society of America recommends that all persons with confirmed HIV infection must receive comprehensive baseline testing before initiating antiretroviral therapy, including HIV RNA viral load level, CD4 cell count with percentage, genotypic resistance testing, HLA-B*5701 testing, and coreceptor tropism assay 7, 2
The Infectious Diseases Society of America also recommends screening for coinfections, such as hepatitis B and C, tuberculosis, and sexually transmitted infections 7

The American Academy of Pediatrics recommends that infants <15-18 months born to HIV-positive mothers require definitive diagnosis using two positive HIV RNA PCR or viral culture tests on separate specimens, as standard antibody tests are unreliable due to maternal antibody transfer 1
The Infectious Diseases Society of America suggests that HIV-2 testing should be considered in persons from endemic regions, their sexual partners, or when clinical evidence suggests HIV disease but HIV-1 tests are negative 7, 1

The American College of Physicians recommends that all persons diagnosed with HIV should be offered antiretroviral therapy immediately upon diagnosis, regardless of CD4 count or viral load, with preferred regimens including an integrase strand transfer inhibitor (INSTI) such as dolutegravir plus two nucleoside reverse transcriptase inhibitors (NRTIs) 2

The Centers for Disease Control and Prevention (CDC) advises against disclosing a positive HIV diagnosis based on screening test alone without confirmatory testing, as false positives can occur with devastating psychological and social consequences 1
The CDC also recommends against using oral fluid-based rapid HIV tests in post-exposure prophylaxis contexts, as they are less sensitive for acute or recent infection detection than blood-based tests 6