Issue:  Vol. 48 / No. 13 / 29 March 2018

CDC, local providers disagree on HIV testing


City Clinic medical director Dr. Stephanie Cohen
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The U.S. Centers for Disease Control and Prevention recently reaffirmed its recommendation that sexually active gay and bisexual men should undergo at least annual HIV screening, but some local providers advise more frequent HIV and sexually transmitted disease tests.

"The San Francisco Department of Public Health recommends quarterly STD screening for HIV-positive and HIV-negative sexually active men and trans individuals who have sex with men, and quarterly HIV screening for those who are HIV-negative," City Clinic medical director Dr. Stephanie Cohen told the Bay Area Reporter.

"This approach to HIV screening has been a critical component of our HIV prevention efforts, and is one of the reasons why approximately 93 percent of people living with HIV in San Francisco know their status," Cohen added.

In 2006 the CDC recommended that everyone between the ages of 13 and 64 should be screened for HIV at least once, and that those at higher risk for infection – including sexually active men who have sex with men – should be rescreened at least annually.

A 2013 review by the U.S. Preventive Services Task Force did not find enough evidence to specify a particular HIV testing interval, but concluded that annual screening for gay men was a "reasonable approach."

However, a growing number of providers who see gay and bi men are offering more frequent HIV screening, typically every three or six months.

In part, this is related to increased use of PrEP. The CDC's 2014 PrEP guidelines call for HIV testing every three months while taking Truvada (tenofovir DF/emtricitabine) for HIV prevention. This is important because Truvada alone is not enough to treat HIV if someone does become infected.

Providers increasingly recommend screening for other STDs such as gonorrhea and syphilis, as well as HIV. Frequent testing allows STDs to be detected and treated early, thereby preventing disease progression and onward transmission.

In light of changing practice, a CDC working group performed an updated systematic review of relevant medical studies and held four expert consultations to determine if there is enough evidence to change the 2006 recommendation for annual HIV screening.

The working group, made up of epidemiologists, clinicians, behavioral scientists, health policy experts, and health economists, reviewed more than 100 studies comparing the benefits of annual versus more frequent screening for men who have sex with men.

The group concluded that "the evidence, programmatic experience, and expert opinions are insufficient to warrant changing the current recommendation" from at least annual screening to more frequent testing.

However, the experts agreed that mathematical models suggest more frequent screening may be beneficial, as prompt HIV treatment also plays a role in prevention. Research conclusively shows that HIV-positive people on antiretroviral therapy with an undetectable viral load do not transmit the virus through sex.

"CDC continues to recommend that clinicians screen asymptomatic sexually active men who have sex with men at least annually," the authors wrote in the August 11 edition of the CDC's Morbidity and Mortality Weekly Report. "Each clinician can consider the benefits of offering more frequent screening (e.g., once every three or six months) to individual MSM at increased risk for acquiring HIV infection, weighing their patients' individual risk factors, local HIV epidemiology, and local testing policies.

"For MSM who are prescribed pre-exposure prophylaxis, HIV testing every three months and immediate testing whenever signs and symptoms of acute HIV infection are reported is indicated," they continued. "MSM who experience a specific high-risk sexual exposure or have symptoms of recent HIV infection should seek immediate HIV testing, and clinicians should be alert for the symptoms of acute HIV infection and provide appropriate diagnostic testing."

Two of the major care providers for gay men in San Francisco are among those that recommend more frequent HIV screening.

"Quarterly testing facilitates early detection of HIV," said City Clinic's Cohen. "Early identification coupled with rapid linkage to care optimizes individual health and reduces the time to virologic suppression, which decreases the chance for ongoing transmission."

The San Francisco AIDS Foundation's Magnet sexual health service at Strut also favors quarterly testing for those at risk of acquiring HIV.

"At Magnet, we recommend that everyone get an HIV test once in their life and people who are more frequently sexually active with multiple partners get tested every three months along with routine gonorrhea, chlamydia, and syphilis testing," Magnet director of nursing Pierre-Cédric Crouch told the B.A.R.

"Frequent HIV testing identifies people with new HIV infections earlier, allowing them to engage in their health," Crouch continued. "Once you are engaged in care with early treatment, you can have a full life with the career you want, the children you may want to have, and the partner you love, but none of that can happen until you get tested."


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