Sexually Transmitted Diseases:
The Real World of STD Prevention
Real-World Strategies to Maximize Guidelines-Driven Serological Screening for HIV and Syphilis
Handsfield, H. Hunter MD
From the Center for AIDS and STD and the Department of Medicine, University of Washington, Seattle, WA
Conflicts of interest: None.
Correspondence: H. Hunter Handsfield, MD, Harborview Medical Center Box 359931, 325 Ninth Ave, Seattle, WA 98104. E-mail: firstname.lastname@example.org.
Received for publication February 18, 2013, and accepted February 19, 2013.
Serological screening has had mixed results as a strategy to prevent syphilis and human immunodeficiency virus (HIV) infection. HIV case finding probably has been beneficial, especially since the advent and refinement of effective antiretroviral therapy, yet the incidence of HIV infection in the United States has been stable at unacceptably high levels and continues to rise in much of the world. In hopes of improving HIV case finding and treatment, in 2006 the Centers for Disease Control and Prevention recommended that all persons 13 to 64 years old be screened at least once in the course of routine medical care, regardless of known or suspected behavioral risks, using a streamlined approach that emphasizes opt-out testing without written consent.1 Since then, many reports have analyzed strategies and procedures to broaden HIV screening in various clinical settings, with generally disappointing results.2,3 During the past 15 years, the rates of syphilis have risen dramatically in men who have sex with men (MSM) in virtually all industrialized countries, especially in HIV-infected men,4,5 despite routine serological screening for syphilis in public sexually transmitted disease clinics and widespread recommendations for screening in other venues.6
This month’s installment of The Real World of STD Prevention, inaugurated recently in this journal, presents 2 studies of strategies to maximize serological screening for HIV or syphilis. Anaya et al.7 studied routine, risk-independent, opt-out HIV screening in patients attending primary care clinics in the US Veterans Affairs health system. Although undertaken in 2 geographic regions with “high HIV seroprevalence,” the investigators anticipated and found a low population prevalence of infection. At the other end of the spectrum of risk and anticipated prevalence, Callander and his colleagues8 analyzed uptake of routine serological testing for syphilis among HIV-infected MSM attending a private practice in Sydney, Australia, that provides comprehensive HIV clinical services. HIV-infected MSM may have the highest incidence of syphilis in any defined population worldwide. For example, in King County, Washington, the estimated annual incidence rates of early syphilis among HIV-infected MSM in 2010 and 2011 were an astounding 3016 and 4083 per 100,000, respectively—that is, 3% to 4% of such men acquired syphilis each year.9
In both studies, the main outcome was not the prevalence of HIV or syphilis—indeed, the Australia study was designed in a way that precluded analysis of test results—but instead the success in increasing screening rates. Qualitatively, these outcomes were similar in the 2 studies, with gratifying rises in screening rates that, nonetheless, fell short of the goals set by the investigators. In the Veterans Affairs primary care clinics, routinely offering rapid oral fluids HIV testing performed by nurses resulted in a sustained increase in testing for HIV to 2364 (28.6%) and 2522 patients (9.1%) at the 2 centers’ clinics, compared with historical experiences of 1.2% and 0.04% of patients, respectively.7 Previously undiagnosed HIV infections were diagnosed in 14 (0.3%) of 4886 patients tested. The main reason for failure to test still more patients apparently was budgetary, that is, the number of tests and nurses available, although it would have been useful to see data on the proportion of patients offered testing and their acceptance rate. In Sydney, automatic syphilis serological testing of blood submitted for HIV viral load analysis resulted in a rise in the mean frequency of syphilis screening from 1.14 tests to 2.45 tests annually, and the proportion of HIV-infected MSM who had at least 1 syphilis test per year rose from 73% to 97%.8 The authors lament their failure to achieve the goal of quarterly serological tests in HIV-infected men, as stipulated in Australian guidelines. However, the testing frequency was directly linked to viral load monitoring, the frequency of which also was guidelines-driven. In any case, it is a remarkable achievement. As suggested by other data from Australia,10 wide implementation of this approach probably would significantly improve syphilis prevention among MSM wherever comprehensive HIV clinical services are provided.
