This week, a landmark U.S. Preventive Services Task Force (USPSTF) decision endorsed routine HIV screening for all American teens and adults aged 15 to 65, as well as all pregnant women.
The new USPSTF score of an "A" for HIV testing means that there is now broad public health consensus that HIV screening should now be as routine as blood pressure screening for Americans.
Perhaps the greatest implication of this recommendation is its impact on how doctors get reimbursed for HIV tests. Though the Centers for Disease Control and Prevention endorsed routine screening in 2006, many doctors still couldn't get reimbursed for HIV screening because HIV testing did not yet have a USPSTF "A" rating. In practical terms, this meant most doctors could only get paid for screening when the patient was pregnant or was considered "high risk" for some other reason. Research shows that provider and patient perceptions about HIV risks are often wrong; this means that many people who underestimated or whose doctors underestimated their risk often didn't get tested. These challenges created enormous disincentives for routine HIV screening.
The new recommendations from the USPSTF removed this critical barrier to HIV testing for providers by allowing health-care providers to finally get paid for routinely testing all patients for HIV. This monumental shift in policy is even more important in the context of the Affordable Care Act, which requires health insurers to cover preventive services that have an "A" USPSTF recommendation.
Here's a real-world example that illustrates the reimbursement challenge: John lives in a neighborhood with 3 percent HIV prevalence, and sees his doctor for treatment for high blood pressure. Because the doctor has only five to 10 minutes for the visit, doesn't believe John is at risk for HIV and won't get paid to provide him an HIV test, he doesn't offer John an HIV test. However, John is HIV-positive and doesn't know it because he's never been tested and hasn't shown any symptoms of HIV/AIDS. John, not knowing he's at risk and presuming that his doctor has his best intentions in mind, also doesn't ask for an HIV test. John leaves the doctor's office and continues to have unprotected sex with his girlfriend, placing her at very high risk for contracting HIV.
Similar scenarios play out in hundreds of clinics across the country each day; the 240,000 individuals who are HIV-positive and don't know it transmit about 50 percent of new HIV infections. These types of "missed opportunities" are a key reason we still have alarmingly high rates of HIV infection in many communities in the U.S.
Now that the USPSTF endorses routine screening, providers will have financial incentives to offer HIV testing to people like John, irrespective of their perceived HIV risks. This is important now more than ever; a groundbreaking 2011 study found HIV-positive individuals who take their AIDS medicines regularly have 96 percent lower probability of transmitting HIV to others, demonstrating the public health benefits of AIDS treatment. However, testing is the critical first step for starting treatment. If we could diagnose more people early in the course of their infection and keep them in care, we could dramatically reduce the scale of the U.S. epidemic. New USPHTF HIV testing guidelines will make this a real possibility.
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