Interpreting and implementing the 2006 CDC recommendations for HIV testing in health-care settings

On September 22, 2006, the Centers for Disease Control and Prevention (CDC) announced recommendations to expand the role of health-care providers in human immunodeficiency virus (HIV) testing. These clearlyjustified guidelines aim to remove traditional testing barriers, and thereby increase the rate of earlier diagnosis. This overarching strategy to increase testing in all health-care settings also includes less traditional sites such as emergency departments and correctional health-care facilities. The motivation for the guidelines is intuitive, as the need for augmented testing is well supported. Of those infected with HIV in the U.S., approximately one-quarter are unaware of their disease status. People who are unaware of their infection disproportionately account for new transmissions and are unable to benefit from treatment. The HIV incidence has not fallen below approximately 40,000 new diagnoses per year, of which approximately 40% are diagnosed late in the course of infection. Universal screening, even in populations with a disease prevalence of 0.1%, has been shown to be cost-effective. While the guidelines have been reviewed in depth, current interpretations do not adequately outline a structure for further debate or facilitate incremental or partial implementation of the recommendations. This must be remedied, as comprehensive implementation of the guidelines will be controversial or logistically impossible in many settings for the foreseeable future. Herein, we provide a clarified interpretation by outlining the core guideline elements individually and within the context of current barriers to implementation. We then discuss potential combinations of the core elements that would enable increased testing in settings where comprehensive guideline implementation is not possible.