These studies are excellent examples of programmatic, operational research to be published under the rubric of The Real World of STD Prevention. Rather than using the oft-stated gold standard of randomized controlled trials or other controlled strategies, the investigators analyzed their existing clinic infrastructures, asked how these could be exploited to achieve desired ends, and compared the outcomes to past experience. The results will resonate with the investigators’ counterparts in other clinics and prevention programs, and both strategies for enhanced screening have potential for widespread adoption. As always, the devil is in the details, and probably few clinics will adopt the interventions unchanged. In the same spirit that drove the designs of the present studies, program managers and clinic directors will make their own pragmatic adaptations. For example, higher rates of routine, opt-out HIV screening and reduced personnel costs might be achieved by laboratory-based rather than relatively labor-intensive point-of-care testing. In view of the low prevalence of infection that usually will pertain in routine opt-out screening, as found by Anaya et al.,7 and because accumulated data and Centers for Disease Control and Prevention recommendations suggest that immediate conveyance of negative test results is not a crucial element of HIV prevention,1 the inherently delayed and likely overall reduced notification with laboratory-based screening may not be a serious impediment. On the other hand, anticipated modification of the US Preventive Services Task Force guidelines, elevating routine HIV testing from a C grade to an A grade recommendation, should assure nearly universal insurance coverage for HIV screening under the Affordable Care Act.11,12 This in turn may obviate the need for special efforts of the sort described by Anaya et al, or may induce other innovative approaches to assure widespread screening. For syphilis screening in MSM receiving HIV clinical care, it might be feasible to link screening to tests other than viral load, such as automatic testing of any blood specimen received longer than 3 months after a prior syphilis serological result. In many settings, this would largely be an exercise in computer programming and data systems. If modifications like these and others prove effective, some of those clinic directors and program managers can be expected to systematically analyze the outcomes and perhaps to submit them for consideration in future installments of The Real World of STD Prevention.
1. Branson BM, Handsfield HH, Lampe MA, et al.. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR
2006;55(RR-14):1–17. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm
. Accessed February 17, 2013.
2. Haukoos JS, Hopkins E, Conroy AA, et al.. Routine opt-out rapid HIV screening and detection of HIV infection in emergency department patients. JAMA 2010; 304: 384–392.
3. Shirreffs A, Lee DP, Henry J, et al.. Understanding barriers to routine HIV screening: Knowledge, attitudes, and practices of healthcare providers in King County, Washington. PLoS One 2012; 7 (9): e44417. doi: 10.1371/journal.pone.0044417.
4. Kerani RP, Handsfield HH, Stenger MS, et al.. Rising rates of syphilis in the era of syphilis elimination. Sex Transm Dis 2007; 34: 154–161.
5. Torrone EA, Bertolli J, Li J, et al.. Increased HIV and primary and secondary syphilis diagnoses among young men—United States, 2004–2008. J Acquir Immune Defic Syndr 2011; 58: 328–335.
6. Lewis FM, Schillinger JA, Taylor M, et al.. Needle in a haystack: The yield of syphilis outreach screening at 5 US sites—2000 to 2007. J Public Health Manag Pract 2011; 17: 513–521.
7. Anaya HD, Butler JN, Solomon JL, et al.. Implementation of nurse-initiated rapid HIV testing at high prevalence primary care sites within the US Veterans Affairs Healthcare System. Sex Transm Dis 2013; 40.
8. Callander D, Baker D, Chen M, et al.. Including syphilis testing as part of standard HIV management checks and improved syphilis screening in primary care. Sex Transm Dis 2013; 40.
10. Bissessor M, Fairley CK, Leslie D, et al.. Frequent screening for syphilis as part of HIV monitoring increases the detection of early asymptomatic syphilis among HIV-positive homosexual men. J Acquir Immune Defic Syndr 2010; 55: 211–216.
11. Bayer R, Oppenheimer GM. Routine HIV testing, public health, and the USPSTF—An end to the debate. New Engl J Med 2013; 368: 881–884.
12. Martin EG, Schackman BR. Updating the HIV-testing guidelines— A modest change with major consequences. New Engl J Med 2013; 368: 884–886.
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